Flashcards in Muscoskeletal Deck (38)
Rheumatology and bone disease: What is rheumatology?
Branch of medicine dealing with joint, bone and muscle disease
Diseases normally inflammatory
Most are “auto-immune” diseases
*arthiritis is key but not everything, can be systemic - fever, skin rash/nodules, pain and stiffness, heart and lung involvement, neurological problems etc
main ones - rheumatoid arthritis (exam questions), crystal arthritis, spondulo-arthiritis, connective tissue disease, infections, vasculitis - inflammation of blood vessels
Rheumatology and bone disease: What are the risk factors for rheumatoid arthritis?
Rheumatology and bone disease: What is rheumatoid arthritis?
Disease of synovial joints
Affects 1% population
Auto-immune, systemic inflammatory illness
Symmetrical joint inflammation & deformity
“extra-articular” features - features outside of the joints - systemic effects
Rheumatology and bone disease: How does rheumatoid arthritis pain present?
Inflammatory joint pain
Early morning stiffness (>30 min)
Stiffness after rest - car journey, watching tv, office job
Ease with use/ exercise - (osteoarthritis gets worse, rheumatoid gets better with exercise)
May have “flu-like” symptoms
NSAIDs eg Ibuprofen – may be helpful - reduces pain, stiffness and swelling
Rheumatology and bone disease: What are the 4 parts of inflammation?
red, hot, painful, swollen
Rheumatology and bone disease: Why is RA treated?
can lead to progressive joint deformity
Rheumatology and bone disease: What deformities of the hand can you get?
Z thumb deformity - hyperextension of the pharyngeal joint and..
swelling - 'boggy' - firm, can be tender, spongy feeling
ulnar deviation of the fingers - due to the tendon deviation...
swan neck deformity - due to the tendons deforming
swelling and subluxation of MCPJs (when fingers drop down)
Rheumatology and bone disease: What are the systemic features of RA?
- Lung fibrosis - crackles with stethescope
- Pleural effusions - high protein content
- Pericardial inflammation/ - effusions
- Valve inflammation
- Amyloidosis - repeated episodes of inflammation
- Rheumatoid nodules - will have positive test for Rheumatoid antibodies
- Vasculitis - around the finger nails blood vessels occlude due to inflammation of the blood vessels wall and immunodeficiency, common in smokers
Secondary Sjogren’s syndrome
Rheumatology and bone disease: What blood tests are done for RA?
Anaemia - normocytic/ may be macrocytic
High/ low platelets - high platelets with inflammation
High inflammatory markers – C reactive protein (CRP), Erythrocyte sedimentation rate (ESR) - may not be high
Up to 75% positive for RF (Rheumatoid Factor - can get this in TB) and/ or anti-CCP (cyclic citrullinated peptide)- more specific antibody for RA
25% of RA have normal blood tests
Rheumatology and bone disease: What do you seen in x rays of RA?
Osteopenia (thinning) around the joints: “periarticular osteopenia”
Soft tissue swelling
Joint space narrowing
Rheumatology and bone disease: What is the treatment for RA?
- NSAIDs (Non-steroidal anti-inflammatory drugs eg Ibuprofen)
Injected into joint/ intra-muscular/ iv/ oral (will not remain on steroids long term)
CONTROL OF DISEASE (immunosuppresive)
- DMARDs (Disease Modifying Anti-Rheumatic Drugs)
Eg Methotrexate (most common drug - comes up a lot in exams), Sulfasalazine, Leflunomide, Hydroxychloroquine - tablet drugs that suppress immune system to decrease inflammation
BIOLOGIC DRUGS - hospital only drugs that do not appear on the prescription list from the GP (all either sc or iv injections)*
- Anti TNF (Tumour necrosis factor) eg Infliximab, Adalimumab, Etanercept
- B Cell depletion (anti CD20) eg Rituximab - reduces antibodies recognising the RA antigens
- Others eg Tocilizumab (anti IL 6), Abatacept (T cell signalling blocker), Jak inhibitors - tablets
- increased risk of sepsis and non melanoma skin cancers as well, been used for 20 years but don't know side effects after that
*so these will not appear on patient’s prescription list from GP
Rheumatology and bone disease: What are the side effects of RA drugs?
- All increase risk
- For biologic drugs: reactivation of TB
Bone Marrow Toxicity
- Low white cell count/ low platelets/ pancytopenia
- Abnormal liver tests (rise in enzymes)
- Nausea, diarrhoea, flatulence
WE ADVISE ALL PATIENTS TO STOP DMARDs/BIOLOGIC DRUGS FOR DURATION OF COURSE OF ANTIBIOTICS & FOR UP TO 2 WEEKS AFTERWARDS
Rheumatology and bone disease: What is methotrexate and how is it prescribed?
- Prescribed as once weekly dose: 15-25 mg/ wk (2.5mg tabs)
- Never co-prescribe with Trimethoprim/ Septrin (folate antagonists, can cause severe risk of bone marrow suppression)
-Risk of severe bone marrow suppression: all anti-folate drugs
- Pneumonitis (fluid, interstitial changes in lungs, most common in first 6 months of treatment) - dried cough, fever, get chest x ray and sats, occurs in less than 1% of patients
- Fibrosis??? - controversial
- Reduce dose/ stop or contact us if patient develops new renal impairment
Contra-indicated in both men and women pre-conception
Nausea, mouth ulcers
Rheumatology and bone disease: What are the risks of biologic drugs?
Much greater infection risk
- Stop 2 weeks prior to surgery/ significant procedure - may need to stop before extractions
- Restart 2 weeks later or when wounds healing
- Remember to ask your patient if they are on one of these
- Contact us
Reactivation of TB/ Hep B & C
Relatively contra-indicated if patient develops cancer
May cause/ exacerbate multiple sclerosis (anti-TNF)
Rheumatology and bone disease: What is rheumatoid neck?
- can get it in longstanding RA
Erosive change at C1/C2 (and lower levels)
Leading to subluxation at the atlanto-axial level or at subaxial levels or both
Important to recognise a “rheumatoid neck” because instability can lead to neurological deficit from spinal cord compression - 1 in 10 have an unstable neck
This may be a problem with intubation or positioning a patient in the dental chair
Rheumatology and bone disease: What do you do if a patient has rheumatoid neck?
Ask about neck pain
Ask about known “Rheumatoid Neck”
When positioning patient, check no new neck pain develops or neurological symptoms such as pins & needles/ numbness in arms/ hands/ legs
Pre intubation: flexion & extension Xrays of cervical spine & discuss with anaesthetist
Rheumatology and bone disease: How may RA affect caries/gingivitis?
- Poor hand/ neck/ shoulder function can impair dental hygiene
- Immuno-suppressive drugs may compound this
- Remember many RA patients have co-existent osteoporosis, so may well be on bisphosphonates too (jaw necrosis)
- Increasing evidence that gingivitis/ caries may be a trigger for RA in genetically susceptible individuals - microbes involved in these may trigger RA?
Rheumatology and bone disease: What is juvenile idiopathic arthritis?
- Inflammatory arthritis occurring before the age of 16
- Up to 50% “grow out of it” by adulthood
-Many different patterns of arthritis
- Jaw underdevelopment
- TMJ inflammation leads to altered mandibular growth
Malocclusion, micrognathia (under development of the jaw)
Pain, biomechanical problems
Rheumatology and bone disease: What is spondyloarthropathy?
- group of arthritis associated with hLA b27
- RF negative diseases, no antibodies associated
Rheumatology and bone disease: What is Ankylosing spondylitis?
inflammation of the spine leading to new bone formation
-Progressive new bone formation/ calcification in spine = severe limitation of movement
Can have rigid, fused neck (risk of fracture) and/ or atlanto-axial subluxation
Rheumatology and bone disease: What are common features of spondyloarthropathy?
- Inflammation of junction between tendon/ ligament & bone
- Eg Achilles tendon - loss of gutters either side of the tendon, tennis elbow
- “Sausage finger” or “sausage toe”
- Combination of joint and tendon sheath inflammation
Inflammatory eye disease
- Iritis (also called anterior uveitis) - iris is very irregular, fibrous strands in the eye, complaining of photophobia and blurred vision
Inflammatory bowel disease
- Ulcerative colitis/ Crohn’s disease
Rheumatology and bone disease: What is psoriatic arthritis?
Swelling of proximal and distal joints, skin changes - flaky dystrophic nails due to psoriasis in the nails
- similar thumb changes to RA
- nail pitting - dented the nail bed
- dactylitis - sausage toes
Rheumatology and bone disease: What is osteoarthritis?
Degenerative process, probably with exaggerated repair response
Leads to pain, stiffness, deformity, reduced joint movement, joint instability
Increases with age
Occupation / hobbies increase risk
Eg Footballers – knees (KNEES ARE BOWING), typists – hands & wrists
bones are sclerotic and whiter than they should be on an x ray
Rheumatology and bone disease: What is the treatment for osteoarthritis ?
Weight loss (lower limb joints)
Paracetamol, co-codamol, NSAIDs
Surgery as final resort
For uncontrolled pain particularly at night
Joint failure eg knee giving way
Rheumatology and bone disease: What is gout?
Acute inflammatory arthritis. Sudden onset – often overnight, hot painful red joint
most common in big toe joint, middle of foot, wrist, finger etc
can't put foot to the ground
more common in men
Rheumatology and bone disease: What happens in gout?
high level of uric acid in the serum
- Urate crystals precipitating out from bloodstream into joints/ soft tissues
- Induces intense neutrophil-led inflammatory response
Needle-shaped urate crystals under microscope
Rheumatology and bone disease: Why does gout happen?
High uric acid
Patient has high serum urate (before attack; urate may be falsely low during attack)
Causes of high urate:
Genetic predisposition (enzyme defects)
Renal impairment - kidney filters uric acid
Diuretics - removal of water concentrated the uric acid
High alcohol/ fructose/ red meat/ shellfish diet
- Part of “metabolic syndrome” – central obesity, diabetes, high blood pressure, high cholesterol
Rheumatology and bone disease: How is gout treated?
PREVENTION OF FUTURE ATTACKS
Urate lowering drugs eg Allopurinol & Febuxostat (both xanthine oxidase inhibitors) - get rid of urate through the kidneys
Rheumatology and bone disease: What can untreated gout lead to?
severe chronic gout -Chronic polyarticular tophaceous gout - collections of uric acid sitting under the skin