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Flashcards in Ra Deck (31)
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1
Q

Define RA

A
Systemic inflammatory disease
Characterised by deforming peripheral polyarthritis
1% prevalence
Peak onset 50 to 60 years
HLA-DR4/1 linked
2
Q

Signs and symptoms ( common )

A

Symmetrical swollen painful stiff small joints of hand and feet
Worse in the morning
Can fluctuate and larger joints may be involved

3
Q

Less common signs and symptoms

A

Sudden onset widespread arthritis
Palindromic rheumatoid arthritis
Persistent mono arthritis e.g. Knee shoulder hip
Systemic illness with an extra articular signs and symptoms
Polymyalgia onset eg. Vague limb girdle aches
Recurrence of soft tissue problems e.g. frozen shoulder, carpal tunnel, de quervains tenosynovitis

4
Q

Early signs

A

Swollen Mcpj, pip, wrist, mtp(red, hot, swollen, typically asymmetrical)

** positive squeeze test

Look for tenosynovitis or bursitis

5
Q

Late signs

A
Ulnar deviation
Subluxation of wrists and fingers
Boutonniers 
Swan neck finger deformity
Z deformity of thumbs
Ruptured hand extensor tendons
Atlanto axial subluxation
6
Q

Resp (extra articular manifestations)

A
Pleurisy
Pleural effusion
Pleural nodules
Pull fibrosis
Caplans syndrome looks like cavitating tb nodules
Obliterating bronchiolitis
7
Q

Cardiac (extra articular manifestations)

A

Pericarditis
Pericardial effusion
Myocarditis
Cardiac nodules causing : valvular disease, conduction defects

8
Q

Heamatological

A

Marrow depression due to folate deficiency
Anemia of chronic disease
Coombs positive hemolytic anemia
Hyper viscosity
Thrombocytosis
Leukocyosis ie. High wcc (Nb.Leucopenic in feltys syndrome)

9
Q

Ocular (extra articular manifestations)

A
Keratotoconjunctivitis sicca 
Episcleritis 
Iritis 
Tenosynovitis of occular muscles
Sjögren's syndrome
Scleritis
10
Q

Systemic (extra articular manifestations)

A

RhF nodules
Peripheral entrapment myopathies eg. Carpal,cubical, radial
Cutaneous vasculitis w. Increased risk of building up atherosclerotic plaque
Tendon rupture
AA amyloidosis of kidneys

11
Q

Lymphoreticular (extra articular manifestations)

A

Lymphadenopathy
Splenomegaly
Feltys syndrome (splenomegaly, lymphadenopathy, anemia-neutropenia-thrombocytopenia—-presenting as recurrent infections and leg ulcers)

12
Q

Ix

A
  1. Fbc normocytic normochromic anemia + reactive thrombocytosis in active RA
  2. Raised esr/crp
  3. U&es goof for baseline cos mess can affect renal function
  4. Lfts- mild raised alp+ggt seen in RA
  5. Rheum factor, most are positive
  6. Ana, anti ccp
  7. Radiography of hands and feet if see synovitis here clinically
  8. Cxr to exclude chest involvement common in RA
  9. Us or mri of joints that accurately identifies synovitis and bony erosions more than X-rays …
13
Q

Suspected RA normal rheum referral

A

For peeps with persistent synovitis with no known cause

14
Q

Urgent two week referral only if

A

Small joints o chandler and feet affected

More than one joint affected

If there’s been delay of 3 month between onset of symptoms and when started seeking medical advice

Nb don’t delay if blood tests are normal or if awaiting lab results

15
Q

Suspected RA rx

A
Pain relief paracetamol and codeine
Still not controlled?
Nsaid eg naproxen, ibuprofen, diclofenac and PPI
Orrrrrrr
Coxib eg. Celecoxib,etoricoxib and PPI

Use lowest effective dose for shortest period of time

Never prescribe corticosteroid in gp

16
Q

Mx of confirmed RA flare

A

Exclude septic arthritis, hot swollen single joint?

Suspect RA flare if stiffness,pain,swelling,fatigue,synovitis,joint tenderness, loss of joint function, raised inflam markers

Mx other causes of worsening symptoms eg. Osteoporotic fractures, stress fracture, avascular necrosis

Symptom control with :
💕nsaid and paracetamol and or codeine
💕Intra articular corticosteroid injection
💕Im corticosteroid methyl pred into gluteal region
💕oral corticosteroids

Specialist drug rx
Combo of dmards and st corticosteroids

1st line methotrexate and at least one other dmard from (sulfasalazine, hydroxycholoroquine)

17
Q

When to refer to surgery

A

If don’t respond to optimal non surgical rx
Persistent localised synovitis,pain,worsening joint function

Should get surgical option before gets more deformed eg.nerve compression, carpal tunnel, stress fracture

18
Q

Ddx for worsening joint symptoms

A

2ry osteoarthritis if minimal or no synovitis, muscle wasting, instability, crepitus, decreased rom

Osteoporotic fracture if he of minimal trauma, pain, immobility

Avascular necrosis if sudden onset pain in pt taking corticosteroids, absence of synovitis

Cervical myelopathy or nerve root compression if neck pain, weakness, parasthesiae

Psychosocial problems

Failure to adhere to Meds…

19
Q

Dmard examples

A

Methotrexate
Sulfasalazine
Hydroxycholoroquine
Leflunomide

20
Q

Se of all dmards

A

Immunosuppression
Pancytopenia
Increased susceptibility to infection
Neutropenic sepsis

21
Q

Methotrexate se

A

Pneumonitis
Oral ulcers
Hepatotoxic
Teratogenic male and female…

22
Q

Sulfasalazine se

A

Rash
Decreased sperm count
Oral ulcers
Gi upset

23
Q

Leflunomide

A

Teratogenic Its
Oral ulcers
High bp
Hepatotoxic

24
Q

Hydroxycholoroquine

A

Retinopathy

Therefore need annual eye screen

25
Q

Moa abatacept

A

Suppress T cells

26
Q

Moa retuximab

A

Suppress B cells

27
Q

Moa adalimumab, etanercept, infliximab (1st line, others are 2nd line)

A

Block chemokines eg tnf alpha

28
Q

Anakinra moa

A

Block IL-1 receptor

29
Q

Tocilizumab moa

A

Block il-6 receptor

30
Q

Biologicals SEs

A
Serious infection
TB reactivation
Hepatitis B
Worsening heart failure
Hypersensitivity
Injection site reactions
Cancers may be more common
31
Q

What is the disease activity score

A
Looks at 28 joints
How many out of 28 are swollen
How many out of 28 are tender
Recent esr crp levels
Pts global assessment using 10cm line between good and v bad