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Flashcards in Rheumatoid Arthritis Deck (19):
1

What is Rheumatoid arthritis

RA is a chronic, progressive, systemic inflammatory disease characterized by:

Destruction of synovial joints with loss of cartilage and bone
Damage to ligaments and tendons
Loss of physical function and decreased quality of life
Disability and underemployment

2

Targeted population for the New RA Diagnostic Criteria August 2010

Patients who
1) have at least 1 joint with definite clinical synovitis (swelling)
2) with the synovitis not better explained by another disease

3

Classification of RA

score-based algorithm: a score of 6/10 is needed for classification of a patient as having definite RA
4 domains: number and location of synovitis, serologic abnormality, elevated acute phase reactants, symptom duration (now 6 weeks)

4

4 domains that are assessed in diagnostic tree for RA

Number and location of joints
Presence or absence of serological markers, RF anti-CCP
Duration of symptoms now cut down to six weeks from 3 months
Presence of elevated acute phase reactants

5

Locations of RA

In RA the DIPJs are not affected and in contrast the MCPJs are affected. An area that is frequently affected are the wrists and shortening of the intercarpal space is common.
MCP and PIP of the index and the long finger are mc in RA
Foot the 4th and 5th MTPJ

6

RA risk factors

Current Smoking

Genetics: Family history confers risk (accurate)
HLA-DRB4 (we do not measure)
Other genetic markers (clinically we do not measure)

Female sex

Age

7

Erythrocyte Sedimentation Rate (ERS) Lab value for RA

Male = age / 2
Female = (age + 10) / 2

Causes of elevated ESR
Infection
CTD
Malignancy
Pregnancy
Anemia
Obesity
Other
**non specific

8

C-Reactive Protein Quantative Lab value

Male = age / 50
Female = age / 50 + 0.6
Rises and falls more quickly than ESR

can be elevated in obesity, diabetes, malignancy, and cigarette smoking and heart disease.

Rises in about 4-6 hours in response to tissue injury and will normalize within the week once the inflammation has abated

9

Rheumatoid Factor

RF not used to measure RA disease activity, but higher titers can be associated with disease severity, erosions, extra-articular manifestations, disability

Not diagnostic
5% have false positive

10

Anti-Cyclic Citrullinated Peptide Antibodies anti-CCP

RA sensitivity—47-76%
specificity---90-96%

Can occur in active TB, SLE, Sjogren’s, Polymyositis, Dermatomyositis, Scleroderma

If (+) CCP progressive radiographic joint damage

11

Radiographic studies with RA

X-rays– standard of care

Ultrasound

Magnetic Resonance Imaging

12

Findings with X-rays

ulnar drift in hands
Symmetrical narrowing
Wrists/MCP/PIP
Mouse bite erosions
Soft and squishy
Pseudocystic
Can be present
Osteopenia

13

Early radiographic progression in RA

Joint-space narrowing and erosion are seen in 67% of patients within the first 2 to 5 years of disease

14

DMARD Pharmacologic Therapy

Corticosteroids– prednisone, methylprednisilone
Hydroxychloroquine-- Plaquenil™
Sulfasalazine -- Azulfidine™
Methotrexate Journal of Rheumatology July 18, 2010 “anchor drug”
Leflunomide -- Arava™
Azathioprine -- Imuran™

15

Biologic Response Modifiers Targets

TNF inhibitors
Etanercept (Enbrel™)
Infliximab (Remicade ™)
Adalimumab (Humira™)
Golimumab (Simponi™)
Certolizumab pegol (Cimzia™)
B cells
Rituximab (Rituxan™)
T cells
Abatacept (Orencia ™)
IL-6
Tocilizumab (Actemra™)

16

Biologic Response Modifiers Pre drug screening

CXR
PPD
Pneumovax
Influenza vaccine
Hepatitis serologies B and C

17

Biologics BRMs Side effect profile

Injection site/infusion reaction
Infection risk (bacterial, TB/other granulomatous, opportunistic, i.e. fungal)
?Malignancy risk
Demyelinating Ds, MS or Family Hx
Heart failure
Drug induced syndromes (ANA, dsDNA)
Cytopenias

18

When to refer to a rheumatologist

Uncertain diagnosis refer early

Confusing lab results

Uncomfortable with DMARD use

Considering use of a biologic

Patient not responding

Erosions or other radiographic changes

19

Take home points for RA

A careful history and physical can help you separate the difference between inflammatory and non-inflammatory arthritis. 

*Appropriately selected laboratory tests, joint arthrocentesis, and selected imaging studies can significantly aid in diagnosing persons with joint pain.

*Early treatment and/or referral for those with inflammatory arthritis is essential.

*Pts with RA and likely AS and PsA have higher risks for CVS disease and should be monitored annually.