Flashcards in Rheumatoid arthritis Deck (15):
1
Define
Chronic systemic inflammatory disease with symmetrical, deforming, peripheral polyarthritis
2
Predisposing
1. Genetic risk
2. Environmental risk
3. Autoimmune risk
3
Pathophysiology
1. Perivascular inflammaT
infiltrate (T, B, dendritic, macroP)
2. Neovascularisation, hemosiderin
3. Organising fibrin covering synovium
and in joint space (rice bodies)
4. neutrophils in synovium (TH17 + number)
5. osteoclasts subchondral: cysts,'erosions
osteoporosis
6. pannus erodes cartilage
7. Eventually bridging two bones->ossifies
4
Radiographic features
1. Soft tissue swelling
2. Joint space narrowing
3. Erosions
4. Periarticular osteoporosis
5. Subluxation of joints
5
Manifestation of rheumatoid vasculitis
Digital arteries--> peripheral
ulcers, gangrene
Vasa nervorum-->peripheral
neuroathy
Leukocytoclastic venitis-->
purpura, ulcer,
nail bed infarcts
6
Clinical features
1. Aged 50-55
2. Female commonly
3. Joint pain/swelling, symmetrical, small joints
4. Morning stiffness
5. Fatigue, fever, weight loss
6. Pericarditis, pleurisy
7
Examination
1. Swollen MCP, PIP, wrist, MTP
2. Tenosyovitis, bursitis
3. Ulnar deviation
4. Boutonniere and swan neck deformity
5. Z deformity thumb
6. Atlanto-axial subluxation
7. Nodules
8. Lymphadenopathy
9. Vasculitis
10. Fibrosing alveolitis
11. Raynauds, carpal tunnel
12. Peripheral neuropathy
13. Splenomegaly
14. Episcleritis, scleromalacia, keratoconjunctivitis
15. Osteoporosis
8
Investigations
1. RF->positive in 60-70% of patients
2. anti-CCP->positive in 70%
3. Radiographs
4. FBC->anemia, +PLT
5. +ESR/CRP
9
Diagnostic criteria
For classification purposes, patients are said to have RA if they satisfy at least 4 of these 7 criteria (criteria 1 to 4 must have been present for ≥6 weeks):
1. Morning stiffness: lasting ≥1 hour before maximal improvement.
2. Arthritis of 3 or more joint areas: simultaneously have had soft tissue swelling or fluid, observed by a physician. The 14 possible areas are right or left proximal interphalangeal (PIP), metacarpophalangeal (MCP), wrist, elbow, knee, ankle, and metatarsalphalangeal (MTP) joints.
3. Arthritis of hands: at least 1 swollen area in a wrist, MCP, or PIP.
4. Symmetric arthritis.
5. Rheumatoid nodules: subcutaneous nodules over bony prominences or extensor surfaces or in juxta-articular regions observed by a physician.
6. Serum rheumatoid factor.
7. Radiographic changes: typical changes in posteroanterior hand and wrist radiographs; must include erosions or unequivocal bony decalcification localised in or most marked adjacent to the involved joints.
10
Management
1. Refer early to rheumatologist
2. Score disease activity with DAS28
3. Early use of DMARDS and biologic agents
4. Steroids for acute exacerbations->don't delay diagnosis
5. NSAIDS for analgesia->try several if one doesn't work.
In early, give fish oil + paracetamol + NSAID
6. Regular exercise, weight loss, diet, smoking cessation, reduce alcohol->Reduce CV risks. Consider BP/lipid management
7. Regular monitoring for drug toxicity and osteoporosis and atherosclerosis->BMD, lipids, glucose, BP, BMI,waist circumference
FBC
LFTs
Opthalmologist (hydroxychloroquine)
8. Assess fatigue, sleep, relationships, work, social
9. Patient education
10. Referrals: rheumatologist, orthopedics, physiotherapist, occupational therapist, social worker
11
Indicators of poor prognosis
1. High RF and anti-CCP
2. Sustained +ESR, CRP
3. >20 swollen joints
4. Early functional impairment
5. Erosions of imaging
12
DMARD options
1. Methotrexate + folic acid
2. Hydroxychloroquine, sulfasalazine if methotrexate contraI/not tolerated
13
Biologics
Use if remission not acheived with DMARDS
1. Abatacept
2. Adalimumab
3. Certolizumab
4. INfliximab
14
Symptom management
1. NSAID
2. Fish oil
3. Paracetamol
4. Codeine or tramadol
5. Amitryptiline
15