Flashcards in Rheumatoid Arthritis Deck (29):
What type of disease is RA?
What does it target?
• Autoimmune, chronic systemic
• Inflammatory disease, symmetrical
• Targets synovial tissues, diarthrodial joints
• Polyarthritis, extra-articular features
Systemic features of RA
-non specific labs
• Fatigue, fever, anemia
• Elevated acute phase reactants (ESR, CRP)
• Constitutional symptoms – malaise, myalgia,
• Affected joints are swollen, warm and tender over PIP and MCP joints
Immunopathology/pathogenesis of RA (two)
• RF produced by RA synovium. RF’s fix complement. Complement consumed in RA joint; recruit PMN’s.
• Anti-cyclic citrullinated peptides
“B” lymphocytes produce autoantibodies, cytokines (TNF alpha, IL-1, IL6), pro-inflammatory cytokines synovial proliferation, increase synovial fluid, leads to ___ that invades cartilage and bone.
leads to pannus in RA
Lab tests to order for RA dx
• Hepatitis panel
What two imaging tests should be ordered in RA - to detect what?
• X-rays of hands and feet – detect symmetrical involvement of MCP/MTP joints; erosions
• CT – more sensitive detecting erosions
4 treatment progressions of RA
• Begin NSAID for pain control
• Early use of DMARD
• May need low dose of steroid for a few weeks
• Monitor progress and toxicity
Three types of Rheumatoid Synovitis
Bursitis, tendinitis, synovitis
Significant cause of mortality in RA
! Heart disease (60%) - CAD, HF, pericarditis due to endothelial damage from chronic inflammation !
-Renal disease (7.8%)
-GI disease (4%)
Who should be tested for RA? Classification criteria
What is definite RA?
1. Have at least one (1) joint with definite clinical synovitis
2. With synovitis not better explained by another disease
A score > 6/10 = definite RA
Serology + APR + Duration of Symptoms
Describe articular manifestations of RA.
-Typically starts in hands/feet (MCP, PIP, MTP)
-Later = larger joints, wrists, knees, elbows, ankles, hips, shoulders
Part of spine that is affected by RA
define swan neck and boutonniere
• Swan neck (hyperextension of PIP joints)
• Boutonniere (button hole
deformity) (hyperflexion of PIP joints)
Rheumatoid nodules = RF+/-?
RF nodules in knee/popliteal
**Describe clinical manifestations of RA - describe the PE of joints, what type of joints, what time of day? Is this abrupt or insidious?
• Pain, swelling, warmth in multiple small joints (less than 3) of hands and/or feet
• Morning stiffness greater than one (1) year
• Less than 10% have abrupt onset of disease
**Dx of RA is active signs of inflammation for at least __ weeks.
**Extra-Articular Manifestations of RA
-more common in what type of RA patient
-what are the manifestations?
• More common in RF positive or Anti-CCP positive
• Skin – subcutaneous nodules; extensor surface of forearm
What is this:
Tender reddish purple papule; leads to necrotic, non-healing ulcer
What is this:
Purpura, petechial, splinter hemorrhages, digital infarct
What is RA + pneumoconiosis + pulm nodules?
What is it due to?
Felty Syndrome. Nodular densities after exposure to coal or silica dust.
What is keratoconjuctivitis sicca?
Extra-articular manifestation of RA due to a secondary Sjogrens Syndrome or SLE (Dry eyes)
- dry eyes, damage to eye surface
- dry mouth, increased tooth decay
Tests for Sjogrens
• Ro/SS-a, La/SS-B (both associated with salivary gland involvement)
• Schirmers test (tear test)
• Slit-lamp exam
Tx for Sjogren's Syndrome
Anti – Inflammatory &
While there is NO SINGLE finding on PE or lab that is pathogneumonic, describe lab findings in RA
• RF positive
• Anti-CCP antibody (remember – 15%-20% of RA patients are negative for these antibodies)
• Inc. ESR or CRP parallels activity of disease
• Anemia (NC-NC, chronic)
• Thrombocytosis (acute phase reactant)
• ANA+ (30% of RA patients)
• Leukopenia / Granulocytopenia
• Low glucose in body fluids
• Synovial fluid – 2/3 PMN’s; WBC’s 5000 – 100,000/mm3
Tx of RA
(which can be used in pregnancy?)
No cure - treat early and to keep in remission; PT/OT
DMARD + bridging therapy (NSAIDs, then CS)
**PREG? YES, then use **antimalarial (hydrochlorquine) and sulfasalazine
**PREG? NO, then use MTX, leflunomide (pyrimidine antag)
(immunosuppressants etanercept, infliximab, adalimumab, rituximab)
-ANALGESICS are necessary to control pain
**Define progression of RA management
• Define extent of joint and extra-articular involvement
• Full dose of NSAID
• Early use of DMARD
• Add a biologic agent
• Low does steroids – flares/bridge
• Adequate pain management
• Monitor progress/toxicity