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General Medicine Pt2 > Rheumatoid arthritis > Flashcards

Rheumatoid arthritis Flashcards

1
Q

Give three presenting features of joint synovitis in rheumatoid arthritis

A
  • Symmetrical peripheral polyarthritis
    • Warm, erythematous joints
    • ‘Boggy’ swelling around joints
    • Inability to make a fist/flex fingers
  • Typically involving the small joints of the hands and feet
    • Most commonly affecting MCP, PIP, wrist, and MTP joints
    • DIPJ are spared
  • Early morning stiffness >1hr
  • Joint pain worse at rest and in the morning
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2
Q

Outline the ACR/EULAR 2010 criteria for rheumatoid arthritis

A
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3
Q

Provide three hand signs in rheumatoid arthritis

A
  • Inability to make a fist or flex fingers
  • +ve MCP squeeze test
  • Sparring of DIPJ
  • Ulnar deviation of MCPJ
  • Dorsal subluxation
  • Boutonniere and swan-neck deformity of fingers
  • Z-deformity of thumb
  • Involvement of large joints
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4
Q

List three risk factors for rheumatoid arthritis

A
  • Female (pre-menopause 3:1)
  • Peak age 30-50
  • Hereditary link in 1o relatives
  • HLA-DR4 associated
  • Smoking
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5
Q

What antibody is highly specific for rheumatoid arthritis?

A

Anti-cyclic citrullinated peptide (Anti-CCP) antibody

98% specificity

Associated with more severe RA and smokers

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6
Q

List 4 radiological findings seen with rheumatoid arthritis

A
  • Symmetrical
  • DIPJ sparring
  • Soft tissue swelling
  • Juxta-articular osteoporosis
  • Erosions of periarticular bare areas
  • Osteopenia (early)
  • Narrow joint space (late)
  • Dorsal subluxation
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7
Q

List six extra-articular features of rheumatoid arthritis

A
  • Rheumatoid nodules: typically elbows, fingers
  • Muscle wasting around joints
  • Peripheral neuropathy, carpal tunnel syndrome; trigger finger
  • Atlantoaxial subluxation
  • Pericarditis; pericardial effusion; atherosclerosis
  • Pulmonary fibrosis, pleural effusion
  • Amyloidosis
  • Vasculitis
  • Sjogren’s syndrome, scleritis and episcleritis
  • Achilles tenosynovitis
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8
Q

Request four investigations for rheumatoid arthritis

A
  • RF; anti-CCP: prognostic markers
  • FBC - normocytic anaemia and reactive thrombocytosis
  • U+Es; LFTs
  • CRP; ESR: usually elevated, treatment markers
  • X-ray of hands and feet
  • USS or MRI - early soft tissue swelling, synovitis
  • CXR: exclude lung manifestations of RA
  • Health Assessment Questionnaire (HAQ): determine baseline
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9
Q

When is a rheumatoid arthritis flare suspected?

A

Worsening:

  • Stiffness, pain, joint swelling; or general fatigue
  • Signs of joint synovitis; tenderness; or loss of function
  • Inflammatory markers raised from baseline
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10
Q

Describe the management of a flare of rheumatoid arthritis

A

Must exclude septic arthritis

  • Short-term glucocorticoids:
    1. Intra-articular glucocorticoid injection
    2. IM glucocorticoid
    3. PO prednisolone
  • Consider NSAIDs ± PPI
  • Refer to rheumatologist if recurs
  • Refer for physiotherapy
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11
Q

What is the medical management of rheumatoid arthritis?

A
  1. cDMARD monotherapy: ideally within 3 months of symptoms
    • eg. MTX; leflunomide; sulfasalazine
    • Can take up to 2-3 months to have effect
    • Consider steroid ‘bridging’ treatment
  2. Step-up strategy: additional cDMARD
    • Early combination treatment slows disease progression
  3. Consider biological DMARDs
    • eg. Sarilumab (IL-6); adalimumab, infliximab (TNF)

  • DMARDs require regular blood monitoring*
  • Women of childbearing age (and men if trying to conceive) should be given contraceptives whilst on MTX and for 3/12 after stopping*
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12
Q

Name two cDMARDs are available for rheumatoid arthritis

A
  • Methotrexate
  • Sulfasalazine
  • Leflunomide
  • Hydroxychloroquine: consider if mild or palindromic disease
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13
Q

What is the dosing regimen of methotrexate?

A
  • Methotrexate once weekly (Monday)
  • Folic acid once weekly (Friday)

MTX inhibits folic acid reductase

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14
Q

List three side effects of methotrexate

A
  • Hair loss
  • Immunosuppression
  • Liver dysfunction
  • Lung fibrosis
  • Neural tube defects (teratogenic)
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15
Q

What monitoring is required whilst taking methotrexate?

A
  • Baseline CXR - check for pulmonary fibrosis
  • FBC: neutropenia and thrombocytopenia
  • U+Es: renal impairment
  • LFTs: hepatitis and cirrhosis

Repeat bloods at 2/4/8 wks, then 8-weekly

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16
Q

Can methotrexate be taken during pregnancy?

A

No, as it is highly teratogenic and abortifacient

Women of childbearing age (and men if trying to conceive) should be given contraceptives whilst on MTX and for 3/12 after stopping

17
Q

How long do DMARDs typically take to provide a beneficial effect?

A

2-3 months

18
Q

Name three side-effects of NSAIDs

A
  • Dyspepsia
  • Rash
  • Peptic ulcers
  • Gastric erosions: offer longterm PPIs
  • Perforation and bleeding
  • Asthma exacerbation
19
Q

Name three side-effects of corticosteroids

A
  • Short-term:
    • Insomnia; psychosis; mania; depression
    • Gastritis; peptic ulceration; acute pancreatitis
    • Thrush
    • Impaired glucose regulation; Cushing’s syndrome
  • Long-term:
    • Osteoporosis; AVN of femoral head
    • Adrenal insufficiency: do not stop abruptly
    • Immunosuppression
    • Cataracts
20
Q

What is the DAS28 score?

A

A measure of disease activity in rheumatoid arthritis, based on:

  • Number of tender joints
  • Number of swollen joints
  • CRP/ESR level
  • Visual analogue scale of pain and discomfort (0-100)

DAS28 score greater than 5.1 (inadequate response) on 2+ DMARDs is the indication for commencing biological therapies

21
Q

Name two biological therapies available for RA?

A
  • Anti-TNF: Infliximab, adalimumab, etanercept, golimumab
  • Anti-CD20: Rituximab
  • IL-6 antagonist: Sarilumab
22
Q

What is the indication for biological therapies in RA?

A

DAS28 score greater than 5.1 (inadequate response) to at least 2 DMARDs

23
Q

What investigation should be done prior to starting anti-TNF therapy for RA?

A

QuantiFERON Gold for latent and active TB, and CMV

Anti-TNF therapy can reactivate any latent TB and other infections, so this must be treated if present prior to starting anti-TNF.

24
Q

What pre-operative screening should be done in patients with rheumatoid arthritis and why?

A

Anteroposterior and lateral cervical spine radiographs

  • Atlantoaxial subluxation is a rare complication of rheumatoid arthritis
    • Can lead to cervical cord compression
  • Ensure the patient goes to surgery in a C-spine collar and the neck is not hyperextended on intubation

General Medicine Pt2 (15 decks)

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