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Flashcards in Rheumatoid Arthritis Deck (63):
1

What class of disease is RA?

Autoimmune, chronic, progressive

2

What things can often trigger the autoimmune mechanism of RA?

Smoking
Infection
Trauma

3

What does the autoimmune reaction in RA cause to happen?

Synovial Hypertrophy and chronic inflammation

4

Can extra-articular manifestations occur?

Yes

5

Where does RA usually initially present?

The small joints of the hands and feet

6

Does RA usually manifest symetrically?

Yes

7

In the history, when is the joint stiffness and pain worst with RA? What makes it better?

It is worst in the morning, and gets better with use.

8

Can larger joints be involved?

Not usually, but sometimes.

9

What are the presenting symptoms of RA?

Swollen, painful, stiff joints lasting 6 weeks or more

10

Is it more common in men or women?

Women

11

When is the peak onset of RA?

40-50 years old

12

How is RA diagnosed?

A combinaton of history (distribution, symptoms, time scale), examination (symetry, swelling, stiffness, pain), exclusion of differentials, and investigations.

13

What investigations can be done to help diagnose RA?

-Rheumatoid factor
-Bloods
-Anti CCP

14

What is rheumatoid factor?

Immune proteins (autoantibody) found in the blood

15

How often is RhF positive in oatients with RA?

70% of cases

16

What is the problem with RhF?

It is not very sensitive or specific

17

What is Anti-CCP?

Anti-cyclic citrullinated peptide - an antibody present in many cases of RA

18

How specific and sensitive is anti-CCP?

Very, in both cases.

19

What bloods test results would indicate RA?

-Anaemia
-Increased CRP
-Increased ESR
-Increased platelets

20

Why does joint pain happen in RA?

1. Swelling causing stretching of of joint capsule
2. Chemicals irritating the nerve endings

21

What can happen when the swelling subsides?

The joints are left unstable or unusually shaped

22

What percentage of RA patients get extra-articular manifestations?

40%

23

Where can nodules present in RA?

Elbows, lungs, CNS, cardiac, lymphadenopathy, vasculitis.

24

What vasculitidies can present with RA? (3)

-Digital arteritis
-Ulcers
-Pyoderma gangrenosum

25

What is pyoderma gangrenosum?

necrotic changes to the tissue causing deep ulcers that usually occur on the legs.

26

What extra-articular CVS features can occur in RA? (6)

-Pericarditis
-Myocarditis
-Endocarditis
-Conduction anomalies
-Coronary vasculitis
-Granulomatous aortitis

27

What systemic features may be present in RA?

-Fever
-Fatigue
-Weight loss

28

What is DAS28?

The 28 joint disease activity score

29

What is DAS28 used for?

Assessment of 28 joints used to measure the activity level of RA

30

What can improve long term outcomes in RA patients?

Early use of DMARDs and biological agents

31

What can be used for symptomatic relief?

NSAIDs (no effect on disease progression)

32

What therapies can be offered?

Specialised OT/PT

33

Can steroids be used in RA?

Yes, they can be useful for acute exacerbations

34

What are DMARDs?

Disease modifiying anti-rheumatic drugs

35

What is the first line therapy for RA?

DMARDs

36

Name 4 DMARDs

Methotrexate
Sulfasalazine
Hydroxychloroquine
Leflunomide

37

What is the main side effect of DMARDs? Why?

Immunosupression as it is potentially fatal

38

What must be monitored with DMARDs and why?

FBC and LFTs due to drugs S/Es of immune supression and hepatotoxicity

39

With which DMARD should the patient have a chest xray before treatment is started?

Methotrexate

40

Why do patients on methotrexate need a CXR before commencing treatment?

It can cause pneumonitis

41

How frequently is methotrexate given?

Weekly

42

How can methotrexate be administered?

PO, IM, or SubCut.

43

How is methotrexate excreted?

Renally

44

What can be used alongside methotrexate?

Other DMARDs - methotrexate is an anchor drug

45

Can methotrexate be given in pregnancy?

No, it is highly teratogenic

46

What must be prescribed alongside methotrexate in women of childbearing age?

Contraception

47

What side effects can be experienced with Sulfasalazine?

Rash
Decreased sperm count
Oral ulcers
GI upset

48

Is sulfasalazine teratogenic?

No

49

What is sulfasalazine designed to do? How?

It is a congugate - one part is designed to fight infection, the other to relieve pain and stiffness

50

What are the side effects of Leflunomide?

Teratogenicity in men and women, oral ulcers, hypertension, hepatotoxicity

51

What are the side effects of Hydroxychloroquine? What should be done?

Retinopathy.
Pre treatment and annual eye screen.

52

Who can initiate biological agents?

Specialist rheumatologists

53

What are the 4 classes/mechanisms of biological agents for RA?

TNF-alpha inhibitors
B cell depletion
IL-1/IL-6 inhibition
Inhibition of T-cell co-stimulation

54

Which TNF-alpha inhibitors are available for treating RA?

Infliximab
Etanercept
Adalimumab

55

When can TNF-alpha inhibitors be used as monotherapy?

When methotrexate is contraindicated

56

What can be a problem with TNF-alpha inhibitors?

The response to them may not be sustained over time

57

Which agent for RA works by B cell depletion?

Rituximab

58

How is rituximab used?

In combination with methotrexate, and in severe RA if DMARDs and TNF-alpha blockers have failed

59

Which IL-6 inhibitor is used?

Tocilizumab

60

What needs to be monitored for when using tocilizumab?

Hypercholesterolaemia

61

When are TNF-alpha blockers contraindicated in RA?

Moderate or severe heart failure
Severe infections

62

When is methotrexate contra-indicated?

Active infection
Ascites
Immunodeficiency syndromes
Significant pleural effusion

63

What are the side effects of biological agents?

Serious infection
Reactivation of TB
Reactivation of Hep B
Worseing Heart Failure
Hypersensitivity