Flashcards in Rheumatoid Arthritis Deck (63):
What class of disease is RA?
Autoimmune, chronic, progressive
What things can often trigger the autoimmune mechanism of RA?
What does the autoimmune reaction in RA cause to happen?
Synovial Hypertrophy and chronic inflammation
Can extra-articular manifestations occur?
Where does RA usually initially present?
The small joints of the hands and feet
Does RA usually manifest symetrically?
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.
Can larger joints be involved?
Not usually, but sometimes.
What are the presenting symptoms of RA?
Swollen, painful, stiff joints lasting 6 weeks or more
Is it more common in men or women?
When is the peak onset of RA?
40-50 years old
How is RA diagnosed?
A combinaton of history (distribution, symptoms, time scale), examination (symetry, swelling, stiffness, pain), exclusion of differentials, and investigations.
What investigations can be done to help diagnose RA?
What is rheumatoid factor?
Immune proteins (autoantibody) found in the blood
How often is RhF positive in oatients with RA?
70% of cases
What is the problem with RhF?
It is not very sensitive or specific
What is Anti-CCP?
Anti-cyclic citrullinated peptide - an antibody present in many cases of RA
How specific and sensitive is anti-CCP?
Very, in both cases.
What bloods test results would indicate RA?
Why does joint pain happen in RA?
1. Swelling causing stretching of of joint capsule
2. Chemicals irritating the nerve endings
What can happen when the swelling subsides?
The joints are left unstable or unusually shaped
What percentage of RA patients get extra-articular manifestations?
Where can nodules present in RA?
Elbows, lungs, CNS, cardiac, lymphadenopathy, vasculitis.
What vasculitidies can present with RA? (3)
What is pyoderma gangrenosum?
necrotic changes to the tissue causing deep ulcers that usually occur on the legs.
What extra-articular CVS features can occur in RA? (6)
What systemic features may be present in RA?
What is DAS28?
The 28 joint disease activity score
What is DAS28 used for?
Assessment of 28 joints used to measure the activity level of RA
What can improve long term outcomes in RA patients?
Early use of DMARDs and biological agents
What can be used for symptomatic relief?
NSAIDs (no effect on disease progression)
What therapies can be offered?
Can steroids be used in RA?
Yes, they can be useful for acute exacerbations
What are DMARDs?
Disease modifiying anti-rheumatic drugs
What is the first line therapy for RA?
Name 4 DMARDs
What is the main side effect of DMARDs? Why?
Immunosupression as it is potentially fatal
What must be monitored with DMARDs and why?
FBC and LFTs due to drugs S/Es of immune supression and hepatotoxicity
With which DMARD should the patient have a chest xray before treatment is started?
Why do patients on methotrexate need a CXR before commencing treatment?
It can cause pneumonitis
How frequently is methotrexate given?
How can methotrexate be administered?
PO, IM, or SubCut.
How is methotrexate excreted?
What can be used alongside methotrexate?
Other DMARDs - methotrexate is an anchor drug
Can methotrexate be given in pregnancy?
No, it is highly teratogenic
What must be prescribed alongside methotrexate in women of childbearing age?
What side effects can be experienced with Sulfasalazine?
Decreased sperm count
Is sulfasalazine teratogenic?
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
What are the side effects of Leflunomide?
Teratogenicity in men and women, oral ulcers, hypertension, hepatotoxicity
What are the side effects of Hydroxychloroquine? What should be done?
Pre treatment and annual eye screen.
Who can initiate biological agents?
What are the 4 classes/mechanisms of biological agents for RA?
B cell depletion
Inhibition of T-cell co-stimulation
Which TNF-alpha inhibitors are available for treating RA?
When can TNF-alpha inhibitors be used as monotherapy?
When methotrexate is contraindicated
What can be a problem with TNF-alpha inhibitors?
The response to them may not be sustained over time
Which agent for RA works by B cell depletion?
How is rituximab used?
In combination with methotrexate, and in severe RA if DMARDs and TNF-alpha blockers have failed
Which IL-6 inhibitor is used?
What needs to be monitored for when using tocilizumab?
When are TNF-alpha blockers contraindicated in RA?
Moderate or severe heart failure
When is methotrexate contra-indicated?
Significant pleural effusion