Rheumatoid Arthritis Flashcards by Eilidh Selfridge

What joints are mainly affected by RA

Peripheral joints
e.g. MCP, PIP, wrists
NOT the DIP though as too small and not enough synovium

Has to be joints with sufficient synovium as this is what gets inflamed
Larger joints like elbow and shoulder can also be affected

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RA is usually symmetrical - true or false

True
e.g. both hands would be affected
Also typically polyarticular - multiple joints

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What is the main structure involved in RA

The synovium

Lies inside of a synovial joint capsule

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Which joints in the body are synovium lined

Hand, wrists, shoulders, C1, C2, TMJ, hip, knees, feet (MTPs) and ankles

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What is the main antibodies involved in RA

Rheumatoid factor

Anti-CCP (more specific)

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Describe the inflammatory process in RA

The synovium gets inflamed and becomes a spongy mass with increased blood flow
This brings even more inflammatory cells to the area
If not treated it can stimulate osteoclasts which erode the bone leading to deformity

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What is a pannus

Thickened synovium due to granulation tissue

Brought on by inflammation

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How is early RA defined

Less than 2 years since symptoms started

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What is the significance of the first 3 months of RA presentation

This is therapeutic window of opportunity
If you catch the disease and start treating it you can alter progression and make it less aggressive - prevent bone damage/erosions

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How can you diagnose RA

History and examination are key 
Routine blood tests 
Inflammatory markers 
Autoantibody test - RF and anti-CCP
Imaging

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What results may you see in a FBC on someone with RA

Anaemia - due to chronic inflammation, bone marrow is under stress
Will be normochromic and normocytic
High platelets - non-specific marker of inflammtion

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What are some common systemic symptoms of RA

SOB

Chest pain

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What are the clinical signs of RA

Prolonged morning stiffness - longer than 1hr - which eases with movement
Involvement of small joints of hands and feet.
Symmetric distribution.
Positive compression tests of MCP and MTP joints.
Trigger finger
Systemic symptoms

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What are some common joint signs of RA

Swelling - feels spongy
Tenderness
Symmetrical involvement
Not able to make fists (due to tendon involvement)

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What is tenosynovitis

Inflammation of a tendon
Common in the extensor tendon
Can become swollen and sore
If not treated the tendons fray and tear

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Describe anti-ccp antibodies

Very specific for RA - 98%
Can be present before symptoms appear
Patients will remain positive for the antibody even after treatment
Related to disease activity and more likely to be associated with erosion - worse prognosis

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Describe how X-rays are used in RA

Done in all patients
May see soft tissue swelling, periarticular osteopenia (early disease) and/or erosions (late)

Disadvantage is absence of findings in early disease

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Describe how US is used in RA

More sensitive than X ray
More likely to spot synovitis in early disease - shows increased blood flow associated with inflammation
Can differentiate between synovial effusions secondary to OA and
synovitis secondary to RA
Detects more MCP erosions

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Describe how MRI scans are used in RA

Most sensitive investigation - gold standard
However very expensive so used sparingly
Can monitor disease activity, detect erosions early, asses tendon integrity and distinguish synovitis

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What is the DAS28 score

A score that assesses disease activity in RA
Investigates 28 joints in the body
Also includes how patient feels on a scale and an inflammatory marker (CRP or ESR)

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What are the thresholds for the DAS28 score

> 5.1 Active disease.
3.2- 5.1 Moderate disease.
2.6-3.2-Low disease activity.
Less than 2.6 Remission.

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Give an overview of RA management

Recognise early 
refer to rheumatology 
Start on DMARDs - early and aggressive in therapeutic window
Treat symptoms with NSAIDs and steroids
Multidisciplinary approach

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Describe the steps of RA treatment

Step 1 - NSAID for symptoms
Step 2 - add steroid
Step 3 - add first DMARD
Step 4 - add another DMARD etc

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How are steroids used in RA

Study These Flashcards

Improve symptoms and reduce radiological damage
Used in combination with DMARDs - bridge as DMARD takes effect
Given orally, IM or IA
Not used long term due to side effects

Name 4 common DMARDs

Methotrexate Sulfasalazine Hydroxychloroquine Leflunomide

What DMARD is first line

Methotrexate

In what order are DMARDs given

``` 1st = Methotrexate 2nd = Sulfasalazine (used second line or alongside MTX) 3rd = Hydroxychloroquine (never used alone as weak) ```

Patients on DMARDs need regular monitoring - true or false

True Drugs have many side effects MTX - LFT and FBC

What are some side effects of Methotrexate

``` Nausea, vomiting and diarrhoea Rash Mouth ulcers Alopecia Increased infection risk ``` Liver function derangement - check LFT regularly Bone marrow suppression Can cause pneumonitis - allergic inflammatory reaction

What are biologic agents

Specialised drugs that inhibit parts of the immune pathway such as cytokines and cells Can be used in RA

What is the major risk with biologic agents

Increased infection risk as immune system is inhibited Can reactivate latent TB etc

How are people recommended for biologic treatment

Expensive treatment so must meet certain criteria | Failure to respond to 2 DMARDs and a DAS28 greater than 5.1 on 2 occasions

What are the main complications of untreated RA

Severe joint damage and deformity | e.g. swan necking

What signs of RA may be seen on imaging

``` Soft tissue swelling Periarticular osteopaenia Bone demineralisation - darker on x-ray Inflammatory pannus - can destroy bone Joint deformity and erosions Ankylosis - joint fusion ```

What causes the soft tissues to swell in RA

Synovial proliferation and reactive joint effusion

What causes bone demineralisation in RA

Hyperaemia | Results in periarticular osteoporosis (around joint)

Which joints commonly fuse in RA

Sacro-iliac | Spine

Why isn't it good if you see RA features on X-ray

Mostly show bone and joint damage that's already happened Hard to pick up early changes By this stage its often too late to modify or prevent the disease

What are the seronegative arthritis'

Psoriatic arthritis - affects small joint of hands and feet Ankylosing spondylitis Reiter's syndrome - affects lower limb joints

What early arthritic signs can be seen on US

Thickening of synovium Increased blood flow

What early arthritic signs can be seen on MRI

Bone marrow oedema | Early inflammation and bone erosion

Why do patients with RA get early morning stiffness

Increased viscosity of synovial fluid secondary to inflammation Eases with movement

Which age groups can be affected by RA

RA can affect any | age group and even children

RA is more common in men - true or false

False | More common in women - 3:1

Smokers | are more likely to be more resistant to treatment in RA - true or false

True | Also more likely to have anti-CCP antibodies

Rheumatoid factor may be positive in which other conditions

Sjogren`s syndrome, vasculitis, infections and | malignancy

Which joints are typically the first to erode in RA

The 5th MTP joint in the foot and the ulnar styloid in the wrist Hand and feet X-ray are typically used as the baseline as a result

Which other tablet must be taken alongside methotrexate

Folic acid MTX prevents it from entering cells MTX given as a weekly dose followed by folic acid at least 24 hours later on the other 6 days

Methotrexate is contraindicated in which patients

Severe lung disease - due to pneumonitis risk Women of childbearing age not on contraception - highly teratogenic Alcoholics - hepatotoxic so they are higher risk

Sulfasalazine is contraindicated in which patients

Those with with allergy to septrin G6PD deficiency Best avoided in autoimmune diseases like SLE as can cause drug induced lupus

List side effects of sulfasalazine

``` Diarrhoea Rash Mouth ulcers Headache It can cause cytopaenias and liver abnormalities ```

Hydroxychloroquine is used alone in RA

False - used as triple therapy with MTX and sulfa However in autoimmune diseases like SLE and Sjogren`s, it has been shown to reduce fatigue, improve arthralgia and reduce progression of the disease and is used in isolation.

List side effects of hydroxychloroquine

GI side effects and rash | Very rarely maculopathy - patient must get annual eye tests

Why must people be screened for TB before starting biologics

Risk of reactivation due to drug effect on immune system | Comprimises the granuloma containing the TB as held together by TNF - therefore anti-TNF high risk

What is the major contraindication to starting biologic therapy

Any active infection

How long do DMARDs typically take to work

12 weeks | Steroids are given as a bridge

When are RA patients given long term steroids

If they have severe organ involvement such as lung or kidney involvement

List some side effects of steroids

cataracts, diabetes, weight gain, osteoporosis (consider bone protection) etc

Why must older patients with RA have DEXA screening

Risk of osteoporosis due to osteoclastic activation by | inflammatory cytokines seen in RA

Rheumatoid Arthritis Flashcards

(59 cards)