Rheumatoid Arthritis Flashcards
(30 cards)
Feature of rheumatoid arthritis
Symmetrical
Distal
Polyarthritis (>=5 joints)
EMS >1h
>6w of symptoms
Rheumatoid nodules
What is rheumatoid factor?
Anti-Fc portion antibodies
Always positive in patients with rheumatoid nodules
What are rheumatoid nodules?
Collections of macrophages/necrotic cells
X-ray features of rheumatoid arthritis
Osteopaenia, erosions, narrowing of joint space
Thumb subluxation
Soft tissue swelling
Blood tests for RA
RF
Anti-CCP
CRP/ESR
FBC (anaemia of chronic disease, thrombocytosis)
Presentation of rheumatoid
Onset over days-weeks
Preferentially affects wrist, MCP, PIP
May be palindromic (i.e. migratory) or acute (esp in women)
Consider in patients with recurrent soft-tissue problems (e.g. de Quervain’s, frozen shoulder, etc…)
Evaluation/workup for RA
FHx + cigarettes (F + F)
DAS28: Tender + swollen joint count, VAS, CRP/ESR
>5.1 severe, <2.6 remission
Early management of RA
Methylprednisolone IM depot 80-120mg > time to titrate DMARDs
Systemic extra-artiuclar features of RA
Fever
Weight loss
fatigue
Anaemia
Thrombocytosis
Amyloid
Splenomegaly
Lymphadenopathy
Cardiovascular features of RA
Pericarditis
Coronary fvasculitis
Conduction abnormalities
Aortitis
Accelerated atherosclerosis + IHD
Neurological features of RA
Cervical cord compression
Mononeuritis multiplex
Compression neuropathy (eg carpal tunnel)
Pulmonary features of RA
Nodules
Fibrosis
Effusions
Caplan’s syndrome (homoegenous nodules on X-ray)
Poor prognostic features of RA
Systemic features
Early erosions
Insidious onset
Persistent activity >12mo
Conventional DMARDs for RA
Methotrexate + folate
Hydroxychloroquine
Sulphasalazine
Leflunomide
SE + monitoring for MTX
FBCs (myelosuppression)
LFTs (hepatitis)
Lungs (pneumonitis), must have pretreatment CXR
Not allowed in pregnancy or child-bearing men (Affects M/F fertility!)
Must be stopped 3mo before pregnancy
Hydroxychloroquine monitoring
Optician review for macular damage
No blood tests necessary!
Safe in pregnancy but NOT breastfeeding
Sulphasalazine monitoring
Myelosuppression (FBC)
Hepatitis (LFTs)
Rash
Leflunomide monitoring
FBC (myelosuppression)
Hepatitis (LFTs)
Diarrhoea
Teratogenic (M/F)
Indications for biologics in RA
DAS >5.1
Failed two DMARDs (incl. methotrexate)
>6/12 illness
MUST DO CXR BEFORE FIRST-LINE
1st-line biologics in RA
Anti-TNF
Infliximab
Adalimumab
Etanercept (decoy receptor)
MUST DO CXR to rule out TB
2nd line biologics in RA
Rituximab (anti-CD20)
Abatacept (CTLA-4 fused with IgG; natural T-cell modulator)
Tocilizumab (anti-IL6R)
Adverse SEs of biologics
Immunosuppression
Reactivation of TB/HBV - esp. anti-TNF
Worsening HF
Ocular features of RA
Scleritis
Episcleritis
Keratoconjunctivitis sicca (dry eye disease)
EULAR vs ACR criteria for RA
EULAR includes
- ACPA,
- !!CRP!!
- counts joint involvement
- has duration criterion
