Rheumatoid Arthritis Flashcards

(57 cards)

1
Q

What is rheumatoid arthritis?

A

An autoimmune condition that causes chronic inflammation of the synovial lining of the joints, tendon sheaths and bursa.

It is inflammatory arthritis.

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2
Q

What is synovial inflammation called?

A

Synovitis

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3
Q

What is the pattern of Rheumatoid arthritis across the body?

A

Tends to be symmetrical and affects multiple joints

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4
Q

What does inflammation of tendon increase the risk of in RA?

A

Tendon rupture

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5
Q

Men or women more likely to be affected by Rheumatoid arthritis?

A

Three times more common in women than men

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6
Q

Which age group is most commonly affected by rheumatoid arthritis?

A

Most common in middle age although it can develop at any age

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7
Q

What are the genetic associations of Rheumatoid arthritis?

A

HLA DR4 - A gene present in RF positive patients

HLA DR1 - A gene occasionally present in RA patients

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8
Q

What antibodies can be present in rheumatoid arthritis?

A

Rheumatoid factor (RF):

  • Present in 70% patients
  • RF is often IgM which targets Fc portion of the IgG antibody. This cause activation of the immune system against IgG and systemic inflammation.

Anti-citrullinated cyclic peptide antibodies (anti-CCP antibodies):

  • More sensitive and specific than RF
  • Often pre-date the development of rheumatoid arthritis and give an indication the patient will go on to develop rheumatoid arthritis at some point.
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9
Q

Presentation within rheumatoid arthritis?

A

1) Symmetrical distal polyarthropathy, often small joints of the hand and feet:
- Pain, which is worsened with rest but improves with activity, morning pain.
- Swelling
- Stiffness

2) Systemic symptoms:
- Fatigue
- Weight loss
- Flu like illness
- Muscle aches and weakness

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10
Q

What is palindromic rheumatism?

A

Self limiting short episodes of inflammatory arthritis with joint pain, stiffness and swelling typically affecting only a few joints.

Typically last 1-2 days

Having positive antibodies, RF and anti-CCP, may indicate that it will process to rheumatoid arthritis

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11
Q

Which joints are commonly affected in rheumatoid arthritis?

A

> Proximal interphalangeal (PIP) joints

> Metacarpophalangeal (MCP) joints

> Wrist and ankle

> Metatarsophalangeal (MTP) joints

> Cervical spine

> Large joints can also be affected such as the knee, hips and shoulders

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12
Q

Which joint in the hands if affected indicate osteoarthritis and not rheumatoid arthritis?

A

The distal interphalangeal (DIP) joints are almost never affected in rheumatoid arthritis.

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13
Q

What is atlantoaxial subluxation?

A

Atlantoaxial subluxation occurs in the cervical spine. It is due to local synovitis and damage to the ligaments and bursa around the odontoid peg of the axis.

The axis (C2) and the odontoid peg (C1) shift within the atlas. Subluxation can cause spinal cord compression, this is a medical emergency.

Changes can be visualised on MRI scans.

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14
Q

Signs in the hand of Rheumatoid arthritis?

A

1) Palpation of the synovial around the joint will give a boggy feeling
2) Z-shaped deformity to the thumb
3) Swan neck deformity (Hyperextended PIP with flexed DIP)
4) Boutonnieres deformity (Hyperextended DIP with flexed PIP)
5) Ulnar deviation of the fingers at the MCP joint

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15
Q

Extra-articular manifestations of rheumatoid arthritis?

A

1) Pulmonary fibrosis with pulmonary nodules (Caplan’s syndrome)
2) Bronchiolitis obliterates (inflammation causing small airway destruction)
3) Fetty’s syndrome (RA, neutropenia and splenomegaly)
4) Secondary sjogren’s syndrome (AKA sicca syndrome)
5) Anaemia or chronic disease
6) Cardiovascular disease (Pericarditis, myocarditis, endocarditis and conduction defects)
7) Eye manifestations
8) Rheumatoid nodules
9) Lymphadenopathy
10) Carpel tunnel syndrome
11) Amyloidosis

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16
Q

Extra-articular manifestations of rheumatoid arthritis - Eye?

A

1) Scleritis
2) Episcleritis
3) Keratitis
4) Keratoconjunctivits sicca
5) Cataracts (secondary to steroid use)
6) Retinopathy (secondary to chloroquine)

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17
Q

Which eye manifestation can steroids lead to?

A

Cataracts

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18
Q

Which eye manifestation can chloroquine lead to?

A

Retinopathy

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19
Q

Investigations used with rheumatoid arthritis?

A

A diagnosis of rheumatoid arthritis is clinical in patients with features of rheumatoid arthritis (symmetrical polyarthropathy affecting small joints)

Other diagnosis:

  • Check Rheumatoid factor
  • If RF negative, check anti-citrullinated cyclic peptide (Anti-CCP) antibodies
  • Inflammatory markers (CRP and ESR)
  • X-ray of hands and feet
  • Ultrasound scan of joint to confirm synovitis
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20
Q

Which X-ray changes are seen in rheumatoid arthritis?

A
  • Joint destruction and deformity
  • Soft tissue swelling
  • Periarticular osteopenia = “low bone density”
  • Boney erosions
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21
Q

When does NICE recommend referral for adults even when they have negative rheumatoid factor, anti-CCP antibodies and inflammatory markers?

A

If there is persistent synovitis.

It should be urgent if the small joints of the hands or feet, multiple joints or symptoms have been present for more than 3 months

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22
Q

How is rheumatoid arthritis diagnosed?

A

1) American College of Rheumatology (ACR)/European League against rheumatism (ELAR) from 2010:
- Joints involved, more and smaller joints score higher
- Serology (RF and anti-CCP)
- Inflammatory markers (ESR and CRP)
- Duration of symptoms

2) DAS28 Score = Disease activity score. It is based on the assessment of 28 joints and joints are given for:
- Swollen joints
- Tender joints
- ESR/CRP raised

3) Health Assessment Questionnaire (HAQ) = this questionnaire measures functional ability.

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23
Q

Which factors effect prognosis in rheumatoid factor?

A
Worse prognosis when:
> Younger onset
> Male
> More joints involved 
> More organs affected
> Presence of RF and anti-CCP antibodies
> Erosions seen on Xray
24
Q

Management of rheumatoid arthritis?

A

1) Multidisciplinary team
2) First presentation and flare ups = Steroids. NSAIDs can help but with PPI to reduce risk or peptic ulcer

3) First line is monotherapy with:
- Methotrexate
- Leflunomide
- Sulfasalazine
- Hydroxychloroquine can be consider for mild disease

4) Second line = two of the above used in combination
5) Third line is methotrexate plus a biological therapy, usually a TNF inhibitor
6) Fourth line is methotrexate plus rituximab (Anti-CD20)

25
Management of rheumatoid arthritis - First presentation ?
1) Steroids | 2) NSAIDs in combination with a PPI
26
Management of rheumatoid arthritis - Flare up?
1) Steroids | 2) NSAIDs in combination with a PPI
27
Management of rheumatoid arthritis - first line?
First line is monotherapy with: - Methotrexate - Leflunomide - Sulfasalazine - Hydroxychloroquine can be considered for mild disease
28
Management of rheumatoid arthritis - second line?
A combination of the two: - Methotrexate - Leflunomide - Sulfasalazine
29
Management of rheumatoid arthritis - third line?
Third line is methotrexate plus a biological therapy, usually a TNF inhibitor
30
Management of rheumatoid arthritis - fourth line?
Fourth line is methotrexate plus rituximab (Anti-CD20)
31
Examples of biological therapies?
1) Anti-TNF (Adalimimab*, infliximab*, etanercept*, golimumab and certolizumab pegol) 2) Anti-CD20 (Rituximab*) 3) Anti-IL6 (Sarilumab) 4) Anti-IL6 receptor (Tocilizumab) 5) JAK inhibitor (Tofacitinib and baricitinib)
32
What is the mechanism of action of methotrexate?
Works by interfering with the metabolism of folate and suppressing certain components of the immune system. Folic acid 5mg is also prescribed along side.
33
Side effects of methotrexate?
- Mouth ulcers and mucositis - Liver toxicity - Pulmonary fibrosis - Bone marrow suppression and leukopenia (low WBCs) - It is teratogenic and should be avoided by both and mother prior to pregnancy
34
What is the mechanism of action of leflunomide?
Is an immunosuppressant medication that works by interfering with the production of pyrimidine. Pyrimidine is an important component of RNA and DNA.
35
Side effects of leflunomide?
- Mouth ulcers and mucositis - Increased blood pressure - Rashes - Peripheral neuropathy - Liver toxicity - Bone marrow suppression and leukopenia (low WBCs) - It is teratogenic and should be avoided by both and mother prior to pregnancy
36
What is the mechanism of action of sulfasalzine?
Sulfasalzine works as an immunosuppressive and anti-inflammatory medication. Mechanism isn't clear but may be related to folate metabolism. Appears to be safe in pregnancy
37
Side effects of sulfasalzine?
- Temporary male infertility (reduced sperm count) | - Bone marrow suppression
38
What is the mechanism of action of hydroxychloroquine?
Traditionally an anti-malarial medication. Acts as an immunosuppressive medication by interfering with toll-like receptors. This disrupts antigen presentation and increases pH in the lysosome of the immune cells.
39
Side effects of hydroxychloroquine?
- Nightmares - Reduced visual acuity (Macular toxicity) - Liver toxicity - Skin pigmentation
40
What is the mechanism of action of Anti-TNF drugs?
Tumour necrosis factor is a cytosine involved in stimulating inflammation. Blocking TNF reduces inflammation.
41
What is adalimumab?
An anti-TNF monoclonal antibody
42
What is infliximab?
An anti-TNF monoclonal antibody
43
What is golimumab?
An anti-TNF monoclonal antibody
44
What is certolizumab pegol?
An anti-TNF monoclonal antibody
45
What is etanercept?
A protein which binds TNF to the Fc portion of IgG and there by reduces its activity
46
Side effects of anti-TNF drugs?
- Vulnerability to severe infections and sepsis | - Reactivation of TB and hepatitis B
47
What is the mechanism of action of Rituximab?
Rituximab is a monoclonal antibody that target CD20 protein on the surface of B cells. This causes destruction of B cells thus decreasing inflammatory response
48
Side effects of rituximab?
``` > Vulnerability to severe infections and sepsis > Night sweats > Thrombocytopenia > Peripheral neuropathy > Liver and lung toxicity ```
49
In terms of side effects of rheumatoid arthritis which drug can cause pulmonary fibrosis?
Methotrexate
50
In terms of side effects of rheumatoid arthritis which drug can cause hypertension?
Leflunomide
51
In terms of side effects of rheumatoid arthritis which drug can cause peripheral neuropathy?
Leflunomide
52
In terms of side effects of rheumatoid arthritis which drug can cause male infertility?
Sulfasalazine
53
In terms of side effects of rheumatoid arthritis which drug can cause nightmares?
Hydroxychloroquine
54
In terms of side effects of rheumatoid arthritis which drug can cause reduced visual acuity?
Hydroxychloroquine
55
In terms of side effects of rheumatoid arthritis which drug can cause reactivation of TB and hepatitis B?
Anti-TNF medications
56
In terms of side effects of rheumatoid arthritis which drug can cause night sweats?
Rituximab
57
In terms of side effects of rheumatoid arthritis which drug can cause thrombocytopenia?
Rituximab