Rheumatoid arthritis + Osteoarthritis +Juvenile idiopathic arthritis Flashcards
(129 cards)
1
Q
What is rheumatoid arthritis?
A
Rheumatoid arthritis is an autoimmune condition that causes chronic inflammation in the synovial lining of joints, tendon sheaths, and bursa. It is a type of inflammatory arthritis, and synovial inflammation is referred to as synovitis. Inflammation of tendons increases the risk of tendon rupture.
2
Q
Describe the pattern of joint involvement in rheumatoid arthritis.
A
Rheumatoid arthritis tends to affect multiple small joints symmetrically across both sides of the body. This pattern is described as symmetrical polyarthritis.
3
Q
What is the gender predilection for rheumatoid arthritis, and what are the common risk factors?
A
Rheumatoid arthritis is 2-3 times more common in women than men. It most often develops in middle age but can occur at any age. Smoking and obesity are risk factors. A family history increases the risk, with HLA DR4 being the most common gene associated with rheumatoid arthritis.
4
Q
How does the disease course vary in rheumatoid arthritis patients?
A
The disease course varies between patients, ranging from mild and remitting to severe and progressive. Disease activity, positive antibodies, and erosions on an x-ray predict worse disease outcomes.
5
Q
What is the significance of HLA DR4 in rheumatoid arthritis?
A
HLA DR4 is the most common gene associated with rheumatoid arthritis. While there is a family history risk, there is no clear inheritance pattern.
6
Q
What are the antibodies associated with rheumatoid arthritis, and how do they contribute to inflammation?
A
Rheumatoid factor (RF) is an autoantibody present in around 70% of RA patients. It targets the Fc portion of immunoglobulin G (IgG), causing immune system activation against the patient’s own IgG, resulting in systemic inflammation. Anti-cyclic citrullinated peptide antibodies (anti-CCP antibodies) are more sensitive and specific, being positive in around 80% of patients. They pre-date the development of rheumatoid arthritis.
7
Q
What are the three joint symptoms of rheumatoid arthritis?
A
The three joint symptoms of rheumatoid arthritis are pain, stiffness, and swelling.
8
Q
Describe the typical joint involvement in rheumatoid arthritis.
A
Rheumatoid arthritis typically causes symmetrical distal polyarthritis affecting the small joints of the hands and feet. The most commonly affected joints include Metacarpophalangeal (MCP) joints, Proximal interphalangeal (PIP) joints, wrist, and Metatarsophalangeal (MTP) joints in the foot. There is tenderness and synovial thickening on palpation, giving the joints a “boggy” feeling.
9
Q
Which joints are very rarely affected by rheumatoid arthritis, and what condition is more likely if they are enlarged and painful?
A
Rheumatoid arthritis very rarely affects the distal interphalangeal joints-and 1st carpometacrpal. Enlarged and painful distal interphalangeal joints are more likely to represent Heberden’s nodes due to osteoarthritis.
10
Q
Besides small joints, what are some large joints that can be affected by rheumatoid arthritis?
A
Large joints such as the ankle, knee, hips, and shoulders can also be affected by rheumatoid arthritis. It can also affect the cervical spine, although not the lumbar spine.
11
Q
What are some associated systemic symptoms of rheumatoid arthritis?
A
Associated systemic symptoms of rheumatoid arthritis include fatigue, weight loss, flu-like illness, muscles aches, and weakness.
12
Q
How do symptoms of inflammatory arthritis differ from mechanical problems like osteoarthritis?
A
Inflammatory arthritis symptoms are worse with rest and improve with activity. They are worst in the morning. Symptoms of mechanical problems (e.g., osteoarthritis) are worse with activity and improve with rest.
13
Q
What is palindromic rheumatism, and how does it differ from rheumatoid arthritis?
A
Palindromic rheumatism involves self-limiting episodes of inflammatory arthritis, with pain, stiffness, and swelling affecting only a few joints. The symptoms last for days and then completely resolve. Joints appear normal between episodes. Rheumatoid factor or anti-CCP antibodies may indicate progression to rheumatoid arthritis.
14
Q
What are the hand signs associated with advanced rheumatoid arthritis?
A
In advanced rheumatoid arthritis, hand signs include Z-shaped deformity to the thumb, Swan neck deformity (hyperextended PIP and flexed DIP), Boutonniere deformity (hyperextended DIP and flexed PIP), and ulnar deviation of the fingers at the MCP joints.
15
Q
Explain the mechanism behind Boutonniere deformity and Swan neck deformity.
A
Boutonniere deformity is caused by a tear in the central slip of the extensor components at the proximal interphalangeal (PIP) joint, resulting in hyperextension of the DIP joint and flexion of the PIP joint. Swan neck deformity, on the other hand, is caused by an extensor mechanism imbalance, leading to flexion of the DIP joint and extension of the PIP joint.
16
Q
What is the significance of Z-shaped deformity in advanced rheumatoid arthritis?
A
Z-shaped deformity in advanced rheumatoid arthritis is observed in the thumb and is a characteristic hand sign associated with the condition.
17
Q
What is atlantoaxial subluxation, where does it occur, and what complications can arise from it?
A
Atlantoaxial subluxation occurs in the cervical spine, involving synovitis and damage to the ligaments around the odontoid peg of the axis (C2). It allows shifting within the atlas (C1) and can cause spinal cord compression, posing as an emergency. Consideration of this condition is crucial during a patient’s general anesthesia requiring intubation. MRI can visualize changes in these areas as part of a pre-operative assessment.
18
Q
List some extra-articular manifestations of rheumatoid arthritis.
A
Extra-articular manifestations of rheumatoid arthritis include Felty’s syndrome (rheumatoid arthritis, neutropenia, and splenomegaly),pulmonary fibrosis, Sjögren’s syndrome (with dry eyes and dry mouth), anemia of chronic disease, cardiovascular disease, eye manifestations, rheumatoid nodules, lymphadenopathy, carpal tunnel syndrome, amyloidosis, bronchiolitis obliterans, and Caplan syndrome (pulmonary nodules in patients with rheumatoid arthritis exposed to coal, silica, or asbestos dust).
19
Q
What are some eye manifestations related to rheumatoid arthritis?
A
Eye manifestations related to rheumatoid arthritis and its treatment include dry eye syndrome (keratoconjunctivitis sicca), episcleritis, scleritis, keratitis, cataracts (secondary to steroids), retinopathy (secondary to hydroxychloroquine).
20
Q
According to NICE clinical knowledge summaries, when is an urgent rheumatology referral recommended for patients with suspected rheumatoid arthritis?
A
NICE recommends an urgent rheumatology referral for patients with persistent synovitis, to be seen within three weeks. In the meantime, considering an NSAID and arranging baseline bloods are suggested while waiting for specialist assessment.
21
Q
What investigations are helpful in the initial assessment of rheumatoid arthritis?
A
Investigations helpful in the initial assessment of rheumatoid arthritis include rheumatoid factor, anti-CCP antibodies, inflammatory markers such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), X-rays of the hands and feet for bone changes, and ultrasound or MRI to detect synovitis, especially when clinical findings are unclear.
22
Q
How is the diagnosis of rheumatoid arthritis made, and what classification criteria can be used?
A
The diagnosis of rheumatoid arthritis is based on clinical findings and blood results. The American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) classification criteria from 2010 can be used to make the diagnosis.
23
Q
What are some X-ray changes associated with rheumatoid arthritis?
A
- Juxta articular osteopenia /Periarticular osteopenia
- Soft tissue swelling
- Narrow of the joint space
- bone erosions
- subchondral cysts
24
Q
What scoring systems are used in assessing rheumatoid arthritis?
A
The Health Assessment Questionnaire (HAQ) measures functional ability and is recommended for a baseline score at diagnosis to assess the response to treatment. The Disease Activity Score 28 Joints (DAS28) is used in monitoring disease activity and response to treatment, involving the assessment of 28 joints and assigning points for swollen joints, tender joints, and the ESR or CRP result.
25
Who is involved in the multidisciplinary team for rheumatoid arthritis management?
The multidisciplinary team for rheumatoid arthritis management includes rheumatologists, specialist nurses, GPs, physiotherapists, occupational therapists, psychologists, and podiatrists.
26
Why is early treatment initiation crucial in rheumatoid arthritis, and what are the treatment goals?
Starting treatment early in rheumatoid arthritis improves outcomes. The goal is to induce remission or get as close to remission as possible. C-reactive protein and DAS28 are used to monitor the success of treatment.
27
What role do short-term steroids play in rheumatoid arthritis treatment?
Short-term steroids, either oral or intramuscular, may be used at initial presentation, when initiating a new treatment, and during flares to quickly settle inflammation and control symptoms.
28
List some conventional disease-modifying anti-rheumatic drugs (cDMARDs) used in rheumatoid arthritis treatment.
Conventional disease-modifying anti-rheumatic drugs (cDMARDs) used in rheumatoid arthritis treatment include methotrexate, leflunomide, sulfasalazine, azathioprine, ciclosporin, cyclophosphamide, and mycophenolate.
29
When is hydroxychloroquine used in rheumatoid arthritis treatment, and why is it considered a "mild" DMARD?
Hydroxychloroquine may be used in mild disease and palindromic rheumatism. It is considered the "mildest" DMARD.
30
What are some risks associated with NSAIDs in rheumatoid arthritis treatment?
NSAIDs are helpful for pain relief in rheumatoid arthritis, but they have associated risks and side effects.
31
How can pregnancy affect rheumatoid arthritis symptoms, and which DMARDs are considered safe during pregnancy?
Pregnancy can improve symptoms in rheumatoid arthritis, but some pregnant women may experience a symptom flare. Hydroxychloroquine and sulfasalazine are considered the safest DMARDs in pregnancy (extra folic acid is required with sulfasalazine). Methotrexate and leflunomide are very harmful in pregnancy and are teratogenic.
32
What are the main targets of biological therapies in rheumatoid arthritis, and can you name some examples?
Biological therapies in rheumatoid arthritis target various components of the immune system. Examples include:
33
What are the various targets of biological therapies used to treat rheumatoid arthritis?
• tumour necrosis factor (TNF) inhibitors (e.g., adalimumab, infliximab, etanercept, golimumab and certolizumab)
• Anti-CD20 on B cells (e.g., rituximab)
• Anti-interleukin-6 inhibitors (e.g., sarilumab and tocilizumab)
• JAK inhibitors (e.g., upadacitinib, tofacitinib and baricitinib)
• T-cell co-stimulation inhibitors (e.g., abatacept)
34
What is the role of Tumour Necrosis Factor (TNF) in inflammation, specifically in the context of rheumatoid arthritis?
TNF is a cytokine involved in stimulating inflammationand stimulate synovial fulid to profilate . In rheumatoid arthritis, blocking TNF is a therapeutic strategy to reduce inflammation.
35
According to the TOM TIP, what are the main biologics to remember in rheumatoid arthritis treatment, and what is their common target?
The main biologics to remember in rheumatoid arthritis treatment are adalimumab, infliximab, and etanercept (TNF inhibitors), and rituximab (a monoclonal antibody targeting CD20 proteins on the surface of B cells). Their common target is TNF, and they cause immunosuppression, increasing the risk of infection, certain cancers (e.g., skin), and reactivation of latent TB.
36
How has the use of cDMARDs and biologics impacted the need for orthopaedic surgery in rheumatoid arthritis management?
The use of cDMARDs and biologics has dramatically reduced the need for orthopaedic surgery in rheumatoid arthritis management, especially when joint deformities develop.
37
How does Methotrexate impact folate metabolism, and what is its dosing frequency?
Methotrexate interferes with folate metabolism and suppresses the immune system. It is given once a week.
38
What side effects are associated with Methotrexate?
Side effects of Methotrexate include: Mouth ulcers and mucositis
Liver toxicity
Bone marrow suppression and leukopenia (low white blood cells)
Teratogenicity (harmful to pregnancy) and needs to be avoided before conception in both women and men |
| How does Leflunomide function as an immunosuppressant, and what is its impact on pyrimidine production? | Leflunomide is an immunosuppressant that interferes with the production of pyrimidine, an essential component of RNA and DNA. |
| List the side effects associated with Leflunomide. | Side effects of Leflunomide include:
Mouth ulcers and mucositis
Increased blood pressure
Liver toxicity
Bone marrow suppression and leukopenia (low white blood cells)
Teratogenicity (harmful to pregnancy) and needs to be avoided before conception in both women and men
Peripheral neuropathy |
| What is the mechanism of action of Sulfasalazine, and what are its side effects? | Sulfasalazine is an immunosuppressive and anti-inflammatory medication. Its exact mechanism is not clear. Side effects include:
Orange urine
Reversible male infertility (reduced sperm count and quality)
Bone marrow suppression |
39
What is the dosing frequency of Methotrexate, and how does it affect folate metabolism?
Methotrexate is given once a week, and it interferes with folate metabolism while suppressing the immune system.
40
What are the side effects associated with Methotrexate?
Mouth ulcers and mucositis Liver toxicity Bone marrow suppression and leukopenia (low white blood cells) Teratogenicity (harmful to pregnancy) and needs to be avoided before conception in both women and men |
41
What is the mechanism of action of Leflunomide, and what does it interfere with in the body?
Leflunomide is an immunosuppressant that interferes with the production of pyrimidine, a crucial component of RNA and DNA.
42
List the side effects associated with Leflunomide.
Side effects of Leflunomide include: Mouth ulcers and mucositis Increased blood pressure Liver toxicity Bone marrow suppression and leukopenia (low white blood cells) **Teratogenicity** (harmful to pregnancy) and needs to be avoided before conception in both women and men Peripheral neuropathy
43
What is the traditional use of Sulfasalazine, and what are its side effects?
Sulfasalazine is an immunosuppressive and anti-inflammatory medication, and its exact mechanism is unclear. Side effects include: Orange urine Reversible male infertility (reduced sperm count and quality) Bone marrow suppression
44
How does Hydroxychloroquine suppress the immune system, and what are its side effects?
Hydroxychloroquine, traditionally an antimalarial medication, suppresses the immune system by interfering with Toll-like receptors, disrupting antigen presentation, and increasing the pH in the lysosomes of immune cells. Side effects include: Retinal toxicity (reduced visual acuity, macular toxicity) Blue-grey skin pigmentation Hair lightening (bleaching)
45
What unique side effects are associated with Methotrexate, according to TOM TIP?
According to TOM TIP, unique side effects of Methotrexate are: Bone marrow suppression and leukopenia Highly teratogenic
46
According to TOM TIP, what are the unique side effects of Leflunomide?
According to TOM TIP, unique side effects of Leflunomide are: Hypertension Peripheral neuropathy
47
Name the unique side effects of Sulfasalazine according to TOM TIP.
According to TOM TIP, the unique side effects of Sulfasalazine are: Orange urine Male infertility (reduced sperm count
48
What unique side effects of Hydroxychloroquine are highlighted by TOM TIP?
According to TOM TIP, unique side effects of Hydroxychloroquine are: Retinal toxicity Blue-grey skin pigmentation Hair bleaching
49
According to TOM TIP, what is a specific side effect associated with Anti-TNF medications?
According to TOM TIP, a specific side effect associated with Anti-TNF medications is the reactivation of tuberculosis.
50
What unique side effects are associated with Rituximab, as per TOM TIP?
According to TOM TIP, unique side effects of Rituximab are: Night sweats Thrombocytopenia
51
What is rheumatoid arthritis and how is it characterized?
Rheumatoid arthritis is an inflammatory autoimmune disorder characterized by joint pain, swelling, and synovial destruction.
52
What are the proposed factors contributing to the etiology of RA?
Genetic predisposition, environmental triggers (infection, smoking), and hormonal factors play a role in the development of RA.
53
How does genetic predisposition relate to RA?
Genetic predisposition is associated with specific HLA types, such as the HLA DRB1 gene.
54
What are some environmental triggers for RA?
Infection and smoking are environmental triggers that can increase anti-CCP and contribute to the development of RA.
55
What is the prevalence pattern of RA in terms of age?
The prevalence of RA peaks between 35-50 years of age.
56
Describe the initial inflammatory process in RA.
Non-specific inflammation initially affects the synovial tissue, later amplified by activation of T cells.
57
What factors may trigger the progression of RA?
Triggers such as smoking, infection, or trauma have been implicated in the progression of RA.
58
What is the role of inflammatory pannus in RA progression?
Inflammatory pannus, or inflammatory granulation tissue, forms and produces proteinases that destroy cartilage extracellular matrix.
59
What happens in the chronic phase of RA?
The chronic phase is characterized by fibrosis and deformity.
60
How do susceptibility genes contribute to RA development?
Susceptibility genes lead to the conversion of arginine into citrulline, and the unfolded protein acts as an antigen, triggering an autoimmune response.
61
What is the role of auto-reactive CD4+ T cells in RA?
Auto-reactive CD4+ T cells, including Th1 and Th17 effector cells, are involved in the autoimmune response in RA.
62
How is rheumatoid factor (RF) related to RA?
RF is an IgM or IgA antibody that binds to the Fc region of IgG. It is found in about 80% of RA patients, and high titres increase the risk of extra-articular disease.
63
What is Anti-CCP, and how is it associated with RA?
Anti-CCP can be present for several years before articular symptoms, is associated with erosive damage, and correlates with disease activity. It is linked to a current/previous smoking history.
64
Is the absence of Anti-CCP a reliable indicator for the absence of RA?
No, the absence of Anti-CCP does not exclude the presence of RA.
65
How does rheumatoid arthritis (RA) typically manifest in terms of onset?
RA can present acutely, subacutely, or insidiously. In most cases (55–65%), onset is insidious over weeks to months.
66
What are the articular manifestations of RA?
- Polyarthralgia with symmetrical pain and swelling in affected joints, most commonly in the small joints of the hands and feet. - Rapid onset. - Early morning stiffness lasting more than 30 mins, improving with activity. - Reduction in grip strength. - Joint deformities, including the 'rheumatoid hand' with Swan neck and Boutonniere deformities. - Atlanto-axial subluxation.
67
What signs may be observed in patients with RA?
- Swelling of affected joints with symmetrical synovitis (doughy swelling). - Positive compression tests of MCP and MTP joints. - Bouchard's nodes (bony swellings of proximal IPJ). - Rheumatoid nodules in 25% of patients. - Synovial herniation, such as Baker's cysts.
68
Name some extra-articular manifestations of RA.
Systemic inflammation in RA can lead to: - Constitutional symptoms (low-grade fever, myalgia, malaise, fatigue, weight loss, night sweats). - Pulmonary involvement (interstitial fibrosis, pleuritis, pleural effusions). - Cardiac complications (pericarditis, myocarditis, increased CVD risk). - Skin issues (pyoderma gangrenosum, Raynaud's phenomenon, rheumatoid skin nodules). - Ocular complications (keratoconjunctivitis). - Other musculoskeletal problems (osteopenia/osteoporosis, Sjogren syndrome).
69
What investigations are useful in diagnosing RA?
Blood tests can reveal raised inflammatory markers and autoantibodies, including rheumatoid factor (60-70% specific) and anti-CCP antibodies (90-99% specific). Imaging techniques like X-rays, ultrasound (USS), and MRI are employed for diagnosis and determining disease severity.
70
How does X-ray imaging contribute to the diagnosis of RA?
X-ray imaging of hands and feet helps in diagnosing and determining disease severity in RA. In early disease, X-rays may be normal or show soft tissue swelling and periarticular osteopenia, while late-stage disease may exhibit erosions and subluxation.
71
When might ultrasound (USS) be useful in RA diagnosis?
USS may be useful in detecting synovial inflammation, especially in early RA, when there is clinical uncertainty. It is also employed for making treatment changes.
72
In what situations is MRI used in the context of RA?
MRI is extremely sensitive and is used in cases of diagnostic doubt in RA.
73
How is disease severity and treatment efficacy monitored in RA?
Disease severity and treatment efficacy in RA are often monitored using the DAS28 score, a composite score that includes CRP or ESR, the number of swollen or tender joints, and a patient-reported measure of global health.
74
What are the symptomatic treatments for RA?
Analgesics, NSAIDs, and steroids can be used short-term for symptomatic relief in RA. Rheumatoid nodules, if problematic, may be excised, although recurrence is common.
75
When should disease-modifying treatment be initiated in RA patients?
All patients with RA should be treated with disease-modifying treatment, and the aim is to start patients on DMARDs within 3 months of symptom onset.
76
What are conventional disease-modifying anti-rheumatic drugs (csDMARDs) and examples of first-line options?
csDMARDs are immunomodulatory medications, and examples of first-line options include methotrexate, leflunomide, hydroxychloroquine, and sulfasalazine. Oral methotrexate is usually the first choice, and it can also be given subcutaneously.
77
What are the important side effects and monitoring requirements for methotrexate?
Methotrexate may cause gastrointestinal side effects, oral ulcers, photosensitivity, hepatic toxicity, cytopenia, immunosuppression, pneumonitis, flu-like symptoms, and teratogenicity. Monitoring includes baseline chest X-ray, hepatitis B and C serology, and regular monitoring of FBC, U&Es, and LFTs.
78
Which csDMARD has the potential for retinal toxicity, and how is it monitored?
Hydroxychloroquine has the potential for retinal toxicity, and monitoring involves retinal screening 5 years after starting, with baseline screening required in those with risk factors.
79
What are the common side effects and monitoring requirements for leflunomide?
Leflunomide may cause nausea, vomiting, diarrhea, cytopenia, rash, hypertension, hyperlipidemia, and teratogenicity. Monitoring includes regular checks of FBC, U&Es, LFTs, and blood pressure.
80
What side effects and monitoring are associated with sulfasalazine?
Sulfasalazine may cause gastrointestinal side effects, rash, agranulocytosis, oral ulcers, reduced sperm count, haemolysis (in G6PD deficiency). Monitoring involves regular checks of FBC, U&Es, and LFTs.
81
When are biological disease-modifying anti-rheumatic drugs (bDMARDs) considered in RA treatment?
bDMARDs are considered if a patient has tried two DMARDs and still has a DAS28 score > 5.1. Examples include anti-TNF agents and T cell receptor blockers. They are usually taken in addition to other DMARDs but may be discontinued if the patient does not see a significant improvement.
82
What are targeted synthetic DMARDs (tsDMARDs), and what are some examples?
tsDMARDs are selective, small-molecule oral DMARDs, including Janus kinase inhibitors. Examples include Baricitinib, Tofacitinib, and Filgotinib, the latter being the first tsDMARD licensed for the treatment of moderate-activity RA.
83
What additional medications are recommended for patients on DMARDs, and why?
Patients on DMARDs should receive the annual influenza vaccine and the pneumococcal vaccine every 5 years. Those aged over 50 years should receive the zoster vaccination before starting bDMARDs or tsDMARDs. These measures are taken to prevent infections, and none of the mentioned vaccines are live.
84
What non-medical management strategies are recommended for RA?
Non-medical management involves the collaboration of physiotherapists, occupational therapists, podiatrists, and orthotists. Surgery, including synovectomy, joint replacement, joint excision, tendon transfers, arthrodesis, and cervical spine stabilization, can be used for resistant disease or to control pain and improve/maintain function.
85
What complications may arise in longstanding RA?
In longstanding RA, involvement of the cervical spine may cause atlanto-axial subluxation, leading to cervical cord compression.
86
How is osteoarthritis often described in terms of its impact on joints?
Osteoarthritis is often described as "wear and tear" in the joints, occurring in synovial joints and resulting from genetic factors, overuse, and injury.
87
What is thought to be the underlying cause of osteoarthritis, and what imbalance is implicated in its development?
Osteoarthritis is thought to result from an imbalance between cartilage damage and the chondrocyte response, leading to structural issues in the joint.
88
What are the risk factors associated with osteoarthritis?
Risk factors for osteoarthritis include obesity, age, occupation, trauma, being female, and family history.
89
Name some commonly affected joints in osteoarthritis.
Commonly affected joints in osteoarthritis include hips, knees, distal interphalangeal (DIP) joints in the hands, carpometacarpal (CMC) joint at the base of the thumb, lumbar spine, and cervical spine (cervical spondylosis).
90
What are the four key x-ray changes in osteoarthritis, and how can they be remembered?
The four key x-ray changes in osteoarthritis are remembered with the "LOSS" mnemonic: Loss of joint space, Osteophytes (bone spurs), Subarticular sclerosis (increased density of the bone along the joint line), and Subchondral cysts (fluid-filled holes in the bone).
91
How might x-ray findings of osteoarthritis be described, and is there always a correlation with symptoms?
X-ray findings of osteoarthritis might be described as "degenerative changes." However, there is not always a correlation between x-ray changes and symptoms; a patient may have significant signs on an x-ray but minimal symptoms, or vice versa.
92
What are the general signs of osteoarthritis?
General signs of osteoarthritis include bulky, bony enlargement of the joint, restricted range of motion, crepitus on movement, and effusions (fluid) around the joint.
93
How does osteoarthritis typically present in terms of joint pain and stiffness?
Osteoarthritis presents with joint pain and stiffness, which tend to worsen with activity and at the end of the day. This is in contrast to inflammatory arthritis, where symptoms are worse in the morning and improve with activity. Osteoarthritis can lead to deformity, instability, and reduced function of the joint.
94
What are some general signs of osteoarthritis in the hands?
General signs of osteoarthritis in the hands include Heberden’s nodes (in the DIP joints), Bouchard’s nodes (in the PIP joints), squaring at the base of the thumb (CMC joint), weak grip, and reduced range of motion.
95
What distinguishes the carpometacarpal joint at the base of the thumb, and why is it prone to wear in osteoarthritis?
The carpometacarpal joint at the base of the thumb is a saddle joint, with the metacarpal bone sitting on the trapezius bone, using it like a saddle. It is prone to wear due to its extensive use.
96
What tip is provided regarding referred pain in osteoarthritis, and how might this present in clinical scenarios?
Patients with osteoarthritis may present with referred pain, particularly in adjacent joints. For example, osteoarthritis in the hip could be considered in patients presenting with lower back or knee pain.
97
According to the NICE guidelines, what criteria are suggested for diagnosing osteoarthritis without investigations?
The NICE guidelines (2022) suggest that a diagnosis of osteoarthritis can be made without any investigations if the patient is over 45, has typical pain associated with activity, and has no morning stiffness (or stiffness lasting under 30 minutes).
98
What non-pharmacological management strategies are recommended for osteoarthritis?
Non-pharmacological management for osteoarthritis involves patient education and lifestyle changes. This includes therapeutic exercise to improve strength and function and reduce pain, weight loss if overweight to reduce the load on the joint, and occupational therapy to support activities and function (e.g., walking aids and adaptations to the home).
99
What pharmacological management options are recommended by NICE for knee osteoarthritis?
NICE recommends topical NSAIDs as first-line for knee osteoarthritis. Oral NSAIDs are recommended where required and suitable, co-prescribed with a proton pump inhibitor for gastroprotection. Weak opiates and paracetamol are only recommended for short-term, infrequent use. NICE advises against using any strong opiates for osteoarthritis.
100
How might intra-articular steroid injections be utilized in osteoarthritis management?
Intra-articular steroid injections may be used in osteoarthritis to temporarily improve symptoms, with the effect lasting up to 10 weeks according to NICE guidelines.
101
In severe cases of osteoarthritis, what intervention might be considered?
In severe cases of osteoarthritis, joint replacement may be considered. The hips and knees are the most commonly replaced joints.
102
What are some potential adverse effects of NSAIDs used for osteoarthritis pain?
NSAIDs (e.g., ibuprofen or naproxen) can have potential adverse effects, including gastrointestinal side effects such as gastritis and peptic ulcers (leading to upper gastrointestinal bleeding), renal side effects like acute kidney injury and chronic kidney disease, and cardiovascular side effects such as hypertension, heart failure, myocardial infarction, and stroke.
103
Why are opiates not recommended for regular use in osteoarthritis?
Opiates are not recommended for regular use in osteoarthritis due to little evidence supporting their effectiveness in chronic pain. They are associated with side effects, risks, tolerance, dependence, and withdrawal, often resulting in dependence without objective benefits.
104
What caution is advised when using NSAIDs in patients with a history of high blood pressure?
NSAIDs cause hypertension by blocking prostaglandins, which cause vasodilation. Therefore, they should be used very cautiously in patients with a history of high blood pressure.
105
How is osteoarthritis (OA) defined in terms of its pathophysiology and its impact on joint tissues?
Osteoarthritis is defined as a chronic disease involving the imbalance between wear and repair of articular (hyaline) cartilage, leading to progressive cartilage loss and accompanying periarticular changes. It is a metabolically active dynamic process that affects all joint tissues, including cartilage, bone, synovium/capsule, ligaments, and muscles. Key pathological changes include localized loss of hyaline cartilage, remodelling of adjacent bone with new bone formation (osteophyte) at joint margins, increased pressure on bony surfaces, inflammation, pain, swelling, thickening of the capsule, and stiffness.
106
What are the primary risk factors for primary OA, and what joints does it commonly affect?
Primary OA, defined as a common complex disorder, has multiple risk factors including genetic factors (40-60%), constitutional factors (aging, female sex, obesity), and biomechanical factors (joint injury, occupational/recreational usage, reduced muscle strength, joint laxity, joint malalignment). It affects weight-bearing or active joints and typically presents in individuals over 50 years old.
107
When does secondary OA occur, and what conditions can lead to its development?
Secondary OA occurs when OA affects an unexpected site due to overuse, previous injury, or previous arthritis. Conditions such as rheumatoid arthritis and gout are examples that can lead to secondary OA.
108
What are the key pathological changes involved in the development of OA?
The key pathological changes in the development of OA include chondrocyte injury (due to genetic and biochemical factors), chondrocyte proliferation (releasing inflammatory mediators, proteases, collagen, and proteoglycans), remodelling and degradation of cartilage, stimulation of inflammatory changes in synovium and subchondral bone, repetitive injury, chronic inflammation, and long-term consequences such as complete wear away of cartilage, subchondral cysts, surface polishing (eburnation), and formation of osteophytes.
109
What are the consequences of long-term OA development, and how does it affect the joint?
Long-term consequences of OA development include the complete wear away of cartilage (bone on bone), subchondral cysts (accumulation of synovial fluid), surface polishing (eburnation or subchondral sclerosis), and the formation of osteophytes (disorganized bone remodelling) that can irritate nerves.
110
What are the types of OA based on its localization, and what is a clinical marker of generalized OA?
Types of OA include localized OA (affecting hips, knees, finger interphalangeal joints, facet joints of lower cervical and lower lumbar spines) and generalized OA (defined as OA at either the spinal or hand joints and in at least 2 other joint regions, e.g., DIP joints, thumb bases, first MTP joints, knees, hips). A clinical marker of generalized OA is the presence of multiple Herbeden's nodes.
111
What are the common symptoms associated with osteoarthritis (OA)?
Common symptoms of OA include pain, which worsens with joint use, night pain, morning stiffness lasting less than 30 minutes, inactivity gelling, instability, and poor grip in thumb OA.
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What signs can be observed in individuals with OA?
Signs of OA include joint line tenderness, crepitus, deformity, stiffness on testing range of motion (ROM), and bony swelling due to osteophytes. Osteophytes can manifest as Heberden's nodes (DIP joints) and Bouchard's nodes (PIP joints). Squaring of the thumb is observed in 1st CMC OA.
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How does knee OA manifest in terms of symptoms and signs?
Knee OA is characterized by osteophytes, effusions, crepitus, restriction of movement, genu varus and valgus deformities, and the presence of Baker's cysts.
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What symptoms may individuals with hip OA experience, and how might the pain be perceived?
Individuals with hip OA may experience pain in the groin, radiating to the knee or anterior thigh. Pain felt in the hip may also radiate from the lower back. Additionally, hip movements are often restricted in hip OA.
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How does spine OA affect individuals in terms of pain and movement restriction?
In cervical spine OA, individuals may experience pain and restriction of movement, with possible occipital headaches if osteophytes impinge on nerve roots. In lumbar spine OA, osteophytes can cause spinal stenosis if they encroach on the spinal canal, leading to pain and movement restriction.
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What are the specific bony swellings associated with OA, and where are they commonly observed?
Bony swellings in OA are caused by osteophytes, which are bony spurs due to chronic trauma. Heberden's nodes (DIP joints) are specific to OA and are not seen in RA. Bouchard's nodes (PIP joints) are less common but can also be seen in RA. Squaring of the thumb is associated with 1st CMC OA.
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How is crepitus described in the context of OA?
Crepitus in OA refers to a crackling or grating sound or sensation observed during joint movement.
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What is "inactivity gelling" in the context of OA symptoms?
"Inactivity gelling" refers to stiffness or reduced mobility experienced after periods of inactivity.
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What deformities are commonly associated with OA?
Deformities commonly associated with OA include genu varus and valgus deformities in knee OA, and squaring of the thumb in 1st CMC OA.
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What types of imaging can be used for investigating osteoarthritis, and when are they typically performed?
Imaging for osteoarthritis includes plain x-rays, MRI scans, and ultrasound (USS). However, these are not typically performed unless there is doubt over the diagnosis, as clinical evaluation based on signs and symptoms is often sufficient.
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What does the acronym "LOSS" stand for in the context of X-ray findings in osteoarthritis?
The acronym "LOSS" in the context of X-ray findings in osteoarthritis stands for Loss of joint space, Marginal Osteophytes, Subchondral Sclerosis, and Subchondral Cysts.
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What are the pitfalls associated with X-ray imaging in osteoarthritis diagnosis?
Pitfalls of X-ray imaging in osteoarthritis include its insensitivity, especially in early disease, poor correlation with disease activity, and the common occurrence of incidental asymptomatic findings in older people.
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What are the non-pharmacological approaches to managing osteoarthritis?
Non-pharmacological management includes education to ensure patients continue to exercise, lifestyle management (e.g., weight loss, exercise, walking aids), physiotherapy, and activity modification (e.g., occupational therapy, hobbies).
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What pharmacological options are recommended for managing osteoarthritis symptoms?
Pharmacological management for osteoarthritis includes analgesia with paracetamol and NSAIDs (with avoidance of opiates) as needed. Local intra-articular steroid injections can be used for flare-ups, with a limit of up to 3 injections per year to avoid potential joint damage.
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What are the potential surgical interventions for osteoarthritis management?
Surgical management options for osteoarthritis include joint replacements (e.g., knee, hip) and arthroscopic surgery to remove loose bodies and address other issues.
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What distinguishes rheumatoid arthritis (RA) from osteoarthritis (OA) in terms of their causes and characteristics?
Rheumatoid arthritis (RA) is an autoimmune inflammatory disease causing progressive and symmetric destruction of at least three joints. It is characterized by morning stiffness lasting more than an hour and improving with use. RA may present with extra-articular symptoms like uveitis, pulmonary fibrosis, and rheumatoid nodules. Treatment involves non-biological and biological DMARDs, NSAIDs, and glucocorticoids. Osteoarthritis (OA) is a chronic condition characterized by the breakdown of joint cartilage and underlying bone due to mechanical stress. Unlike RA, it is considered a mechanical degenerative joint disorder. Symptoms of OA include joint pain, stiffness, and decreased range of motion. Treatment involves weight loss, physical therapy, and pain management with acetaminophen and NSAIDs.
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What are the key features of rheumatoid arthritis?
Rheumatoid arthritis is characterized by autoimmune inflammatory processes leading to progressive and symmetric destruction of at least three joints, especially the proximal interphalangeal joints. It causes morning stiffness lasting more than an hour and improving with use. Extra-articular symptoms may include uveitis, pulmonary fibrosis, and rheumatoid nodules. Treatment includes non-biological and biological DMARDs, NSAIDs, and glucocorticoids.
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How does osteoarthritis differ from rheumatoid arthritis in terms of its nature and causes?
Osteoarthritis is a chronic condition characterized by the breakdown of joint cartilage and underlying bone due to mechanical stress. It is considered a mechanical degenerative joint disorder. Unlike rheumatoid arthritis, which is an autoimmune disorder, osteoarthritis results from the daily stress applied to joints throughout one's lifetime, especially weight-bearing joints like those in the ankle, knee, and hip. Symptoms include joint pain, stiffness, and decreased range of motion. Treatment involves weight loss, physical therapy, and pain management with acetaminophen and NSAIDs.
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What are the symptoms of osteoarthritis, and how is it managed?
Symptoms of osteoarthritis include joint pain, stiffness, and decreased range of motion. Management involves losing weight, physical therapy, and pain management with drugs like acetaminophen and NSAIDs.
