Rheumatoid Arthritis Profoma Flashcards
Epidemiology of Rheumatoid Arthritis
More likely in females than males (3:1)
Disease onset occurs at younger age in women & peaks at 75 in men
Risk doubles for Pakistani’s who have moved to the western world.
High prevalence in Native US Americans, Caucasians, North Europeans & Japanese.
Risk factors for rheumatoid Arthritis
Smoking
Female
Obesity
Immunisation
Blood transfusion
Dietary risk factors - Vitamin C & Vitamin E have a protective effect.
How does RA cause joint inflammation?
Main pathological abnormality is synovitis - inflammation of synovium.
Inflammation:
1. Inflammatory cells e.g. lymphocytes (CD4+ & B cells), plasma cells, dendritic cells & macrophages enter synovium & proliferate.
2. They produce cytokines & activate B cells to produce autoantibodies
3. Synovial macrophages are activated by interferon-gamma (INF-𝛄) & TNF-⍺
- The macrophages then produce pro-inflammatory cytokines: TNF-⍺, IL-1 and IL-6
NOTE: release of IL-6, triggers the production of acute phase proteins by the liver e.g. CRP, C3…
- The cytokines act on synovial fibroblasts to produce further cytokines.
- The synovial fibroblasts proliferate causing, synovial hypertrophy.
How does RA cause joint pain?
Prostaglandins & nitric oxide cause vasodilation, causing pain and swelling.
How does RA cause joint damage?
- Synovial fibroblasts produce metalloproteinases, which degrade soft tissue & cartilage.
- Pannus formed (an abnormal growth of chronically inflamed tissue) from macrophages & osteoclasts which erodes articular cartilage.
- Peri-articular osteoporosis is caused by osteoclast activation , stimulated by M-CSF from synovial cells.
- Over time this causes joint deformity.
Presentation of Rheumatoid Arthritis- joint pattern?
Joint pattern:
Symmetrical polyarthritis (3 or more joints)
Mainly small & medium joint involvement.
Usually involves hands -characteristic of the disease.
- PIP
- Wrist
- Feet - MTP & PIP
Knees, elbows & shoulders can sometimes be affected too.
DIP joints less likely to be affected- When they are it is usually after PIP & MCP joints have been affected.
Presentation of Rheumatoid arthritis- articular features?
Synovitis - warm, red, tender, swelling, stiffness, loss of function.
Early morning stiffness - over an hour
Stiffness eases w/ movement.
Pain worse w/ rest
Foot deformities:
- Forefoot & Hindfoot synovitis - can cause erosions & displacement, patients feel they are “walking on marbles”.
- Metatarsalgia - pain under the ball of the foot.
- Rheumatoid nodules e.g. achilles tendon
Claw toe - flexion at PIP & DIP joints
- Hammar toe - PIP joint flexion
Hand deformities:
- Ulnar deviation - where fingers bend towards the ulnar bone because the joints in the hand & wrist have shifted.
- Subluxation - when a joint is partially dislocated or misaligned
- Boutonniere deformity - PIP flexion & DIP hyperextension. (Booty is near = PIP bent!)
- Swan-neck deformity- PIP hyperextension & DIP flexion
- Z-deformity - thumb - hyper extension of IP joint & subluxation of MCP joint.
Spine deformities:
- Atlantoaxial subluxation - inflammation & erosion of the first 2 cervical vertebra = neck pain.
- Subaxial subluxation- below 1st cervical vertebra.
- thoracic & lumbar spine not affected
NOTE- View images on notes!
Presentation of rheumatoid arthritis- extra-articular features?
Bursitis - inflammation of bursa.
Carpal tunnel syndrome - median nerve compression.
Tenosynovitis - inflammation of the synovium that surrounds a tendon (common in flexor tendons of fingers).
Rheumatoid Nodules (fingers, elbows, Achilles tendon)
NOTE- View images on notes
Presentation of Rheumatoid Arthritis- systemic features?
RA is an autoimmune disease so patients can have systemic features & feel generally unwell.
- Generally unwell - SAWTEM - Sleep, Appetite, Weight loss, Temp (fever), Energy (lethargy), Mood
- Anaemia - low Hb count - occurs a lot in chronic conditions because bone marrow is too busy manufacturing WBCs to manufacture enough red blood cells.
- Autoimmune haemolysis - a type of anaemia that develops when your immune antibodies damage your red blood cells.
- Felty Syndrome - defined by the presence of 3 conditions: RA, enlarged spleen & decreased WBC count = repeated infections.
- Rheumatoid lung disease - inflammation and scarring of the lungs.
Classification criteria of Rheumatoid Arthritis?
- Nodules
- Radiographic erosions
- anti-CCP positive
(for 6 weeks)
- Morning stiffness > 1 hour
- Arthritis of >3 joint areas
- Hand involvement
- Symmetry
- four criteria = diagnosis of RA
Investigations for Rheumatoid Arthritis?
FBC - low Hb can show*haemolytic anaemia; high platelets can show infection; low WBC can indicate Felty’s.
CRP - high but could be normal
ESR - high but could be normal
anti-CCP - +ve = definitely RA
U&E - urine & electrolytes - kidney function test
LFT - liver function test
HLA B27 - can help w/ prognosis not really for diagnosis.
Radiological findings of Rheumatoid arthritis?
X-ray: 4 main signs
- Joint space narrowing (symmetrical & uniform)
- Juxta-articular bone erosions - common on the radial side of MCP
- Soft tissue swelling
- Peri-articular osteopenia
-Subluxation & other deformities
NOTE- view x-ray image on notes!
Management of Rheumatoid Arthritis- Conservative?
Conservative
- Physio
- rest & exercise
- Monitor disease:
1. DAS28 - Disease Activity Score - measure of how swollen/painful joints are & uses CRP or ESR values too. Remission is defined as DAS score of less than 2.6. Moderate disease activity is a DAS score greater than 5.1.
2. HAQ - measure of ability to carry out everyday tasks e.g. eating, walking, hygiene, dressing, gripping…
3. Radiographic progression - erosions, joint space loss…
4. Treat to target - involves frequent assessment of RA disease activity (e.g. every month) followed by a change in treatment (higher doses or new drugs) until disease activity is brought down to an agreed target.
Management of Rheumatoid Arthritis- Pharmacological?
Paracetamol
NSAIDs - control pain but don’t stop disease progression.
- Naproxen + PPI e.g. Lansopizole
Celecoxib - COX II inhibitor
Weak opioid e.g. Co-codamol= paracetamol + codeine.
DMARDs- FIRST line
-suppress inflammation = slow progression of disease. Can be used in combination.
- Methotrexate + folic acid
- Sulphasalazine
- Hydroxychloroquine
- Leflunomide
Corticosteroids - bridging therapy - short term use only
- Prednisolone**
- DMARDs can take 6 weeks to have an effect.
- Intra-articularly to treat local synovitis = avoids systemic symptoms of steroid use.
- Intra-muscular - for general flair ups.
Biologic therapies - do chest x-ray to check for TB before starting these.
- Anti-TNF⍺ - Adalimumab
- Antibodies against B cells - Rituximab
- Blocks Interleukins - Tociluzimab
Management of Rheumatoid Arthritis- Surgical?
- Arthroplasty
- Synovectomy
- Tendon rupture fixing
- Entrapment neuropathy release i.e. carpal tunnel syndrome
- Cervical decompression for myelopathy.
