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FinalMB Part I - Medicine > Rheumatology > Flashcards

Flashcards in Rheumatology Deck (235)
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Osteoarthritis note:

Osteoarthritis is not an inflammatory condition like RA. It occurs in the synovial joints and is a result of a combination of genetic factors, overuse and injury.


RF's for osetoarthritis ?

-Being female
-Family history


It is thought that osteoarthritis is the result of an imbalance between the cartilage being worn down and the chondrocytes repairing it, leading to structural issues in the joint. These abnormalities can be seen on an xray, what are they ?

Four key Xray changes (LOSS):
-L - Loss of joint space
-O - Osteophytes
-S - Subarticular sclerosis (increased density of the bone along the joint line)
-S - Subchondral cysts (fluid filled holes in the bone)

Note: Xray changes do no necessarily correlate with symptoms. Significant xray changes might be found incidentally in someone without symptoms. Equally, someone with severe symptoms of osteoarthritis may have only mild changes on an xray.


Presentation of osteoarthritis ?

It presents with joint pain and stiffness. This pain and stiffness tends to be worsened by activity in contrast to inflammatory arthritis where activity improves symptoms. It also leads to deformity, instability and reduced function in the joint.


What joints are commonly affected in osteoarthritis ?

-Sacro-iliac joints
-Distal interphalangeal joints (DIPs)
-The MCP joint at the base of the thumb
-Cervical spine


Signs of osteoarthritis in the hands ?

-Heberdens nodes (in the DIP joints)
-Bouchards nodes (in the PIP joints)
-Squaring at the base of the thumb at the carpo-metacarpal joint
-Weak grip
-Reduced range of motion

Note: The carpo-metacarpal joint at the base of the thumb is a saddle joint with the metacarpal bone of the thumb sat on the trapezius bone, using it like a saddle. It gets a lot of use from everyday activities. This makes it prone to wear when used for complex movements.


Diagnosis of osteoarthritis ?

NICE (2014) suggest that a diagnosis can be made without any investigations if the pt is over 45, has typical activity related pain and has no morning stiffness or stiffness lasting less than 30 minutes.


Management of osteoarthritis ?

Start with patient education about the condition and advise on lifestyle changes such as weight loss if overweight to reduce the load on the joint, physiotherapy to improve strength to support the joint and occupational therapy and orthotics to support activities and function.

Stepwise use of analgesia to control the symptoms:
1. Oral paracetamol and topical NSAIDs or topical capsaicin (chilli pepper extract)
2. Add oral NSAIDs and consider also prescribing a PPI to protect their stomach such as omeprazole. They are better used intermittently rather than continuously.
3. Consider opiates such as codeine and morphine. These should be used cautiously as they can have significant side effects and pts can develop dependence and withdrawal. They also don't work for chronic pain and result in pts becoming dependent without benefitting from pain relief

Intra-articular steroid injections provide a temporary reduction in inflammation and improve symptoms.

Joint replacement can be used in severe cases. The hip and knee are the most commonly replaced joints.


What is rheumatoid arthritis ?

It is an autoimmune condition that causes chronic inflammation of the synovial lining (synovitis) of the joints, tendon sheaths and bursa. It is a symmetrical polyarthritis. Inflammation of the tendons increases the risk of tendon rupture.


Is RA more common in men or women, at what age does it usually present and is family history relevant ?

It is three times more common in women than men.

It most often develops in middle age but can present at any age. Family history is relevant and increases the risk of RA.


Genetic associations of RA ?

HLA DR4 (a gene often present in RF positive pts)
HLA DR1 (a gene occasionally present in RA pts)


What is rheumatoid factor, what does it target,what does this lead to and what class of immunoglobulin is RF normally ?

It is an autoantibody presenting in around 70% of RA pts. It targets the Fc portion of the IgG antibody. This causes activation of the immune system against the pts own IgG resulting in systemic inflammation. RF is most often IgM, however they can be any class of immunoglobulin.


What are anti-citrullinated cyclic antibodies (anti-CCP antibodies) ?

Autoantibodies that are more sensitive and specific to RA than RF. Anti-CCP antibodies often pre-date the development of the RA and give an indication that a pt will go on to develop RA at some point.


Presentation of RA ?

It typically presents with a symmetrical distal polyarthropathy. The key symptoms are joint:

Pts usually attend complaining of pain and stiffness in the small joints of the hands and feet, typically the wrist, ankle, MCP and PIP joints in the hands. They can also present with larger joints affected such as the knees, shoulders and elbows. The onset can be very rapid (i.e. overnight) or over months to years.

There are also associated systemic symptoms:
-Weight loss
-Flu like illness
-Muscle aches and weakness



Pain from an inflammatory arthritis is worse after rest but improves with activity. Pain from a mechanical problem such as osteoarthritis is worse with activity and improves with rest.


What is palindromic rheumatism, how long does it last and what may indicate that it will progress to full RA ?

This involves self limiting short episodes of inflammatory arthritis with joint pain, stiffness and swelling typically affecting only a few joints. The episodes typically only last 1-2 days and then completely resolve. Having positive antibodies (RF and anti-CCP) may indicate that it will progress to full RA.


Common joints affected by RA ?

-PIP joints
-MCP joints
-Wrist and ankle
-MTP joints
-Cervical spine
-Large joints can also be affected such as the knee, hips and shoulders



The DIP joints are almost never affected by RA. If you come across enlarged painful DIP joints this is most likely to be Heberden's nodes due to osteoarthritis.


What is atlantoaxial subluxation ?

It occurs in the cervical spine of RA pts. The axis (C2) and the odontoid peg shift within the atlas (C1). This is caused by local synovitis and damage to the ligaments and bursa around the odontoid peg of the axis. Subluxation can cause spinal cord compression and is an emergency. This is particularly important if the pt is having a general anaesthetic and requiring intubation. MRI scans can visualise changes in these areas as part of pre-operative assessment.


Signs in the hands of RA ?

- Z shaped deformity to the thumb
- Swan neck deformity (hyperextended PIP with flexed DIP)
- Boutonnieres deformity (hyperextended DIP with flexed PIP)
-Ulnar deviation of the fingers from the MCP joints


Extra-articular manifestations of RA ?

- Pulmonary fibrosis with pulmonary nodules (Caplan's syndrome)
-Bronchiolitis obliterans (inflammation causing small airway destruction)
-Felty's syndrome (RA, neutropenia and splenomegaly)
-Secondary Sjogren's Syndrome (AKA sicca syndrome)
-Anaemia of chronic disease
-Eye manifestations
-Rheumatoid nodules
-Carpal tunnel syndrome


Name some eye related complications of RA ?

-Keratoconjunctivitis sicca
-Cataracts (secondary to steroids)
-Retinopathy (secondary to chloroquine)


The diagnosis of RA is clinical in pts with features of RA (i.e. symmetrical polyarthropathy affecting small joints). Which extra investigations are required at diagnosis ?

-Check RF
-If RF negative, check anti-CCP antibodies
-Inflammatory markers such as CRP and ESR
-X-ray of hands and feet

US scan of the joints can be used to evaluate and confirm synovitis. It is particularly useful where the findings of the clinical examination are unclear.


Xray changes seen in RA (4) ?

-Joint destruction and deformity
-Soft tissue swelling
-Periarticular osteopenia
-Bony erosions


When do NICE recommend a referral of suspected RA and when would it be urgent ?

Any adult with persistent synovitis, even if they have negative RF, anti-CCP antibodies and inflammatory markers.

The referral should be urgent if it involves the small joints of the hands or feet, multiple joints or symptoms have been present for more than 3 months.


Diagnosis of RA note:

Diagnostic criteria come from the American College of Rheumatology (ACR) / European League Against Rheumatism (ELAR) from 2010. Pts are scored based on:
-The joints that are involved (more and smaller joints score higher)
-Serology (RF and anti-CCP)
-Inflammatory markers (ESR and CRP)
-Duration of symptoms (more or less than 6 weeks)

Scores are added up and a score greater than or equal to 6 indicates a diagnosis of RA.


What is the DAS28 score + what is it used for ?

It is the disease activity score. It is based on the assessment of 28 joints and points are given for:
-Swollen joints
-Tender joints
-ESR / CRP result

It is useful in monitoring disease activity and response to treatment in RA.


What is the health assessment questionnaire (HAQ) ?

The questionnaire measures functional ability. NICE recommend using this at diagnosis of RA to check the response to treatment.


Prognosis of RA ?

Prognosis varies between pts from mild and remitting to severe and progressive. There is a worse prognosis with:
-Younger onset
-More joints and organs affected
-Presence of RF and anti-CCP antibodies
-Erosions seen on xray.


Management of RA ?

Starting treatment early is associated with better outcomes. It is important to have fully involvement of MDT including specialist nurses, physiotheraphy, OT, psychology and podiatry.

A short term of steroids can be used at first presentation and during flare ups to quickly settle the disease. NSAIDs are often effective but risk upper GI bleeding so are often avoided or co-prescribed with PPIs.

The aim is to induce remission or get as close to remission as possible. CRP and DAS28 is used to monitor the success of treatment. Aim to reduce the dose to the "minimal effective dose" that controls the disease.

NICE guidelines for DMARDS:
- First line is monotherapy with methotrexate, leflunomide or sulfasalazine. Hydroxychloroquine can be considered in mild disease and is considered the "mildest" anti rheumatic drug.
- Second line is 2 of these used in combination
- Third line is methotrexate plus a biological therapy, usually a TNF inhibitor.
- Fourth line is methotrexate plus rituximab.

Note: Pregnant women tend to have an improvement in symptoms during pregnancy, probably due to the higher natural production of steroid hormones. Sulfasalazine and hydroxychloroquine are considered as DMARDs in pregnancy.