T2 - Artrite Reumatoide

Question 1

Frequência de Artrite Reumatóide?

Answer 1

0,7%

3:1 (mulheres:homem)

Question 2

Heridabilidade da Artrite Reumatóide?

Answer 2

30%

Question 3

Fatores Ambientais na Artrite Reumatóide?

Answer 3

Virus (EBV, parvovirus B19)
Tabaco
Stress/Comida
Álcool
Fatores Hormonais (prolactina como imunomodulador)

Question 4

Gene que aumenta risco de Artrite Reumatóide?

Answer 4

PTPN22

Question 5

Manifestações articulares da Artrite Reumatóide?

Answer 5

Monoartrite (punho e joelho)
Tenosinovite isolada
Oligoartrite
Poliartrite Simétrica (IFPs, MCFs, punho e MTFs) - Típico
Idosos - Poliartrite Rizomélica

Question 6

Detection of synovitis?

Answer 6

• Soft tissue swelling
• Tenderness
• Limited motion (frequently)

Question 7

Extra-articular manifestations of Rheumatoid Arthritis?

Answer 7

• Fever
• Pericarditis
• Pleuritis

Question 8

Laboratory investigations in Rheumatoid Arthritis?

Answer 8

• Elevated erythrocyte sedimentation rate and C-reactive protein
• Thrombocytosis; sometimes leucocytosis
• Rheumatoid factor in high titles
• Anti-cyclic citrullinated peptides

Question 9

Conventional radiographic examinations in Rheumatoid Arthritis?

Answer 9

• Hands
• Wrists
• Feet
• Baseline assessment

Question 10

Gold Standard?

Answer 10

Conventional radiography

Presence of erosions: key feature

Question 11

Early conventional radiographic signs of Rheumatoid Arthritis?

Answer 11

• Soft tissue hipertrophy, mainly in MCPs and PIPs
• Periarticular osteoporosis in MCPs and PIPs
• Marginal erosions (1st. Carpus; second MCP; ulnar styloid; lateral fifth metatarsal head)

Question 12

Advantage of High-resolution ultrasonography with power Doppler?

Answer 12

Higher sensitivity

Question 13

Magnetic resonance imaging (MRI) in Rheumatoid Arthritis?

Answer 13

Higher sensitivity.

Bone marrow edema is also typical, which is a predictor of subsequent erosions.

Question 14

Rheumatoid Arthritis classification criteria?

Answer 14

Joint involvement
Serology
Acute-phase reactants
Duration of symptons

Question 15

Diagnóstico diferencial na Artrite Reumatóide?

Answer 15

Distinguir de Osteoartrite

Question 16

Prediction of outcome in Rheumatoid Arthritis?

Answer 16

Prediciton of future physical disability
Prediciton of future structural damage
Prediciont of increased mortality

Question 17

Hands involvement in Established rheumatoid arthritis?

Answer 17

Boutonnière deformity
Z or 90-90 thumb
Swan-neck deformity
MCP deformities
Volar subluxation of the wrist

Question 18

Elbow and shoulder involvement in Established Rheumatoid Arthritis?

Answer 18

Elbow
• Frequently involved
• Early sign: loss of extension
• After: loss of supination 
Shoulder
• Not very frequently;
• Synovitis leads to erosion and damage of both the humeral head and glenoid fossa.

Question 19

Mais comum Subluxação da atlanto-axial?

Answer 19

Anterior (space between the odontoid process of C2 and the arch of the atlas
≥ 3 mm in cervical x-ray with the head in the flexed position)

Question 20

Lower limbs involvement in Established rheumatoid arthritis?

Answer 20

Knee
• Frequently involved (80%)
• Early sign: reduction of knee extension
• After: Baker`s cyst in the popliteal region and Valgus knee.
Hip
• Infrequently involved

Question 21

Feet involvement in Established Rheumatoid Arthritis?

Answer 21

• Triangle forefoot deformity
– Hálux valgus + quintus varus
• MTP joints subluxation
– Clawing of the toes
• Evolution: valgus flat foot
• Calcaneal valgus

Question 22

Other joints involvement in Established rheumatoid arthritis?

Answer 22

Temporal-mandibular joint
• Painful limitation of mouth opening
Cricoarytenoid joint
• Hoarseness
Ear ossicles
• Hearing loss independent of medication-induced effects

Question 23

Tenossinovites mais comuns?

Answer 23

• Flexor tenosynovitis
• Ulnar extensor carpi tenosynovitis
• Common fingers extensor tenosynovitis

Question 24

Typical Bursitis in Established rheumatoid arthritis?

Answer 24

Olecranon bursitis

Sub-Achilles bursitis

Question 25

Subcutaneous nodules in Established rheumatoid arthritis?

Answer 25

Extensor aspects of the proximal ulna Other pressure locations Not exclusive of rheumatoid arthritis

Question 26

Extra-articular manifestations in Established rheumatoid arthritis?

Answer 26

``` Secondary osteoporosis Secondary Sjögren`s syndrome Infections (artrocentese em monoartrite com AR controlada) Hematological abnormalities Splenomegaly (Sind. Felty) Renal disease Gastrointestinal manifestations ```

Question 27

Eye complications in Established rheumatoid arthritis?

Answer 27

* Episcleritis * Dry eyes * Escleromalacia * Ocular perforation * Iritis

Question 28

Vasculitis in Established rheumatoid arthritis?

Answer 28

* Uncommon (1%), related to disease severity and activity * Necrotising vasculitis * Cutaneous ulceration * Peripheral neuropathy

Question 29

Pulmonary disease in Established rheumatoid arthritis?

Answer 29

* Pleuritis * Intersticial pneumonitis * Intersticial fibrosis * Bronchiectasis

Question 30

Rare Pulmonary disease in Established rheumatoid arthritis?

Answer 30

* Nodular lung disease | * Caplan Syndrome (macronodular AR + silicosis)

Question 31

Cardiac and cardiovascular disease in Established rheumatoid arthritis?

Answer 31

Arteriosclerosis | Pericarditis

Question 32

Mortality in Rheumatoid arthritis? Causes?

Answer 32

In severe forms, reduction of 5 years in life expectancy Causes: • Cardiovascular • Infectious

Question 33

Therapeutic targets in Rheumatoid arthritis?

Answer 33

``` Suppress inflammation Protect against joint destruction Preserve function Prevent comorbidities (cardiovascular and others) Improving the quality of life ```

Question 34

Disease assessment in Rheumatoid arthritis?

Answer 34

• Tight control: every 3 months • Global disease activity assessment by the patient on VAS • Number of tender joints (pressure) • Number of swollen joints (pressure) Stanford Health Assessment Questionnaire (HAQ)

Question 35

Remission criteria in Rheumatoid arthritis?

Answer 35

Tender joint count < 1 Swollen joint count < 1 Patient global assessment < 1 PCR < 1 mg/dl

Question 36

Symptomatic treatment in Rheumatoid arthritis?

Answer 36

``` Rest Analgesics NSAIDs CCTs • Severe disease; NSAIDs contraindicated • Average dose: prednisolone 7,5 mg/day • EV methylprednisolone (500 mg to 1g/day, 3 consecutive days → flares) ```

Question 37

Indications of glucocorticoids in early arthritis and established rheumatoid arthritis?

Answer 37

* Intra-articular in mono or oligo-articular flares * In established rheumatoid arthritis for symptomatic control * In a polyarticular flare for symptomatic control

Question 38

Fármacos modificadores da doença reumática (imunosupressores)?

Answer 38

Justification • Effective control of clinical and biological signs of disease • Prevent /retard radiological progression • Induce remission Time of prescription • The earliest possible: after diagnosis Duration prescription • Long as it remains effective and well-tolerated

Question 39

DMARDs com Potencial prognóstico benigno ou dúvidas diagnósticas? E com prognóstico sério ou indeterminado? Ausência de resposta?

Answer 39

Hidroxicloroquina. Metotrexato e Leflunamida. Anti-TNF e Combination therapy.

Question 40

Conclusion remarks on Rheumatoid arthritis?

Answer 40

Disabling condition: • High morbidity • Disability Decrease in life expectancy in five years, compared to the general population Window of opportunity • Need for early diagnosis • Need to establish early the patient outcomes • Early institution of the most appropriate therapy Need for tight control