Case 1: RA

Question 1

What is the most common form of chronic inflammatory arthritis that can result in joint damage and physical disability?

Answer 1

RA

Question 2

T/F: RA is a systemic disease with a lot of extra-articular manifestations?

Answer 2

True

Question 3

Risk factors for RA

Answer 3

• Genetics
• F >> M
• Smoking
• Peak incidence 25-55 (females of childbearing age)

Question 4

Risk factors Genetics

Answer 4

HLA-DRB1 genes “shared epitope”

Question 5

Risk factors Gender

Answer 5

Estrogen is a component of creating TNF (inflammatory response)

Question 6

Pathophys: What tissue is the main target for RA autoimmune process?

Answer 6

Synovial tissues

Question 7

Pathophys: What is a pannus formed from?

Answer 7

• Synovial proliferation
• Pannus invades & destroys bone and cartilage

Question 8

Pathophys: What is the preclinical stage?

Answer 8

• Breakdown of self-tolerance
• RA and anti-CCP are detected years before manifestations of RA occur

Question 9

Clinical Manifestations Joints

Answer 9

• Insidious onset
• Morning stiffness > 30 mins (also after prolonged inactivity)
• Symmetric swelling
• Many joints (tender/painful)

Question 10

What are the joints that are most affected in RA?

Answer 10

• PIP
• MCP
• MTP
• (also wrists, ankles, knees)

Question 11

Clinical Manifestations Hands

Answer 11

• Ulnar deviation of MCP joints
• Swan neck deformity
• Boutonniere deformity

Question 12

Describe a Swan neck deformity

Answer 12

Hyperextension of PIP, flexion of DIP

Question 13

Describe a Boutonniere deformity

Answer 13

Flexion of PIP, extension of DIP

Question 14

Clinical Manifestations General

Answer 14

• Fatigue
• Weight loss
• Low grade fever

Question 15

Clinical Manifestations Rheumatoid Nodules

Answer 15

• Almost only in those who are RF positive
• Often on extensor surfaces (forearms), over joints, pressure points
• Firm, non tender
• in lungs, sclerae, other tissues

Question 16

Clinical Manifestation Vasculitis

Answer 16

• Attacking blood vessel
• Anything from small lesions to large bruises

Question 17

What is the most common ocular clinical manifestation?

Answer 17

Keratoconjunctivitis sicca (2/2 Sjogren syndrome, could also include xerostomia, dry eye)

Question 18

What is the most common pulmonary clinical manifestation?

Answer 18

Pleuritis (arthritic CP, dyspnea)

Question 19

Clinical Manifestations Cardiac

Answer 19

• Chronic inflamm increasese risk for CV dz
• Pericardial effusions
• Pericarditis

Question 20

Felty Syndrome Triad

Answer 20

1. Splenomegaly
2. Neutropenia
   
   1. could be asympto or have recurrent bacterial infxn
3. RA
   
   1. seropositive, erosive, severe

Question 21

SANTA?

Answer 21

• Splenomegaly
• Anemia
• Neutropenia
• Thrombocytopenia
• Arthritis

Question 22

What 4 specific labs should you order for RA?

Answer 22

1. Anti-CCP
2. RA(RF)
3. ESR
4. CRP

Question 23

What is the most specific bloodwork for RA?

Answer 23

Anti-CCP antibodies (95% specific)

Question 24

What percentage of RA patients are RF positive?

Answer 24

80%

Question 25

What percentage of RA patients are seronegative?

Answer 25

About 15%

Question 26

T/F: ESR/CRP will be normal in RA patients

Answer 26

False - elevated

Question 27

What else might you see on lab results for RA?

Answer 27

* Mild anemia * Thrombocytosis * WBC nl/mild * Leukocytosis (platelets can be inc or dec)

Question 28

What might you see with the synovial fluid of a RA patient?

Answer 28

* inflammatory effusion * Leukocytes (1500-25k) * PMNs predominate

Question 29

T/F: Radiographs in early stages of disease will likely be normal

Answer 29

True

Question 30

What will you see on radiographs initially?

Answer 30

* Soft tissue swelling * Osteopenia around joint * Earliest changes show in _wrists or feet_

Question 31

What will you see on radiographs later in the RA dz process?

Answer 31

* Joint space narrowing and erosions * MRI or U/S can be used

Question 32

American College of Rheumatology 2010 Classification Criteria Summary and Takeaways?

Answer 32

* Must get a score of at least 6 * Get most points for involvement of small joints * Do not need RF to make Dx * Duration _\>_ 6 wks

Question 33

Criteria for the Dx of RA?

Answer 33

* Inflammatory arthritis involving **_\>_ 3 joints** * **Positive RF and/or anti-CCP** * **Elevated** ESR and/or CRP * Duration of **_\>_ 6 wks** * Excluded other causes (osteomyelitis, SLE)

Question 34

What if a patient is seronegative? How do you Dx RA?

Answer 34

If seronegative - can still Dx RA if you have excluded other causes and all other characteristics are met

Question 35

What are the treatment goals for RA?

Answer 35

* Control pain and inflammation * Preserve function * Prevent deformity * Early Dx and initiation of DMARDs (Dz Modifying Anti-Rhematic Drugs)!! * Rheumatologist involvement * infusions, multiple meds

Question 36

T/F: RA patients often just need monotherapy of DMARDs

Answer 36

False - often need combination of DMARDs (MTX + TNH inhibitor) MC

Question 37

Pretreatment Screening

Answer 37

* Hep B & C * Baseline CBC, Cr, LFTs, ESR, CRP * Ophthalmic screening (eye toxicity) * _Hydroxycholorquine MC S/E_ * Check for Latent TB * R/O pregnancy * Baseline radiographs

Question 38

What medication is used for symptom relief but doesn't alter the disease course of RA?

Answer 38

NSAIDs - all are about equal (NOT for monotherapy)

Question 39

What medication is very helpful for both sx relief and slowing the rate of joint damage?

Answer 39

Corticosteroids (NOT for monotherapy or long term use!)

Question 40

What medication is a good choice to use to bridge while starting a DMARD?

Answer 40

Corticosteroids **Start Prednisone 5-20mg QD** (depending on severity) Taper as soon as possible

Question 41

If the patient has sever RA what DMARD should be started?

Answer 41

Biologics (TNF Inhibitor): * Etanercept (Enbrel) * Infliximab (Remicade) * Adalimumab (Humira)

Question 42

What are some conventional DMARDs?

Answer 42

* **Methotrexate = MC** * Sulfasalazine * Hydrocychloroquine * Leflunomide

Question 43

Starting dose for Methotrexate?

Answer 43

**7.5mg PO weekly** Usually note improvement within **2-6 wks**

Question 44

Contraindications for Methotrexate?

Answer 44

* Pregnancy (teratogenic) * Liver dz * Heavy EtOH * Severe renal impairment

Question 45

Methotrexate S/E?

Answer 45

* GI upset * Stomatitis * **Need close monitoring:** CBC (cytopenias) - watch for suppression of bone marrow * LFT's for hepatotoxicity

Question 46

What should be given with every patient on Methotrexate?

Answer 46

* **Folic acid 1 mg PO QD OR** * Leucovorin Ca+ 2.5-5mg weekly * To prevent hematologic and other S/E

Question 47

TNF Inhibitors

Answer 47

* REFER to Rheum * SQ or IV (infusion) * Expensive!! * Well tolerated - low S/E * Much higher risk of **serious bacterial infxn** * granulomatous infxn _(esp reactivation of TB)_

Question 48

What MUST you screen for prior to starting TNF Inhibitors?

Answer 48

Latent TB

Question 49

What is the TNF Inhibitor of choice?

Answer 49

Etanercept

Question 50

Follow Up

Answer 50

* Assess sx and functional status at all visits * Monitor lab work for dz activity and potential toxicities of medication * Follow radiographs q 2 yrs

Question 51

Prognosis?

Answer 51

* Prior to MTX - very poor morbidity, mortality, and financial loss * With successful tx: less deformity, joint SX, morbidity, mortality * Pts will have dz flares * Higher motality with RA attributed to CV dz from chronic inflammation

Question 52

What are poor prognosis factors?

Answer 52

* RF or anti-CCP positive * Extra-articular dz * Functional limitations * Erosions on radiograph

Question 53

What are the 4 categories for the scoring of RA?

Answer 53

1. Joint involvement (tender/swollen) 2. Serology 3. Acute-phase reactant 4. Duration of sx