what is the definition of RA
chronic, systemic, inflammatory autoimmune disease of uknown etiology
-chronic, symmetric, erosive synovitis of peripheral joints
-extraarticular manifestations
what is phase 1 of RA
genetic risk
what is phase 2 of RA
preclinical autoimmunity
what is phase 3 of RA
clinical disease
which antigens can cause RA?
- viruses: retroviruses, EBC, parvo
- mycoplasma: GI system/ microbiome
- heat shock proteins, carilage antigens, peptides
what is the genetic susecptability
HLA-DR1
HLA-DR4
what is the screening tool for RA
- significant discomfort with squeezing the MCP and MTP joints
- prescene of 3 or more swollen joints
- more than 1 hour of morning stifness
what is the RA history
-degree of joint pain
-duration of morning stifness
-poor sleep patterns:
-prescense or absense of fatigue
-limitation of function: especially hand
-weight loss
what is the RA physical exam
-joint count of actively inflammed joints
mechanical joint problems:
-loss of motion
-crepitus
-instability
-malalignment
-deformity
what are some extraarticular manifestation
-scleritis
-rhematoid nodules
-vasculities
-intersitial lung disease
-pericardial disease
talk about sclertisi
blood shot eyes
-someone needs to see eye doctor immediatley because they are at risk of losing their eyesight
talk about vasculities
the tissue becomes necrotic
what are some poor prognostic indicators
-earlier age at onset, female
-polyarticular synovitis >13 joints
-lab tests: high tier rhemaotoid factor or anti CCP, elevatedf ESR or CRP level, HLA-DR4
-erosions or cartilage loss on x-ray
-poor functional status
-extra articular manifestation
what is on the HAQ
-dressing/grooming
-arising
-eating
-walking
-pain
-fatigue/tiredness
-sleeping
-ambulatpru aiodes and independence
talk about the cervical spine manifestation
-atlantoaxial subluxation due to laxity/rupture of the transverse ligament
-fracture/erosion of the odontoid process
-anterior sublux of the atlas on the axis=most common
-posterior sublux of atlas on axis due to fracture= rare
-vertical sublux of odontoid in relation to atlas= brainstem impingement
symptoms: asymp, cergical/occipital pain, cord impingement
talk about thoracic manifestation
usually spared in RA
-compression fractures secondary to steroid therapy is a risk
talk about the shoulder manifestastion
-GH joint and AC joint
-subacromial bursitis
-rotator cuff tendinitis/rupture
-bicipital tendinitis/rupture
talk about the elbow manifestation
-flexion deformities and loss of lateral stability can develop
-entrapment of ulnar nerve or radial nerve due to synovitis
-olecranon bursitis: infection
-extensor surface of forearm: nodules
talk about hand and wrist manifestations
-DIPs spared
-ulnar drift at MCP
-palmar subluxation of MCP
-swan-neck and boutonnieere deformity
-tenosynovitis:
flexor tendons= weakness, creptius, carpal tunnel syndrome, extensor tendons= 3/4/5 tendon ruputure due to abrasion by eroded ulnar styloid
talk about hip manifestations
-1/2 pts with RA have radiographic evidence of hip disease
-protrusio acetablui: 5%
-trochanteric, iliopsoas and ischial bursitis
-avascular necrosis of the femoral head
talk about knee manifestations
-effusions and synovial thickening
-quad atrophy; loss of full ext
-tricompartment loss of joint space on x-rays
-bakers (popliteal) cyst
what is RA initial treatment
-NSAIDs to reduce joint pain and swelling and improve function
-multidisiplinary care: RA consultation, PT and OT, podiatry, orthopedics
-steroids?
-disease modifying drugs (DMARDs) start within 2-3 months of diagnosis
what are the drug treatment options
- NSAIDS: symptom relief, improved function, no change in disease progression
- low-dose steroids: may substrituee for NSAID, used as bridge therapy, if long term, OA risk
- intraarticular steroids: useful for flares
- DMARDs: immunosuppressive drugs
- biologic therapies: TNF inhibitors
what is the health-care maintenance
- OA: dexa scans, calcium/Vit D, bisphosphonates
- CV disease risk/modify
- quit smoking
- infection risk: flu vaccine, pneumococcal vaccine, shingles vax
