RA

Question 1

what is RA?

Answer 1

• autoimmune, chronic, systemic
• infl dz, symmetrical
• targets synovial tissues, diarthrodial tissues
• polyarthritis
• extra-articular features
• idiopathic

Question 2

RA- systemic features

Answer 2

• fatigue, fever, anemia
• elevated ESR, CRP
• constitutional sx’s- malaise, myalgia, depression

Question 3

RA- immunopathogenesis

Answer 3

• RF produced by RA synovium
• RF’s fix complement- recruit PMN’s
• CCP ab’s

Question 4

RA- pathophysiology

Answer 4

• genetic factors (1/3 of pts)- inc risk of severe RA
• infiltration of leukocytes, cytokines, macrophages- act T cells
• B cells prod autoab’s
• pannus formation

Question 5

RA- imaging?

Answer 5

• Xrays- hands of feet

- CT- more sensitive detecting erosions

Question 6

RA- tx

Answer 6

• NSAID- for pain control
• DMARD
• low dose steroid for a few wks

Question 7

RA- epidemiology

Answer 7

• F 2-3X > M; 30-60 yo
• Native Ams- 5%
• improves during pregnancy

Question 8

why is RA important?

Answer 8

• significant mortality- CAD, HF due to endo damage from chronic infl
• young adults- peak incidence
• disables pts
• no perfect tx

Question 9

mortality assoc w RA

Answer 9

• infection (immunosuppressive drugs)
• renal dz
• GI dz
• HD
• malignancy

Question 10

RA classification criteria

Answer 10

Aat least 1 joint w clinical synovitis

• joint involvement- mult, small joints
• serology- RF, ACCP
• CRP and ESR
• duration of sx’s (>6 wks)

Question 11

Articular manifestations of RA

Answer 11

• diarthrodial synovial joint
• starts in hands and feet- MCP, PIP, MTP
• later larger joints
• C1-C2
• inc risk osteoporosis

Question 12

Hands

Answer 12

• DIP almost never involved
• swan neck
• boutonniere

Question 13

rheumatoid nodules

Answer 13

• elbow

- always RF +

Question 14

RA- radiographic progression

Answer 14

• bony erosions
• feet- MTP
• wrist- radial deviation; carpal tunnel syndrome
• knee- Bakers cyst (popliteal)
• C1-2

Question 15

PE

Answer 15

• tenderness, swelling, warmth, erythema fever
• wt loss, anorexia
• symmetrical joint involvement
• infl at least 6 wks

Question 16

Extra-articular manifestations

Answer 16

• more common in RF or ACCP +
• subcutaneous nodules (elbow)
• Pyoderma gangrenosum
• rheumatoid vasculitis
• HF, pericarditis, CAD (chronic endo infl)
• lungs
• secondary sjogrens syndrome

Question 17

Pyoderma gangrenosum

Answer 17

• tender reddish purple papule

- leads to necrotic, non-healing ulcer

Question 18

Rheumatoid vasculitis

Answer 18

-purpura, petechial, splinter hemorrhages, digital infarct

Question 19

RA- lungs

Answer 19

• pleuritis most common
• nodules, interstitial lung dz
• pulm fibrosis

Question 20

Caplan syndrome

Answer 20

-nodular densities after exposure to coal or silica dust (pneumoconiosis) + RA

Question 21

dry eyes/mouth- rule out what?

Answer 21

• SLE
• AIDS assoc keratoconjunctivitis
• vit A def

Question 22

Sjogren’s syndrome- tests?

Answer 22

• Ro/SS-A; La/SS-B
• schirmer’s test (filter paper under eyelids- collects tears)
• slit-lamp exam

Question 23

Sjogren’s syndrome- tx

Answer 23

• lubrication w artificial tears

- oral hygiene

Question 24

Sjogren’s syndrome and RA

Answer 24

• SS seen in 35% of RA pts

- keratoconjunctivitis sicca (dry eyes)

Question 25

Feltys syndrome

Answer 25

- RA - splenomegaly - neutropenia (<2000), anemia, thrombocytopenia - fever - RF and Anti-CCP +

Question 26

RA- other joints

Answer 26

- atlantoaxial subluxation- erosion of odontoid process | - peripheral neuropathy

Question 27

Dx of RA

Answer 27

-no SINGLE finding on PE or lab test is pathognomonic

Question 28

RA- lab

Answer 28

- RF +; Anti-CPP ab (15-20% of RA pts are neg) - ESR and CRP inc - anemia, thrombocytosis, leukopenia - ANA+ (30%) - hyperglobulinemia - low gluc in body fluids - synovial fluid- 2/3 PMN's; WBCs 5000-100,000

Question 29

RA- tx

Answer 29

- articular rest - goal is disease remission (50% of pts if tx'ed early) - NSAIDs- for pain relief- GI toxicity - corticosteroids- bridge tx!! (flare therapy) - DMARDs- immunosuppressive- inc risk of infection- takes 2-6 months

Question 30

RA tx- non-biologics

Answer 30

- Methotrexate (inhibits folic acid)- monitor labs; toxicity- hepatic, myelosupression, pulm; dont give during pregnancy - Hydroxychloroquine (antimalarial)- safe in pregnant pts - Leflunomide (pyrimidine antagonist)- dont use w pregnant!!! - Sulfasalazine

Question 31

RA tx- biologics- toxicity

Answer 31

- inc risk of infection - react of latent TB! - neoplasia - MS - autoimmune dz

Question 32

RA tx- biologics

Answer 32

Anti- TNF alpha (pro-infl cytokine) - Etanercept - Infliximab - Adalimumab - Rituximab

Question 33

Managing RA

Answer 33

- NSAID - DMARD - add biologic agent - low dose steroids- flares/bridge