What are criteria to be diagnosed with RA?
needs score of 6 - Joint involvement 0 = 1 large joint 1 = 2-10 large joints 2 = 1-3 small joings 3 = 4-10 small joints 5 = >10 joints - Serology (at least 1 test result is needed for classification) 0 = neg RF and neg ACPA 2 = low + RF or low + ACPA 3 = high + RF or high + ACPA - acute phase reactants (at least 2 test needed) 0 = normal CRP and normal ESR 1 = Abnormal CRP or abnormal ESR - duration of sx: 0 = < 6 weeks 1 = > or equal 6 weeks
What are systemic manifestations of RA?
- Morning stiffness - Difficulty in moving upon awakening
- Anorexia
- Weight loss
- fatigue
What joints are typically involved in RA?
- Hands
- Wrists
- Elbows
- shoulders
- Knees
- Ankles
- Feet
What does hand involvement of RA look like?
- Swelling of PIP joints
- Fusiform or sausage like appearance
- 3rd and 4th PIP affected
What does swan neck deformity look like?
PIP hyperextension and flexion of DIP
- Hypermobility at chronically inflamed PIP- volar subluxation and PIP hyperextension
- Volar capsule of PIP is stretched, lateral bands move dorsally- tension on FDP by the PIP flexes the DIP
What does boutonniere deformity look like?
flexion of PIP and hypertension of DIP
What are characteristics of RA in ankles and feet?
- Synovitis of MTP joints-metatarsalgia
- Hallux valgus
- Bunion - painful bursitis of medial aspect of 1st MTP joint
- Hammer toes
What are characteristics of RA in knees?
- Large amount of synovium- commonly involved
- Chronic synovitis- distension of joint capsule
- Destruction of joint surfaces
- Painful knees- flexion contractures
What is m involvement in RA?
- Atrophy of intrinsic muscles of the hand
2. Quadriceps atrophy - Disuse atrophy, Myositis, Steroid induced myopathy, or Peripheral neuropathy
Most common extra articular manifestation; 25% of patients with RA; Extensor surface of elbows, forearms, dorsum of hands, Achilles tendon
Rheumatoid nodules
Redness in the eye due to systemic inflammation in the eye from RA
- episcleritis
2. scleromalacia
non healing ulcers that appear when RA is chronic
vasculitis
Is RA benign?
no:
- severe functional disability
- substantial morbidity
- Increases mortality: most common cause of death with RA = heart disease due to ongoing inflammation
Why does chronic inflammation happen?
pro-inflammatory cytokines overwhelm anti-inflammatory cytokines
- IL-6, TNF alpha, IL-1
Why is early treatment important with RA?
results in easier remission with less joint damage
- damage occurs within first 2 years
What are lab tests for RA?
- Elevated Erythrocyte sedimentation rate (ESR)
- Elevated C reactive protein (CRP)
- Rheumatoid factor
- Cyclic citrullinated peptide antibodies (Anti CCP)
- CBC - Anemia; Thrombocytosis (increased platelet count)
Marginal erosions of the bone; close to the sides and joint line
peri articular osteopenia
- detected by US longitudinal and coronally
- MRIs more sensitive, but more expensive
Mothed of scoring severity of joint space narrowing (normal, focal, >50%, < 50% and ankylosing) and bone erosion (discrete to complete collapse)
Modified sharp scoring method
Name the classes of RA according to the global functional status of RA (I-IV)
I = completely able to perform usual everyday life II = Able to perform self-care and vocational activities, but limited to avocational activities III = able to perform ADLs, but limited in ability to perform vocational and avocational activities IV = Limited ADLs, vocational and avocational activities
What is the first line of drugs for managing RA?
Methotrexate
- if does not control inflammation, need to adjust medications
Analog of dihydrofolic acid; Inhibits dihydrofolate reductase; Immunomodulatory effects at low doses; GI complaints, mucositis, alopecia, LFT elevations, infections; Injectable form improves bio availability
Methotrexate
- most common complication is ulcers - folic acid helps
- Methotrexate induced pneumonitis, teratogenicity
Hydroxychloroquine is administered orally; approximately 75% of the drug is absorbed. Gastrointestinal toxicity is relatively common should preferably be given with food; extensively tissue bound and has a long elimination half-life of the order of 40 days.; preferentially stored in melanized tissue and hence has a propensity to concentrate in the skin and retinal pigment.
Hydroxychloroquine (plaquenil)
- needs eye evaluation
- can cause skin rash, in which case it needs to be stopped
What are the ADRS of antimalarials?
- Gastrointestinal tract-Nausea, abdominal discomfort, diarrhea
- Skin- Rash, depigmentation
- Eye- Blurring of vision, rarely retinopathy
- Central nervous system- Tinnitus, headache
- Muscle- Myopathy** = m weakness
- Pregnancy-Crosses placenta and risk of fetal abnormalities
Inhibits dihydro orotate dehydrogenase; Decreases T & B cell proliferation; Lack of renal toxicity; Diarrhea- improves with dose reduction; Elevation of LFTs, hypertension, transient leukopenia; Contraindicated in pregnancy and lactation
Leflunomide
