Term
| decreased joint space as seen with an x-ray |
|
Definition
| best indicator of disease progression in RA |
|
|
Term
|
Definition
| joints commonly involved in RA and OA |
|
|
Term
MUCH OF THE JOINT DAMAGE BEGINS EARLY IN THE COURSE OF THE DISEASE
swan neck deformities: caused by tendon laxity, bony fusion (ankylosis)
rheumatic nodules
ulnar deviation or "drift"
joint pain and stiffness of more than 6 weeks
fatigue, weakness, low-grade fever, loss of appetite
muscle pain and afternoon fatigue
tenderness with warmth and swelling over affected joints usually involving hands and feet
joints involved symmetrical |
|
Definition
| clinical signs and symptoms of RA |
|
|
Term
vasculitis
pulmonary fibrosis and pulmonary nodules
ocular:
keratoconjunctivitis - no longer able to produce tears
inflammation of sclera, episclera, and cornea
cardiac:
pericarditis
myocarditis with or without conduction abnormalities
Felty's syndrome:
spleenomegaly - thrombocytopenia, neutropenia |
|
Definition
| extra-articular manifestations of RA |
|
|
Term
CBC with complete differential:
normochromic, normocytic anemia, thrombocytopenia, leukopenia
inflammation is causing shorter life span of these cells
acute phase proteins:
ESR - affected more by confounding variables
CRP
rheumatoid factor:
positive in 60-70% of patients with RA
active hepatitis C and lupus can elevate RF
anti-cyclic citrullinated peptide antibodies:
anti-CCP antibodies
more predictive for diagnosis than RF
shows up more quickly than RF
RF and anti-CCP are strong prognostic indicators |
|
Definition
| laboratory abnormalities of RA |
|
|
Term
5 of 7 must be present
first 4 continuous for > 6 weeks
morning stiffness > 1 hour duration
arthritis of 3 or more joint groups with soft tissue swelling or fluid
swelling involving one or more of the following joint groups: wrists, proximal interphalangeal, metacarpophalangeal
symmetric joint swelling
subcutaneous nodules
positive RF
radiographic changes consistent with RA |
|
Definition
| diagnosis of RA based on ACR criteria |
|
|
Term
DISEASE DURATION:
< 6 months
6-24 months
> 24 months
DISEASE PROGNOSIS:
functional limitations
high RF titer or positive anti-CCP antibodies
bony erosions documented radiographically
extra-articular manifestations
DISEASE ACTIVITY:
low, moderate, or high |
|
Definition
| ***treatment decisions of RA are based on these 3 criteria*** |
|
|
Term
high counts of swollen, tender joints
evidence of radiographic erosions
increased RF or anti-CCP concentrations
elevated ESR level
elevated CRP level
older age
female gender
genotype (HLA-DRB1 shared epitope)
cigarette smoking
increased HAQ (health assessment questionnaire) |
|
Definition
| prognostic factors for RA: the more present, the worse the prognosis of RA |
|
|
Term
|
Definition
| Does RF assess inflammation in the body? |
|
|
Term
NO
used for diagnostic purposes only |
|
Definition
| should anti-CCP levels be monitored to show RA progression? |
|
|
Term
|
Definition
| would CRP or ESR change after initiation of RA therapy? |
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|
Term
prodrug of M1 that inhibits dihydrooronate dehydrogenase inhibiting pyrimidine synthesis
significant enterohepatic recirculation: if patient is given antibiotic that kills gut flora then it may decrease recirculation and cause disease flares
teratogentic
may take up to 6 months to clear without washout using cholestyramine |
|
Definition
| clinical pearls of leflunamide |
|
|
Term
reduces inflammation by blocking activity of COX and lipoxygenase; antioxidant action that traps free radicals
needs folic acid supplementation |
|
Definition
| clinical pearls of sulfasalazine |
|
|
Term
HPA suppression
hyperglycemia
osteoporosis
hypertension
water retention
steroid psychosis
buffalo hump
immunosuppression
ELEVATED WBC
hypokalemia
insomnia
cataracts |
|
Definition
| side effects of corticosteroids |
|
|
Term
TNFa inhibitors:
infliximab - concurrent administration with methotrexate is recommended to decrease risk of serious infusion reactions and loss of efficacy
adalimumab - no foreign proteins (humanized), less antigenicity and infusion site reactions
golimumab
certolizumab pegol
etanercept - soluble receptor that binds to and inactivates TNFa |
|
Definition
| what are the first line biologic DMARDs for RA? |
|
|
Term
non-TNFa agents - used in patients who have failed TNFa agents
rituximab - monoclonal antibody that targets CD20 of B-cells causing B-cell depletion; should be used in conjugation with methotrexate, premedicate with prednisolone
abatacept - costimulation modulator (CD80/86)
anakinra: IL-1 receptor antagonist; should not be used in combination with TNFa inhibitors |
|
Definition
| second line biologics for RA |
|
|
Term
patients who stop initial treatment due to lack of efficacy are 2.3 x more likely to fail 2nd drug due to lack of efficacy
patients who stop initial treatment due to toxicity are 2.7 x more likely to fail 2nd drug due to toxicity |
|
Definition
| consequences of switching between TNFa inhibitors |
|
|
Term
withhold medication for >/= 1 week before/after surgery:
abatacept
TNFa agents
rituximab
biologics decrease the immune system and patients are at a greater risk of infection |
|
Definition
| recommendations for withholding biologic DMARDs in preoperative periods |
|
|
Term
infectious disease/TB
hematology/oncology
cardiac
liver
renal
neurologic
pregnancy/breastfeeding |
|
Definition
| contraindications to biologic DMARDs |
|
|
Term
latent TB should be treated with isoniazid x 9 months
anti-TNF may be safely started 1 month following isoniazid |
|
Definition
|
|
Term
CBC, liver tranaminases, creatinine should be monitored with all:
hydroxychloroquine, leflunomide, methotrexate, minocycline, sulfasalazine, biologic agents
hepatitis B and C testing:
leflunomide and methotrexate
ophthalmologic exam:
hydroxychloroquine |
|
Definition
|
|
Term
| monitor CBC, LFTs, and creatinine monthly for first 6 months then 1-2 months thereafter |
|
Definition
|
|
Term
platelet aggregation and sheer stress
collateral circulation inhibition: building of new heart vessels is mediated by COX2; people on a COX2 inhibitor are more likely to die from an MI b/c can't build new blood supply to the heart
diclofenac = BAD
naproxen = GOOD
ischemic preconditioning (COX2 mediated)
RA patients on methotrexate has less CV complications than RA patient on a different therapy |
|
Definition
| cardiovascular SEs and NSAIDs |
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