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RA is chronic symmetrical polyarthritis for ≥ _____
6 weeks
What genes are involved in RA?
MHC, HLA-DRB1, DRw4
What non-genetic RF contribute to the pathogenesis of RA?
diet, immobility, viral predisposition, aging, smoking, sex hormones
T/F: Patients with RA may notice an IMPROVEMENT in symptoms during pregnancy
True- estrogen is protective
What is the primary target tissue in pathogenesis of RA?
Synovium
What is a key player in synovial inflammation contributing to RA?
TNF-alpha
What is the New ACR Criteria for diagnosis for RA?
1 large joint (knee MC) OR 2-10 other joints PLUS Anti-CCP
What is the MC large joint that’s involved in RA?
Knee
What serology is the best indicator of RA?
anti-CCP antibodies (no longer RF)
What are the ABCDS of reading an XR?
Alignment
Bony detail
Cartilage
Density
Soft tissue
T/F: radial deviation of the MCP joints is seen in RA
FALSE- ulnar deviation of MCPs
Which joints in the hand are spared in RA?
DIPs
Which RA deformity?
Swan neck
Which RA deformity?
Boutonniere
What pattern does RA follow when affecting joints?
symmetrical
RA rarely affects the spinal column. What is the exception?
Atlas (C1) & Axis (C2)
What would you see on imaging of RA in the C-spine?
Wink sign: antlanto-axis subluxation
What is the best initial test for C-spine imaging in RA?
Open mouth view
Does RA in the knee usually cause hallux valgus or hallux varus?
Hallux valgus (knock knees)
What would an Xray of RA in the hips show?
acetabulo protusio, acetabular joint narrowed
What does RA in the feet/ankle/toes cause?
Pronation and eversion, hammertoe, splaying of forefoot
Extra-articular involvement in RA indicates what?
poor prognosis
What are skin manifestations of RA?
vasculitis & infarction
What are ocular manifestations of RA?
keratoconjunctivitis sicca, episcleritis, uveitis, scleritis, scleromalacia perforans
What are pulmonary manifestations of RA?
ILD
What is Caplan syndrome?
presence of rheumatoid lung nodules in the setting of pneumoconiosis (silicosis, coal miners)
What is the #1 cause of death in RA patients?
ASCVD (d/t proinflammatory state)
What are renal/GI manifestations of RA?
rarely affected by RA alone- more affected by NSAIDs/drugs
What is used to measure disease activity in patients with RA?
Disease activity score (DAS28)
DAS28 score >_____ implies active disease
5.1
DAS28 score <_____ implies well controlled disease
3.2
DAS28 score <_____ implies remission
2.6
What joints are missing in the DAS form??
feet: tarsals/metatarsals, ankle, hips
What is the Gold standard medication for treatment of RA?
*also first line
MTX
What do you need to give w/ MTX?
oral folic acid
What maximizes MTX absorption?
take on empty stomach
What are the MC side effects of MTX?
Elevated LFTs, Mouth sores, Blood count abnormalities (suppression), Lung problems
What RA tx is effect, but very expensive?
biologic modifiers (used w/ MTX)
What are SE of using biological modifiers?
inc risk of infxn (TB), inc risk for lymphoma & melanoma, autoantibody production (drug-induced ANA or lupus)
What is 2nd line treatment for RA?
TNF-alpha inhibitors (biologics)
Which drugs are TNF inhibitors?
Infliximab (remicade), etanerecept (enbrel), adalimumab (humira), Golimumab (simponi)
Which drug class for has a BBW for increased risk of CV events?
Jak Kinase inhibitors
What is the MC form of childhood arthritis?
Juvenile Idiopathic Arthritis (JIA)
Which JIA pattern:
Variable joint group involvement + constitutional symptoms
Systemic (sJIA)
Which JIA pattern:
Can be either RF+ or RF-, or anti-CCP+; ≥5 joint groups involved
Polyarticular (poJIA)
Which JIA pattern:
≤4 joint groups involved, often ANA+ (causing uveitis)
Oligoarticular (oJIA)
Which JIA pattern:
Nail changes, dactylitis, often RF-
Psoriatic (pJIA)
Which JIA pattern:
SI joint tenderness, HLA B-27+, uveitis, males >6 yo
Enthesitis-related (eJIA)
Which JIA pattern:
early arthritis, does not fit into any other category
Undifferentiated (uJIA)
What is the diagnostic criteria for JIA?
Adult RA criteria, PLUS
Age < 16 + exclusion of other causes
In oJIA, what is usually (85% cases) seen in serology testing?
(+) ANA
In poJIA w/ +RF, what else is seen in serology?
(+) Anti-CCP
What is the tx for JIA?
similar to RA: NSAIDs, steroids, MTX, & TNFi/biologics
Are women or men more affected by OA?
*~2x
Women
What are the RF for OA?
inc age, F > M, genetic predisposition, obesity, trauma/repetitive
Which subtype of OA is erosive?
Inflammatory
What is the primary target tissue in pathogenesis of OA?
Cartilage
What is the Gelling phenomenon?
difficulty initiating joint movement after inactivity/sitting for a while
Gelling phenomenon is seen in (OA/RA)
OA
What are Heberden's nodes?
nodes at DIP joints in OA
What are Bouchard's nodes?
nodes at PIP joints in OA
Which joints in the hand are spared in OA?
MCPs
What do the acute phase reactions show on labs in OA?
normal
What do plain Xrays of OA show?
bony sclerosis, eburnation, osteophytes, loss of cartilage
Does OA in the knee usually cause hallux valgus or hallux varus?
Hallux varus (bow legged)
What conditions is DISH associated with?
T2DM, Metabolic syndrome, Males
What is Syndesmophytes seen in?
DISH
What are Syndesmophytes?
tortuous paravertebral masses d/t ossification of the longitudinal ligaments
Is intervertebral disk space preserved in DISH?
yes
What is the1st line treatment for OA?
Topical NSAIDs (then oral NSAIDs)
What is 2nd line tx for OA?
other analgesics: acetaminophen, PT, wt loss, intra-articular steroid injections
When should you prescribe systemic steroids for OA?
NEVER
Which NSAID has COX-2 selectivity only in low doses?
Meloxicam (Mobic)
Which COX-2 meds were removed d/t CVD SAEs?
Vioxx (rofecoxib), Bextra
True or False: Osteoarthritis affects the joints asymetrically
True
What are the end products of the Arachidonic Acid Pathway?
Prostaglandins/Prostacyclines, Thromboxane A2, Leukoktrienes
What drugs are COX-2?
Celebrex & Mobic
