Rheum E1 -RA & OA

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