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87 Cards in this Set
- Front
- Back
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What are the diagnostic criteria for rheumatoid arthritis?
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Morning stiffness lasting at least 1 hr*
Arthritis in at least 3 joints* Arthritis of hand joints( Symmetric arthritis* Abnormal RF levels Rheumatoid nodules Typical changes in xray of hand/wrist * must last at least 6 weeks |
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What is the stereotypical person who is diagnosed with RA?
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WOMAN between 35 and 60
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What is the impact of RA on finances/work?
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50% decreased lifetime earning potential
30 days of lost productivity/year |
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Having RA puts you at an increased risk for this?
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CV disease
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What predisposes someone to RA?
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HLA-DR4 mutations
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What are the joints involved in RA?
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Hands: MCP, PIP joints
Wrists Elbows Shoulders Hips Knees Ankles Feet Cervical spine |
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What part of the body is spared in RA?
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Thoracic spine
Lumbar spine DIPs |
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What are the typical physical findings of RA?
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Soft tissue swelling
Warmth Deformities |
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What are the typical findings of RA on a radiograph?
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Periarticular osteopenia
MARGINAL EROSIONS |
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What are the typical labs found in RA?
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Increased ESR
RF Anemia Thrombocytosis Hypoalbuminemia |
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What are the different causes of systemic rheumatic disease?
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SLE
Scleroderma Polymyositis Vasculitis |
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What types of arthritis can involve the TMJ? What don't?
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Do: RA, Juvenille RA
Rare: Gout |
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What types of arthritis can involve the larynx? What don't?
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Do: RA
Don't: all others |
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What types of arthritis can involve the elbows/wrists/MCPs? What don't?
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Do: any synovitis
Don't: OA |
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What types of arthritis can involve the DIPs? What don't?
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Do: OA, psoriatic arthritis
Don't: RA |
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What types of arthritis can involve the hips? What don't?
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Do: OA, RA
Doesn't: Gout |
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What types of arthritis can involve the cervical spine? What don't?
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Do: Everything but gout
Don't: Gout |
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What types of arthritis can involve the thoracolumbar spine? What don't?
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Do: Spondyloarthropathies, OA
Don't: Gout, RA |
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What kinds of arthritis shows markedly elevated leukocyte counts?
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Gout
Septic arthritis Juvenille RA RA |
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What kinds of arthritis show a white count that isn't elevated much at all?
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OA
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Where on the bone do you typically see damage happening in RA?
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ON the side, where there isn't any cartilage to protect the bone from the inflamed synovium
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What does the histology of RA look like?
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Severe inflammation of the synovium
-Immune cells -Hyperplasia -Angiogenesis |
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What are some bacterial triggers of RA?
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Gram + cocci
Mycobacteria Proteus E. coli Mycoplasma P GINGIVALIS |
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What are some viral triggers of RA?
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EBV
Parvovirus Retroviruses CMV Rubella HHV6 |
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What dental condition is associated with RA? What bacteria is implicated?
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Peridontal disease
P. gingivalis |
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What are the genetic risk factors for RA? Environmental?
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Genetic:
MHC Class Ii alleles (HLA-DR4) Environmental SMOKING!! |
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Why should you counsel someone with a history of RA to stop smoking?
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IT PUTS THEM AT SIGNIFICANTLY INCREASED RISK FOR RA!!!
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What are the different kinds of autoantibodies in RA?
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RF
anti-citrullinated peptides (anti-CCP) |
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What is the structure of the RF antibody?
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an IgM antibody against the constant region of IgG
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What is the problem with using RF as a test for RA?
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It's present in a lot of other conditions!!!
Also, if someone doesn't have it, you can't rule out RA: 20% have RA but aren't RF positive |
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What is citrulline? What causes it to be present in the body?
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It's a derivative of arginine
PADI (peptidyl arginine deaminase) is responsible for it being in the body: arginine ------PADI-----> citrulline |
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Where are citrullinated proteins present in large numbers?
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They're found in inflamed synovium
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What is the effect of smoking on the lung?
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Aside from catastrophic damage, you cause...
CITRULLINATION OF THE PROTEINS |
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What kind of bacteria expresses PADI?
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Our dental friend...
P. gingivalis |
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What kinds of immune cells are involved in the pathogenesis of RA?
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T-cells
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What inteleukins are found in RA?
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IL-17
-Found in arthritis joints -Administering makes the symptoms worse |
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What interleukins induce IL-17 expression?
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IL-6, IL-1
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What causes an undifferentiated helper T cell to differentiate into the differet kinds of T helper cells? What interleukins do the different kinds of T helper cells produce?
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What are the pro-inflammatory cytokines in chronic inflammation?
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TNF alpha
IL-1 |
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What are some of the antiinflammatory cytokine inhibitors in chronic inflammation?
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Soluble TNF receptor
IL-10 IL-1 receptor antagonist |
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Where is TNF found? Where does it act?
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TNF is found on the cell surface of a macrophage or activated T cell
When it gets cleaved off, it goes to different cell types |
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What are the activites of TNF throughout the body?
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Endothelium: adhesion molecules, angiogenesis via EGF
Macs: cytokine release Hepatocytes: increased CRP Synoviocytes: articular cartilage degeneration via increased MMPs Osteoclast progenitors: RANKL expression-->erosions |
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What do you want to block in RA?
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TNF-alpha
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What are the hematologic manifestations of RA?
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Anemia
Thrombocytosis Frelty's syndrome (uncommon) -Leukopenia -Splenomegaly (see picture!) -+/- infections, leg ulcers |
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What is the composition of the RA nodules? Who is more likely to have them?
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Pallisading granuloma
More common if someone's RF+ |
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What are some of the "other" complications of RA?
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Hematologic
Nodules Sjogren's syndrome Secondary amyoiditis Ocular PNS Pulmonary Serositis |
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What are the symptoms of Sjogren's?
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Dry eyes
Dry mouth |
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What is the cause of Sjogren's syndrome?
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Lymphocytic infiltrate in salivary, lacrimal glands
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What's a serious complication of Sjogren'?
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LYMPHOMA
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If someone has secondary amyloidosis in RA, how do they present?
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Proteinuria
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What vascular problems can RA cause?
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Rheumatoid vascuitis
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What are some of the ocular manifestations of RA?
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Keratoconjunctivits sicca (dry, inflamed eye)
Episcleritis SCLERITIS (DANGEROUS - SEE PICTURE) |
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What are some of the PNS complications of RA?
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Peripheral neuropathy
Nerve entrapments Mononeuritis multiplex due to arteritis |
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What are some ofthe pulmonary complications of RA?
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Interstitial infiltrates
BOOP (bronchiolitis obliterans - organizing pneumonia) |
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What types of serositis can occur during RA?
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Pleural effusion
Pericardial effusion: can result in tamponade or constriction if serious enough |
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What are the properties of a pleural effusion within RA?
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Low glucose
Low complement Variable WBC High protein Basically, low glucose in the context of no infection (odd.) |
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What are some of the different classes of drugs used to treat RA?
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NSAIDS
Corticosteroids DMARDS |
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What is the general principle for medication administration in RA?
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POlypharmacy - more drugs is better!
You've got to monitor carefully for side effects. |
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When should you use NSAIDS in RA?
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Short term: analgesic, anti-inflammatory, anti-pyretic effects for a number of reasons
Long term: treatment for chronic inflammatory RA |
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What are different ways that you can use steroids in RA?
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Flares: inject it in the joints
Low dose, long term: adjunct to the biologics (below 10 mg/day) Higher doses: vasculitis, etc. |
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What should you never, ever do to someone who's been on steroids?
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Don't let them abruptly stop!!!
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What are some example of conventional DMARDS for RA?
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Anti-malarials
Tetracyclines Sulfasalazine |
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What are some of the cytotoxic/immunosuppressive agents used to treat arthritis/RA?
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Methotrexate
Azathioprine Leflunomide Cyclosporin |
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What is the mechanism of hydroxychloroquine?
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Inhibits H transport in lysosomes
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What are the side effects of hydroxychloroquine?
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Ocular toxicity!
Rash GI Rare: hemolytic anemia, neuromopathy Most benign |
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What is the dosing of hydroxychloroquine?
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200-400 mg/day, 6.5 mg/kg ideal body weight
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What are the indications for sulfasalazine?
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RA
IBD |
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What is the action of sulfasalazine?
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Unknown.
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What are the toxicities associated with sulfasalazine?
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Indigestion
headache rash Hepatitis Neutropenia |
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What's the dosing of sulfasalazine?
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Initially 500 mg big
Increase to 1.0-1.5 gm bid |
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What is the mechanism of methotrexate?
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Folic acid antagonist
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What's the dosing of methotrexate?
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5-20 mg/WEEK given po, im, iv
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What are some of the toxicities associated with methotrexate?
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Nausa/vomiting
Oral ulcrs/stomatitis Bone marrow suppression , esp. in people with bad kidneys Pulmonary toxicity Hepatotoxicity Teratogenesis Infection |
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What is the mechanism of leflunomide?
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Pyrimidine synthesis inhibitor
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What's the dosing of leflunomide?
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10-20 mg qd
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What are the toxicities of leflunomide?
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Alopecia
Hepatitis Infection |
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How do you get rid of leflunomide toxicity?
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Washing out with a couple days of cholestryamine, which is a binder of the drug.
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What are some of the different kinds of TNF inhibitors used to treat RA?
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Etanercept
Infliximab Adalimumab Golimumab Certolizamab |
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What kind of a TNF inhibitor comes from Speedy Gonzalez, a mouse?
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Infliximab
He INFLIX lots of pain on the cat! |
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What is the mechanism of Infliximab?
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Binds to soluble, membrane-bound TNF with lots of affinity
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What is the mechanism of etanercept?
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Has the TNF receptor on connected to the Fc region of IgG1 --> consumes TNF inside the cell
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What are some of the consequences of administering anti-cytokines ?
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Infection
Malignancy |
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What are some conditions that are containdications to giving TNF inhibitors? Why?
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Histoplasmosis
TB Many others YOU NEED TO BE ABLE TO FORM GRANULOMAS TO GET RID OF THESE GUYS...IF YOU DON'T HAVE TNF, NO GRANULOMAS! |
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What rheumatic disease can you cause, in a way, by giving TNF inhibitors?
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SLE
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What cell does Rituximab target? What molecule?
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B cells
anti-CD20 |
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What cells does Abatacept target? What molecule?
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T cell costimulation through CD28
CTLA-4-Ig |
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What is the target of Tocilizumab?
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IL-6
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