Rheumatoid Arthritis Overview

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Questions and Answers

What is the primary cause of morbidity in rheumatoid arthritis patients?

Cardiovascular disease (correct)

Pulmonary complications

Skin rashes

Joint deformities

Which demographic has the highest prevalence of rheumatoid arthritis?

Elderly men aged 70 and above

Men aged 15-45

Women aged 15-45 (correct)

Children under 12

What role does the HLA-DR4 antigen play in rheumatoid arthritis?

It ensures effective joint mobility.

It is a treatment marker for RA severity.

It is associated with an increased risk of RA. (correct)

It decreases the risk of developing RA.

Which of the following is NOT considered an extraarticular manifestation of rheumatoid arthritis?

Joint inflammation Signup and view all the answers

What is a significant factor that can exacerbate rheumatoid arthritis severity?

Smoking Signup and view all the answers

How does age affect the prevalence of rheumatoid arthritis?

Prevalence increases until the 70s. Signup and view all the answers

What is the estimated reduction in life expectancy for rheumatoid arthritis patients compared to the general population?

3-10 years Signup and view all the answers

Which statement accurately reflects the genetic predisposition in rheumatoid arthritis?

Monozygotic twins have a significantly higher risk. Signup and view all the answers

Which of the following joints are typically affected by rheumatoid arthritis (RA)?

Small joints like hands and feet Signup and view all the answers

What is a key laboratory finding for the diagnosis of rheumatoid arthritis?

Presence of elevated C-reactive protein (CRP) Signup and view all the answers

What is the dosing schedule for oral Methotrexate in the treatment of rheumatoid arthritis?

Start at 7.5 mg once weekly, adjusting by 5 mg every 2 to 4 weeks Signup and view all the answers

What is a common adverse effect associated with Leflunomide therapy?

Bone marrow suppression Signup and view all the answers

What should be monitored regularly during Methotrexate therapy?

Liver function tests (LFTs) and complete blood count (CBC) Signup and view all the answers

Which of the following is contraindicated when using Methotrexate?

Pregnancy Signup and view all the answers

Which statement accurately describes Hydroxychloroquine's indications in RA treatment?

Used for all durations and severities of the disease Signup and view all the answers

What distinguishes rheumatoid arthritis from other diseases?

It mounts an attack on self and non-self Signup and view all the answers

Which of the following correctly identifies a potential trigger for autoimmune responses?

Viral infections like Epstein-Barr Signup and view all the answers

What trend has been observed regarding antinuclear antibodies (ANA) prevalence over the years?

It has significantly increased Signup and view all the answers

Which time period showed a notable increase in ANA prevalence, reaching 27 million people?

1999-2004 Signup and view all the answers

What does the rise in the prevalence of ANA suggest about autoimmune diseases?

There may be environmental or genetic factors at play Signup and view all the answers

How is rheumatoid arthritis primarily characterized?

By inflammation and cell proliferation Signup and view all the answers

Which of the following best describes the relationship between autoimmune diseases and age according to the data?

Older individuals have a higher prevalence Signup and view all the answers

What can be inferred about the overall impact of antinuclear antibodies on health?

They can indicate a variety of autoimmune conditions Signup and view all the answers

What is one likely consequence of the increase in rheumatoid arthritis cases?

Increased healthcare resources needed for management Signup and view all the answers

Which of the following factors is least likely to be associated with the rising trend of autoimmune diseases?

Strict dietary regimes Signup and view all the answers

What condition is characterized by splenomegaly and neutropenia, leading to increased susceptibility to bacterial infections?

Felty Syndrome Signup and view all the answers

Which of the following are considered extra-articular involvements in Rheumatoid Arthritis?

Cardiac complications Signup and view all the answers

Which symptom is NOT typically associated with extra-articular involvement in Rheumatoid Arthritis?

Swelling of joints Signup and view all the answers

What is the potential consequence of splenomegaly in patients with Rheumatoid Arthritis?

Increased risk for bacterial infections Signup and view all the answers

Which of the following is a common manifestation of Rheumatoid Arthritis that could lead to a secondary condition?

Anemia of chronic disease Signup and view all the answers

What type of system involvement is common in Felty Syndrome, associated with Rheumatoid Arthritis?

Lymphatic system Signup and view all the answers

Which of the following involves symptoms that may occur due to extra-articular manifestations in Rheumatoid Arthritis?

Fever and malaise Signup and view all the answers

What does the presence of lymphadenopathy indicate in patients with Rheumatoid Arthritis?

Immune system activation Signup and view all the answers

Which pulmonary condition could potentially arise from rheumatoid arthritis?

Interstitial lung disease Signup and view all the answers

What characteristic suggests a poor prognosis in patients suffering from Rheumatoid Arthritis?

Presence of anti-CCP antibodies Signup and view all the answers

What is the primary consequence of chronic inflammation in rheumatoid arthritis?

Formation of pannus tissue Signup and view all the answers

What role do T-cells play in the pathology of rheumatoid arthritis?

They stimulate osteoclasts to remove bone Signup and view all the answers

Which antibody is primarily produced in most rheumatoid arthritis patients?

Anticitrullinated Protein Antibody (ACPA) Signup and view all the answers

What is the significance of rheumatoid factors in rheumatoid arthritis diagnosis?

They aid in making a diagnosis Signup and view all the answers

In the context of serology, what does a value greater than 60 EU/mL indicate?

Strongly positive for rheumatoid arthritis Signup and view all the answers

Which of the following agents is NOT primarily released by T-cells and macrophages during inflammation?

Complement proteins Signup and view all the answers

What is a potential consequence of the invasion of pannus tissue?

Destruction of cartilage and bone Signup and view all the answers

What is the role of macrophages in the pathophysiology of rheumatoid arthritis?

They stimulate T-cells to promote inflammation Signup and view all the answers

How does the presence of anticitrullinated protein antibody (ACPA) influence prognosis in rheumatoid arthritis?

Indicates a poorer prognosis Signup and view all the answers

Which inflammatory mediators are specifically categorized as cytokines in rheumatoid arthritis?

TNF-alpha, IL-1, and IL-6 Signup and view all the answers

Study Notes

Rheumatoid Arthritis (RA)

RA is a chronic, progressive autoimmune disease causing inflammation in joints and other body systems.
It results in painful deformities and immobility, most commonly affecting fingers, wrists, feet, and ankles.
RA can affect more than just the joints, also impacting skin, eyes, lungs, heart, and blood vessels.

Objectives of RA Study

Students will understand epidemiology, pathophysiology, and diagnosis of RA.
Students understand signs, symptoms, complications, extra-articular manifestations, and treatments of RA.
Students will learn to select appropriate therapy for individual RA patients, including place in therapy, side effects, and monitoring.

RA Definition

RA is a chronic, progressive autoimmune disease
It causes inflammation in joints and other parts of the body, ultimately leading to pain and immobility.
Deformity and immobility result from the inflammation.
Usually presents in fingers, wrists, and feet commonly.

Epidemiology

RA prevalence is 1% worldwide.
Prevalence rises to age 70.
RA is three times more prevalent in women than in men (a 6:1 ratio) in the 15-45 age range.
Cardiovascular disease is the leading cause of death in RA patients.
RA is a predictor of cardiovascular disease.
Life expectancy is 3–10 years less than the average.

Genetic Predisposition

Dizygotic (non-identical) twins and siblings have a 6x higher risk.
Monozygotic (identical) twins have up to a 30x higher risk.
HLA-DR4 and HLA-DR1 are antigens associated with a higher RA risk (a 3.5x increase).

Environmental Exposure

Smoking significantly impacts disease severity.
Epstein-Barr virus, E. coli, and periodontal disease are infectious mediators potentially contributing to RA.

Pathophysiology

Synovial inflammation and tissue attacks
Immune system attacks synovial and other connective tissues.
Chronic inflammation leads to tissue proliferation, resulting in pannus formation.
Pannus (abnormal tissue layer) invades cartilage and bone, damaging the joint.

Pathophysiology: Inflammation of the Joint

Antigen-presenting cells (APCs) present the antigen to T-cells.
T-cells stimulate B-cells to produce antibodies, and osteoclasts to destroy and remove bone.
Macrophages promote inflammation, degrade the bone matrix, and produce proinflammatory cytokines.
TNF-alpha, IL-6, and IL-17 are released by T-cells and macrophages, promoting destruction, increasing blood flow, and increasing cellular invasion.
Histamine, kinins, and prostaglandins contribute to inflammation.

Pathophysiology: Antibodies

RA patients may produce antibodies to self-components; these are called rheumatoid factors (RF).
RF does not indicate the severity of disease.
Antibodies directed against the Fc portion of Immunoglobulin G (IgG) are also present in RA.
RF and anti-cyclic citrullinated peptide (anti-CCP) antibodies can aid in diagnosis.
A negative RF/Anti-CCP does not exclude RA.

Anticitrullinated Protein Antibody (ACPA)

ACPA is another antibody produced in most RA patients.
This is observed during various types of inflammation.
ACPA is diagnosed as an aid but is NOT definitive.
Can appear before symptoms show an association with poorer prognosis.

Serology

Normal ACPA values are less than 20 EU/mL (the upper limit of normal).
20-39 EU/mL = weakly positive.
40-59 EU/mL = moderately positive.
Greater than 60 EU/mL = strongly positive.

Key Inflammatory Mediators

Cytokines like TNF, IL-1, and IL-6 are key inflammatory mediators.
Prostaglandins, leukotrienes, and matrix metalloproteinases also play a role.

Patient Clinical Presentation

Symptoms include joint pain/stiffness lasting 6 weeks or longer.
Signs include tenderness, warmth, and swelling in affected joints, particularly in hands and feet.
Other symptoms including fatigue, weakness, low-grade fever, loss of appetite.
Possible signs of symmetrical joint involvement and/or rheumatoid nodules.
Lab tests like RF, anti-CCP, ESR, and CRP often elevated in RA.
Joint fluid aspiration may reveal increased white blood cell counts, without infection. Presence of crystals in fluid may be observed.
Joint radiographs may show signs of periarticular osteoporosis, joint space narrowing, and/or erosions.

Extraarticular Involvement

Rheumatoid nodules: bumps on joints (20% of RA patients), typically located on extensor surfaces of elbows, arms, hands, typically asymptomatic.
Vasculitis: potentially progress to ulcers, can affect blood vessels, potentially affecting skin, eyes, lungs, heart.
Eyes: blurred vision can occur.
Neurological complications.
Cardiac Involvement
Pulmonary involvement
Lymphadenopathy (swollen lymph nodes)
Splenomegaly (enlarged spleen)
Felty syndrome: occurs in some patients with RA, characterized by splenomegaly, neutropenia, and an increased susceptibility to bacterial infections.

Joints Affected

Commonly small joints in hands, feet, and wrists, can potentially expand to larger joints like knees, hips, elbows, and shoulders as inflammation continues.
Disease is persistent for hours or all day

Diagnosis

Synovitis (inflammation of a joint) in one joint with no other explanation.
Positive lab results, including RF, ACPA, CRP, and ESR.
Duration of symptoms of at least 6 weeks
Criteria > 6/10 (based on a criteria scale).

Disease Activity Score

Measures RA disease activity.
Various scales (like PAS or PASII, RAPID3, CDAI, DAS28) are used.

Prognostic Factors

Higher tender/swollen joint counts
Radiographic erosions (bone damage visible on X-ray)
Elevated RF and anti-CCP Elevated ESR and CRP
Age
Female gender

Treatment Goals

Achieving remission or lowering disease activity.
Reducing the progression of the disease itself.
Maintaining joint function.
Reducing the risk of joint damage.

Non-Pharmacological Treatments

Rest (appropriate amount): avoid too much rest to prevent muscle atrophy, reduced range of motion.
Occupational therapy/physical therapy.
Assistive devices.
Weight reduction (in people who are overweight or obese).
Surgery (if needed).
Mental health support.

Pharmacological Treatments

Disease-modifying antirheumatic drugs (DMARDs): conventional synthetic DMARDs (methotrexate, sulfasalazine, hydroxychloroquine, and others) and biological DMARDs (TNF-a inhibitors, other biologics, including abatacept , interleukin-6 receptor antagonists, JAK inhibitors)
Non-steroidal anti-inflammatory drugs (NSAIDs)
Corticosteroids (oral or injected)

Additional Treatments

Methotrexate
Leflunomide (Arava)
Hydroxychloroquine (Plaquenil)
Sulfasalazine
Other DMARDs
Biological DMARDs and TNF-a inhibitors
Biologics or JAK Inhibitors

Monitoring

Crucial for effective treatment and prevention of complications.
Regular monitoring of blood counts, liver function tests, etc. is imperative.
Timing of monitoring will vary on the medications and treatment.
Early and consistent monitoring is essential.

Treatment Strategies

DMARD monotherapy
Combination therapy (dual, triple)
Selection should be based on patient's individual needs.

Biosimilars

Biosimilars are extremely similar to an original biologic drug.
They should be clinically equivalent to the original biologic.
Integration of biosimilars is beneficial and economical.

Supporting Therapies

NSAIDs for symptom management (analgesia and anti-inflammatory)
Corticosteroids for flares (adjunct therapy, bridging therapy)
Acetaminophen, too, offering symptomatic relief, but less effective than NSAIDs for RA.

How to Select Therapy

Treat-to-target approach is now favored over a non-target approach.
Establish a therapy target (remission or reduced activity).
Continuous monitoring is required.
Providers should collaborate with patients.

Recommendations

Employ a treat-to-target strategy.
Consider MTX as the first choice for single DMARD therapy.
Add a second/third DMARD or a biologic if monotherapy isn't enough.

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Description

This quiz explores the fundamentals of Rheumatoid Arthritis (RA), including its epidemiology, pathophysiology, and diagnosis. Students will learn about the signs, symptoms, complications, and treatments of RA, gaining a comprehensive understanding of this chronic autoimmune disease.