RA

Question 1

RF for RA

Answer 1

1. Genetics
2. infectious agent
3. Sex hormones
4. Smoking
5. Parental Hx of substance abuse

Question 2

infectious agents that cause RA

Answer 2

EBC
mycoplasma
Rubella

innate susceptibility but infxn causes it to switch on

Question 3

sex hormones and RA

Answer 3

more common in women

subsides during pregnancy

less common in women taking OC

Question 4

RA patho (general)

Answer 4

trigger sets off an autoimmune reaction in a genetically susceptible person

Question 5

RA patho (8) (long)

Answer 5

1. inflammation in synovial membrane and synovial space
2. destructive enzyme activation
3. reactive oxygen species form
4. synoviocyte cells proliferate extensively, cross synovial membrane and get into cartilage
5. synovium relates MMP that destroys cartilage and stimulate osteoclastic bone reabsorption
6. pro inflammatory cytokines released cause systemic symptoms
7. osteoclast activation = osteoporosis
8. articular surface damage causing destruction of the bones
9. fibrous adhesions = permanent joint deformities

Question 6

cells that cause RA inflammation

Answer 6

CD4/T cells
monocytes
neutrophils
fibroblasts

Question 7

enzyme destruction to which joint

Answer 7

cartilage
tendons
ligaments
bone

Question 8

PDGF

Answer 8

angiogenesis into the joint

Question 9

pro inflammatory cytokines RA

Answer 9

TNF alpha
IL-6

produce systemic symptoms

Question 10

systemic symptoms caused by cytokines

Answer 10

weight loss
organ inflammation
fever

Question 11

pathogenies of RA

Answer 11

1. activation of pro inflammatory cytokines causing joint swelling, stiffness, destruction
2. pannus acts like locally invasive bone tumor
3. cytokines cause systemic inflammation symptoms and worsened comorbidities

Question 12

Epidemiology of RA

Answer 12

F > M

MC in Native American, least common in Caribbean Black

35-50 years

Family hx

Question 13

hallmark feature of RA

Answer 13

persistent symmetric poly arthritis that affects small joints of hands, wrists, ankles and feet

insidious onset

Question 14

RA joints on PE

Answer 14

swelling, tenderness, warmth and decreased ROM

atrophy of interosseous muscles

worse in AM

Question 15

lab eval of RA (6)

Answer 15

1. ESR/CRP
2. CBC (ACD, thrombocytosis)
3. RF (non diagnostic)
4. Anti-CCP
5. Anti MCV
6. ANA

Question 16

RF

Answer 16

IgM against IgG

60-80% of pts with RA over course of dz but NOT specific for RA

NEITHER necessary nor specific

Question 17

seropositive RA

Answer 17

presence of RF in serum

increased likelihood of severe erosive arthritis, rheumatoid nodules, extra-articular dz

Question 18

ACPA abs include

Answer 18

anti-CCP abs

AntiMCV

Question 19

anti-CCP Abs

Answer 19

MOST specific biomarker for RA but found in other dz

indicates higher likelihood of erosive arthritis and worse prognosis

Question 20

ANA in RA

Answer 20

if NEGATIVE can help distinguish RA from SLE

Question 21

joint aspiration

Answer 21

inflammatory fluid (>10k WBC)

• crystals, - culture

Question 22

imaging study of choice

Answer 22

Plain fim XR

bone erosion and uniform joint space narrowing

Question 23

RA on plain film

Answer 23

osteopenia
symmetric narrowing of joint spaces
erosions
bony crowding due to loss of cartilage

Question 24

first 4 criteria for RA diagnosis (1987)

Answer 24

1. Morning stiffness lasting at least 1 hr
2. soft tissue swelling or fluid in 3 joint spaces
3. at lease one area swollen in wrist, MCP, PIP
4. symmetric arthritis

Question 25

joints MC involved in RA

Answer 25

1. MCP 2. wrist 3. PIP also knee, MTP, joint, ankle. C spine, hip/elbow/temporomandibular joint

Question 26

4 criteria for RA in 2010

Answer 26

1. joint involvement 2. serology test results 3. actue phase reactant test results 4. duration of symptoms

Question 27

why is early diagnosis of RA essential?

Answer 27

high risk of permanent joint deformities | decreased ability to do ADLs

Question 28

extra articular disease of RA (who gets it, MC_

Answer 28

fatigue, myalgia, malaise mc in pts with seropositive RF

Question 29

rheumatoid nodules (MC site)

Answer 29

extensors surfaces and areas of mechanical trauma olecranon, ulna. back of heel, occiput

Question 30

ocular manifestations of RA

Answer 30

dry eyes/MM Uveitis Episcleritis Nodular scleritis (red eye, painful with movement)

Question 31

list of RA organ systems affected:

Answer 31

1. anemia (microcytic) 2. infections 3. GI issues (stomach and intestinal upset) 4. osteoporosis 5. pulmonary dz 6. lymphoma

Question 32

pulmonary disease and RA

Answer 32

increased risk of intersistial lung dz,pleuritis, pleural effusion, rheumatoid pulm nodules

Question 33

Cardiac Dz in RA

Answer 33

CAD not attributable to typical risk factors MI, pericardial effusion, myocardial dysfunction

Question 34

MSK dz in RA

Answer 34

synovial cysts tendon rupture nerve entrapment tenosynovitis

Question 35

cervical spine dz in RA

Answer 35

subluxation of C1 and C2

Question 36

boutonniere deformity

Answer 36

contracture of PIP joint and hyperextension of DIP joint

Question 37

swan neck deformity

Answer 37

hyperextension of PIP joint and flexion contracture of DIP

Question 38

tx goals of RA

Answer 38

control pain preserve joint fxn prevent joint deformity early referral + therapy

Question 39

NSAIDs in RA

Answer 39

pain management and improve daily fxn do NOT inhibit disease progression/disability and NOT as sufficient as mono therapy risk of GIB/GI ulcer, renal dysfunction, HF exacerbation

Question 40

w/u prior to RA tx

Answer 40

CBC, Chem Panel, ESR/CRP LFTs, viral hepatitis panel, TB screen

Question 41

pharm tx of RA (list) (

Answer 41

1. Glucocorticoids 2. non biologic DMARDs 3. Biologic DMARDs

Question 42

glucocorticoids use in RA

Answer 42

1. acute exacerbation 2. starting DMARD 3. unable to take DMARD

Question 43

long term SE of glucocorticoids

Answer 43

weight gain HTN osteoporosis hyperglycemia

Question 44

when do you start DMARD?

Answer 44

EARLY (<6 mo) of tx is standard

Question 45

vaccinations and DMARDs

Answer 45

``` pneumococcal hep A, hep B influenza vax HPV herpes zoster ```

Question 46

pts started on DMARDs MUST be tested for"

Answer 46

TB viral hep endemic fungal infections

Question 47

initial DMARD of choice

Answer 47

Methotrexate therapy should be adjusted after 6 mo if incomplete response

Question 48

biologic prescribing rules

Answer 48

all are equally efficacious more effective than non biologics should only give one at a time

Question 49

Biologic CIs

Answer 49

Chronic viral hep B and C malignancy in last 5 yrs CHF AHA class III or IV fungal infection/tb

Question 50

biologic DMARDs and vaccines

Answer 50

cant receive live virus vaccine (MMR, yellow fever, intranasal, herpes zoster, varicella) give all killed viruses HZE live should be given before starting DMARD or Biologics

Question 51

monitoring while taking DMARDS biologics

Answer 51

CBC, liver, renal panel, and viral hep panel at baseline and q 4 months

Question 52

HF and TNF agents

Answer 52

CI in pts with NYHA class II or IV ESP infliximab

Question 53

RA prognosis

Answer 53

disabled in 10 years typically die 10-15 years before (2.5x mortality)

Question 54

MC cause of premature death

Answer 54

CAD not associated with traditional risk factors secondary to chronic inflammation

Question 55

factors indicating poor RA prognosis

Answer 55

RF seropositivity >30 joints involved Extra-articular manifestation

Question 56

Felty's syndrome MC in

Answer 56

RF positive, long duration of RA (>10 yrs), extra articular manifestations

Question 57

Felty's syndrome patho

Answer 57

splenic sequestration and destruction of granulocytes

Question 58

Felty's syndrome triad

Answer 58

RA Splenomegaly neutropenia

Question 59

tx of Felty's syndrome

Answer 59

IV abx (Neuopgen) usual RA tx Steroids (limited efficacy)

Question 60

Triple therapy

Answer 60

Max MTX dose Sulfasalazine Hydroxychloroquine if this fails go to biologic