Rheumatoid arthritis

Question 1

8 week pain and stiffness. What is your differential diagnosis?

Answer 1

RA, psoriasis arthritis, OA, reactive arthritis, AI connective tissue disease

Question 2

Which genes are associated with RA?

Answer 2

HLA DR4 and HLA DR1

Question 3

What are the side effects of steroids?

Answer 3

CUSHINGOID FAM
cushing's
ulcers
HTN
infectious
necrosis
growth restriction
osteoporosis
immunosuppression
diabetes
fluid retention
acute pancreatitis
myopathy

Question 4

What is the management of RA?

Answer 4

pain relief
DMARD- steroids, methotrexatae + sulphasalazine, biologics
MDT_ physio, OT, podiatry

Question 5

What are the side effects of methotrexate?

Answer 5

immunosuppression, bone marrow suppression, GI upset, hepatotoxicity

Question 6

SE of sulphasalazine?

Answer 6

immunsuppression, bone marrow suppressiob, GI upset, hepatotoxicity, RASH

Question 7

What is hydroxychloroquine used to treat?

Answer 7

RA

Question 8

What are the SE of hydroxychloroquine?

Answer 8

generic: immunosuppression, bone marrow suppression, GI upset

Visual changes, skin

Question 9

Which RA drugs are safe in pregnancy?

Answer 9

hydroxychloroquine and sulphasalazine

Question 10

What are the components of a biologic screening?

Answer 10

CXR, TB test, HIV/hep B + C, VZV, FBC U+E LFT CRP

Question 11

Which RA blood marker is highly specific?

Answer 11

Anti-CCP (RF is more sensitive but not as specific)

Question 12

Explain a high CRP and low Hb in patient with RA

Answer 12

Anaemia of chronic disease- due to ongoing chronic inflammatory process= use up iron
CRP- transient protien that is realeased during active acute inflammation

Question 13

Name two ocular complications associated with RA

Answer 13

scleritis and episcleritis

Question 14

Name two blood tests to confirm RA

Answer 14

RF and anti-CCP

Question 15

What is the treatment for RA?

Answer 15

NSAIDs, steroids, biological, DMARDs

Question 16

Name four features of XR of RA

Answer 16

loss of joint space
juxta articular osteopenia
subchondral cysts
periarticular erosion
soft tissue swelling

Question 17

Define RA

Answer 17

Chronic systemic inflammatory disease characterised by

a symmetrical, deforming, peripheral polyarthritis.

Question 18

What is the genetic association of RA?

Answer 18

HLA-DR4/DR1

Question 19

State three specific deformities seen in RA

Answer 19

1. Swan neck
2. Boutonniere
3. Z-thumb
4. Ulnar deviation of the fingers
5. Dorsal subluxation of ulnar styloid

Question 20

Three extraarticular features of RA?

Answer 20

Nodules
Pericarditis
Carpal tunnel syndorome
Pleural effusion
Episcleritis
Sjorgen's syndrome
Raynaud's
Felty's syndrome
Vasculitis 
Lymphadenopathy

Question 21

Define felty’s syndrome

Answer 21

RA +splenomegaly + neutropenia

Question 22

Two tests that are highly specific to RA?

Answer 22

RF and anti-CCP

Question 23

Three investigations for RA?

Answer 23

1. Bloods- FBC (anaemia, neutropenia), CRP
2. RF +anti-CCP
3. Radiography, US, MRI

Question 24

Discuss three aspects of medical management in RA

Answer 24

1. DMARDs/biologics
2. Steroids
3. NSAIDs
4. CV prevention
5. Osteoporosis prevention
6. Gastric ulcers prevention

Question 25

Prophylaxis for which condition must be managed in RA?

Answer 25

Cardiovascular events associated with athersclerosis

Question 26

List two DMARDs and provide one SE of each

Answer 26

1. Methotrexate- hepatotoxic 2. Sulfasalzine- hepatotoxic 3. Hydroxychloroquine- retinopathy

Question 27

One side effect common in all DMARDs?

Answer 27

myelosuppression -> pancytopenia

Question 28

Two examples of biologics?

Answer 28

 Infliximab: chimeric anti-TNF Ab  Etanercept: TNF-receptor  Adalimumab: human anti-TNF Ab  Rituximab (anti-CD20 mAb)

Question 29

Two side effects of biologics?

Answer 29

infection, autoimmune disease, cancer

Question 30

MOA of infliximab?

Answer 30

anti-TNF

Question 31

MOA of adalimumab?

Answer 31

anti-TNF

Question 32

Which sex is a risk factor for RA?

Answer 32

females

Question 33

What was the old classification for RA?

Answer 33

4/6 symptoms: morning stiffness, >2 joints, hand and wrist joints, rheumatoid nodules, RF positive (serology), and X-ray changes

Question 34

What is the most recent classification of RA?

Answer 34

presence of bilateral MCP or PIP joint enhancement on MRI

Question 35

How do sero-negative inflammatory arthropathies differ from RA?

Answer 35

normal bone density, periostitis, ankylosis (fusion), asymmetrical pattern

Question 36

Describe the pathophysiology of RA

Answer 36

1. Initiation in the periphery 2. Propagation in the synovium 3. Tissue damage- bone and cartilage. Involves dysregulated inflammation with antigen presentationm T cell activation, and autoantibody production. Fibroblasts are activated, forming inflammatory panus. Activation of osteoclasts, leading to erosion of bone.

Question 37

In which other conditions is rheumatoid factor raised?

Answer 37

SLE, infection, increasing age

Question 38

One example of early RA stage you can see on XR?

Answer 38

peri-articular osteopenia, soft tissue swelling

Question 39

Two late stage examples of RA seen on XR?

Answer 39

erosion, joint destruction, subluxation/angulation

Question 40

Name two NSAIDs used in the treatment of RA?

Answer 40

ibuprofen, naproxen, diclofenac

Question 41

Which DMARD is teratogenic?

Answer 41

methotrexate

Question 42

Pregnant lady with RA, which DMARD?

Answer 42

sulfasalasine, hydroxychloroquine

Question 43

How can you monitor disease progession in RA?

Answer 43

DAS28= disease activity in 28 joints= scoring system.

Question 44

Three components of DAS28?

Answer 44

CRP/ESR, XR changes, pain, swelling, subjective assessment/questionnaire

Question 45

Which screening is conducted prior to biologic DMARD therapy

Answer 45

viral hep, HIV, varicella (chickenpox), CXR (TB), and vaccinations (influenza)