Rheumatoid Arthritis

Question 1

What type of disorder is rheumatoid arthritis (RA)?

Answer 1

It is an inflammatory autoimmune disorder which leads to painful & disabling joints

Question 2

What is the cause of death in patients with RA?

Answer 2

CVD, because the inflammatory mediators associated with RA also speed up atherosclerosis

Question 3

Which gender is more prone to RA?

Answer 3

Females

Question 4

What happens in the joints to cause RA?

Answer 4

Synovium of joints gets infiltrated by chronic inflammatory cells, leading to the creation of their own environment and forming a tumour (pannus)

Question 5

What are the symptoms of RA?

Answer 5

Pain/stiffness/swelling of small joints of hands/feet
Hammer toes
Swollen wrist joints
Other joint deformities

Question 6

What conditions are RA patients more at risk of developing?

Answer 6

Osteoporosis
Anaemia
Depression
CVD
Dry eye syndrome

Question 7

Why is paracetamol not an ideal option to give in RA?

Answer 7

Because paracetamol is not non-inflammatory, so not ideal.

Question 8

Why do NSAIDs produce GI side effects?

Answer 8

Because they inhibit PGE2 from the COX-1 enzyme, which is responsible for protecting the gastric mucosa

Question 9

Why are corticosteroids powerful anti-inflammatory drugs?

Answer 9

Because they inhibit phospholipase A2, so arachidonic acid formation is also inhibited & this blocks all inflammatory pathways.

Question 10

What drug is given if a patient has had a previous ulcer history, but no CVD?

Answer 10

A COX2 inhibitor, e.g. celecoxib or etoricoxib

Question 11

Which 2 NSAIDs provide CV protectivity (include doses)?

Answer 11

Naproxen 1g
Ibuprofen 1.2g

Question 12

When are corticosteroids given in RA?

Answer 12

Only during flare ups as they have rapid anti-inflammatory effects.

Question 13

What are some side effects of corticosteroids?

Answer 13

Weight gain
Diabetes
Depression
Increased BP - from fluid retention
GI side effects

Question 13

Which corticosteroid (with dose) is given to RA patients, & for how long?

Answer 13

Prednisolone 7.5mg weekly for 2-3 years to reduce the rate of joint destruction

Question 14

What are the 4 conventional DMARDs which can be used in RA?

Answer 14

Methotrexate
Sulfasalazine
Leflunomide
Hydroxychloroquine

Question 15

Which DMARD is given to women who are planning on getting pregnant?

Answer 15

Sulfasalazine

Question 16

Which cDMARD must be given with long-term contraception?

Answer 16

Leflunomide

Question 17

What drugs are given in step 1 treatment of RA?

Answer 17

Methotrexate 7.5mg weekly (max 20mg weekly) + folic acid 5mg 24h after dose
Prednisolone 7.5mg daily for short-term use

Question 18

If methotrexate if not tolerated/appropriate as 1st line, what other drugs could you start the patient with?

Answer 18

Any other cDMARD (hydroxychloroquine, sulfasalazine, or leflunomide)

Question 19

What specific side effect should RA patients taking methotrexate look out for?

Answer 19

Shortness of breath, because it can cause pulmonary toxicity

Question 20

Which cDMARD can cause retinopathy & hence needs regular eye screenings?

Answer 20

Hydroxychloroquine

Question 21

Which cDMARD has the quickest onset of action (4-6 weeks)?

Answer 21

Leflunomide

Question 22

What are some side effects of leflunomide?

Answer 22

Increased BP
Hepatotoxicity
Increased risk of infections
Bone marrow toxicity

Question 23

What monitoring is required for methotrexate?

Answer 23

FBC
Renal function
LFTs

Question 24

What side effects should RA patients report if they are taking sulfasalazine? Why should they be reported?

Answer 24

Bleeding Unexpected bruising Sore throat/fever They should be reported because sulfasalazine reduces WBCs, which can lead to further blood disorders.

Question 25

What close monitoring should be done when taking sulfasalazine?

Answer 25

FBC + WBCs + platelet count

Question 26

What is the mechanism of action of methotrexate?

Answer 26

It inhibits the enzyme dihydrofolate reductase, which reduces folic acid levels in the body

Question 27

Why should NSAIDs/aspirin never be given with methotrexate?

Answer 27

Because NSAIDs/aspirin inhibit the renal excretion of MTX, causing toxicity.

Question 28

What is step 2 of RA treatment, if methotrexate alone hasn’t worked?

Answer 28

You add a second cDMARD (leflunomide/sulfasalazine) + prednisolone 7.5mg

Question 29

When do you add a biological DMARD or JAK inhibitor in RA treatment?

Answer 29

If methotrexate + other cDMARD has not worked.

Question 30

What is the DAS28 score? What does it take into account?

Answer 30

Scoring system /10 which measures the disease activity of RA It takes into account: How many joints are tender, swollen, ESR, and how the person is feeling

Question 31

What 2 DAS28 scores indicate moderate, & severe?

Answer 31

Moderate: >3.2 Severe: >5.1

Question 32

What are the 4 Janus Kinase inhibitors (JAKi) which can be given?

Answer 32

Remember it as BARI & TOFA Tofacitinib Baricitinib Upadacitinib Filgotinib

Question 33

What are the 3 bDMARDs which can be given?

Answer 33

Infliximab Adalimumab Etanercept

Question 34

If a patients DAS28 score is >5.1, what drug options can you give them?

Answer 34

Any JAK inhibitor or bDMARD, except rituximab

Question 35

What should you do if the patient is not responding to their bDMARD/JAK inhibitor?

Answer 35

Either change the bDMARD, or introduce rituximab (or switch to JAK inhibitor if not using it before)

Question 36

What change in the DAS28 score indicates a good response?

Answer 36

1.2

Question 37

What are the 4 drugs which can be used as the final step, if the patient cannot have rituximab/is intolerant?

Answer 37

Filgotinib (JAKi) Updatacitinib (JAKi) Sarilumab (IL-6 inhibitor) Tocilizumab (IL-6 inhibitor)

Question 38

Which drug is only given as part of clinical trials in RA?

Answer 38

Akinra

Question 39

What is the whole step by step treatment for RA?

Answer 39

STEP 1: cMARD given (MTX 7.5mg weekly + 5mg folic acid+ prednisolone 7.5mg) STEP 2: If cannot take MTX, then give either leflunomide, sulfalazine, or hydroxychloroquine STEP 3: If above unresponsive, measure DAS28 score. If it is >3.2, you can choose either: - bDMAD: infliximab, etanercept, or adalimumab - JAK inhibitor: filgotinib, or upadacitinib STEP 4: If above unresponsive, & their DAS28 is >5.1, you can give any JAK inhibitor (tofacitinib, baricitinib, upadacitinib, or filgotinib) or bDMAD STEP 5: If their DAS28 is still high, either initiate rituximab or choose another drug STEP 6: If their DAS28 is still >5.1, you HAVE to give rituximab STEP 7: If rituximab not tolerated, then any medication can be given STEP 8: if the above step does not work, you can choose from: filgotinib, upadacitinib, sarilumab, or tocilizumab