Rheumatoid arthritis

Question 1

Define rheumatoid arthritis

Answer 1

A chronic auto immune systemic illness characterised by a polyarthritis and other systemic features

Question 2

What is polyarthritis

Answer 2

When at least 5 joints are affected by arthritis

Question 3

What joints are most affected by rheumatoid arthritis

Answer 3

Small joints of hands, feet and wrist are most affected - metacarpal-pharyngeal joint, proximal inter-pharyngeal joint

Question 4

What joint in the hands doesn’t get affected by rheumatoid arthritis

Answer 4

Distal inter-pharyngeal

Question 5

What is ACR criteria used for

Answer 5

Lupus and rheumatoid arthritis

Question 6

What score in the ACR criteria is diagnostic of rheumatoid arthritis

Answer 6

6 or more

Question 7

Which gender is rheumatoid arthritis most common in

Answer 7

Females 3 : 1 Males

Question 8

What age does rheumatoid occur at

Answer 8

4th and 5th decade but can occur at any age after 16 years old

Question 9

Which gene is associated with rheumatoid arthritis

Answer 9

HLA-DRbeta1

Question 10

What environmental triggers can cause rheumatoid arthritis

Answer 10

Cigarette smoking
Chronic infection e.g epstein barr virus

Question 11

What hormonal factors can cause rheumatoid arthritis

Answer 11

Early age menopause

Low testosterone in men

Question 12

Describe how rheumatoid arthritis is caused

Answer 12

Arginine changes into citrulline - the body recognises the protein as a foreign pathogen and activated dendritic cells which produce B and T lymphocytes to defend - the protein is commonly found in the synovium which is the common site of infection of rheumatoid arthritis

Osteoclasts then become activated and start eroding bone

Question 13

how does rheumatoid arthritis present

Answer 13

Pain
Morning stiffness which lasts longer than 30 minute - characteristic of inflammatory joint conditions
Poor function
Systemic symptoms

Question 14

What is morning stiffness longer than 30 minutes characteristic of

Answer 14

Inflammatory joint conditions

Question 15

What is expected to see on examination of a patient with rheumatoid arthritis

Answer 15

swelling
tenderness
the joints will feel warm and appear red
There will be restricted movement in the joints

Question 16

What joints is rheumatoid arthritis normally not present in

Answer 16

the joints in the central line e.g spine
Distal inter-phalyngeal joint

Question 17

What is ulnar deviation

Answer 17

All the fingers drift to the ulnar side - seen in hand deformity caused by untreated rheumatoid arthritis

Question 18

What are the systemic symptoms of rheumatoid arthritis

Answer 18

Fatigue, weight loss, anaemia

Question 19

What are the extra-articular manifestations of rheumatoid arthritis

Answer 19

Eyes, lungs, nerves, skin and kidneys

Question 20

What is the long term complication which can occur due to rheumatoid arthritis

Answer 20

In any untreated inflammatory condition, there is increased cardiovascular risk
malignancy can occur as well

Question 21

What are the haematological manifestations of rheumatoid arthritis

Answer 21

Anaemia
Thrombocytosis - high platelets
Fetty’s syndrome

Question 22

What is Fetty’s syndrome

Answer 22

Triad of low neutrophils (neutropenia) , splenomegaly and rheumatoid arthritis

Question 23

What bloods are checked in rheumatoid arthritis

Answer 23

FBC, kidney function, liver function, CRP and ESR

Question 24

What investigations are done for rheumatoid arthritis

Answer 24

Baseline bloods
Immunology
X rays
Ultrasound

Question 25

What is checked in the immunology for rheumatoid arthritis

Answer 25

Rheumatoid factor Anti cyclic citrullinated antibodies (Anti-CCP)

Question 26

What is used to assess rheumatoid arthritis

Answer 26

Disease activity score (DAS score)

Question 27

What DAS numbers suggest remission

Answer 27

less than 2.6

Question 28

What DAS numbers suggest need for biologic therapy

Answer 28

more than 5.1

Question 29

What is the tactic for management of rheumatoid arthritis

Answer 29

early and aggressive intervention

Question 30

What is the first line of management of rheumatoid arthritis

Answer 30

Methotrexate

Question 31

What is used to treat symptoms when patient comes for the first time or during a flare up

Answer 31

NSAIDS - naproxen and ibuprofen Glucocorticoids - prednisone, hydrocortisone, prednisolone

Question 32

What kind of drug is methotrexate

Answer 32

conventional systemic DMARDs - disease modifying anti-rheumatic drugs

Question 33

When is methotrexate not indicated as first line for rheumatic arthritis

Answer 33

Pregnant women - causes foetal abnormalities Bad lung disease - can lower immune system and cause fibrosis

Question 34

What are other examples of conventional synthetic DMARDs

Answer 34

Leflunomide Hydroxychloroquine sulfasalazine

Question 35

What is the order of drugs given in treatment if no remission

Answer 35

Methotrexate (unless pregnancy or severe lung disease) - sulfasalazine - biologic DMARDs e.g infliximab, golimumab)

Question 36

What is the function of conventional DMARDs

Answer 36

They are slow acting and have a slow onset effect They don't stop the process but they modulate the immune system to make the process slower Has the risk of toxicity

Question 37

What is the difference between biologic DMARDs therapy compared to non biologic

Answer 37

Biologic DMARDs are large complex proteins that work rapidly but can increase the risk of infection

Question 38

What is TNFalpha inhibitor

Answer 38

Tumour necrosis factor alpha inhibitor - a biologic

Question 39

What are the issues with biologics

Answer 39

Injection site reactions Infection risk increase Malignancy Cost - they are very expensive