Rheumatoid Arthritis

Question 1

What is early rheumatoid

Answer 1

Rheumatoid 2 years from symptom onset

Question 2

What is the definition of rheumatoid arthritis

Answer 2

Symmetrical inflammatory arthritis affecting mainly the peripheral joints which is untreated can lead to joint damage and irreversible deformities leading to a loss of function and increased morbidity and mortality

Question 3

women are affected _ times as commonly as men

Answer 3

3

Question 4

What is the autoimmune mediated by?

Answer 4

HLA-DR4

Question 5

There is no link between smoking and RA T/F

Answer 5

F- there is a link, cigarette smoking are seen as potential triggers

Question 6

What structures does the synovial line

Answer 6

The synovial joint capsule and tendon sheath

Question 7

Which two joints in the spine are synovial lined

Answer 7

C1/C2

Question 8

DIP joints are not involved in RA T/F

Answer 8

T- there is not enough synovial

Question 9

Synovitis is the hallmark of RA T/F

Answer 9

TRUE- very inflamed

Question 10

What does an osteoclast do?

Answer 10

Dissolve bone

Question 11

What inflammatory cytokines are being produced by the macrophages?

Answer 11

TNFa
IL-1
IL-2

Question 12

What cell produces the rheumatoid factor?

Answer 12

B-cell

Question 13

What is the ACR/EULAR classification criteria for RA

Answer 13

Joint distribution (0-5)
Serology (0-3)
Symptom duration (0-1)
Acute phase reactants (0-1)
If over 6 then definite RA

Question 14

How is it diagnosed?

Answer 14

History and clinical examination
Routine blood testing-anaemia or chronic disease ,raised platlets
Inflammatory markers (CRP,ESR,Plasma viscosity)
Autoantibodies
Imaging

Question 15

What are clinical features?

Answer 15

Prolonged moring stiffness
involvement of small joints of hands and feet
Symmetric distribution
Positive compression tests or MCP and MTP joints

Question 16

Clinical presentation

Answer 16

PIP,MCP,wrist,MTP synovitis
Monoarthiritis
Tenosynovitis
Trigger finger
Carpal tunnel syndrome
Polymyalgia rheumatica
Palindromic rheumatism
Systemic symptoms
Poor grip strength

Question 17

What is carpal tunnel syndrome?

Answer 17

compression of the medial nerve

Question 18

What is palindromic rheumatism

Answer 18

rare episodic form of inflammatory arthritis – meaning the joint pain and swelling come and go.

Question 19

What are the two autoantibody that can be testing in clinical practise?

Answer 19

Rheumatoid factor ( Rheumatoid IgM)- around 75% sepecific
Autoantibodies to cyclic cirullinated peptide (Anti-CCP antibodies)-around 95% specific

Should not base diagnosis on absence of these as they are only around 70% sensitive

Question 20

What are anti CCP most likely to be associated with

Answer 20

Erosive damage

Question 21

What 3 imaging techniques could be used?

Answer 21

Plain X-rays of hands and feet
Ultrasound scanning
MRI scans

Question 22

Plain X-rays are especially good at visualising

Answer 22

Soft tissue swelling
Periarticular osteopanenia
Erosions

however absence of findings in early disease

Question 23

Ultrasound scans can detect up to _ times more MCP erosions than plain x-rays in early RA. IT ALSO HAS INCREASED SENSITIVITY FOR SYNOVITIS in early disease

Answer 23

7

Question 24

Whats is the DAS 28 score

Answer 24

Disease activity score calculator for rheumatoid arthritis. 28 because there are 28 joints

Question 25

What score of DAS represents remission

Answer 25

2.6

Question 26

Which scan can distinguish synovitis from effusions?

Answer 26

MRI scan

Question 27

What is the DAS28 scoring for active disease?

Answer 27

over 5.1

Question 28

What is the management for RA

Answer 28

Early rec and diagnosis and care by rheumatologist Early treatment with disease modifying anti-rheumatic drugs for all patients with RA Use of NSAIDs e.g. aspirin and steroids only as adjuncts Patient education and MDT involvement

Question 29

Steroids for RA?

Answer 29

Shown to reduce symptoms and reduce damage Used in combination with DMARDs-NOT to be used as a sole therapy Can be given orally, IA,IM If fewer than 5 joints involved - IA injections

Question 30

Name the most popular DMARDs?

Answer 30

Methotrexate sulfasalazine Hydroxychloroquine- does not prevent erosions

Question 31

How often is methotrexate taken and what must it be taken with

Answer 31

Weekly drug(max 25mg) Folic acid must be given with it because it affects folic acid absorption by bones

Question 32

What can methotrexate do to the lungs?

Answer 32

Pneumonitis

Question 33

What combination therapy should be used?

Answer 33

MTX(methotrexate) and SASP(sulfasalazine) and HCQ(Hydroxychloroquine) Imprortant to discuss contraception

Question 34

What are the negatives of DMARDs

Answer 34

``` Regular monitoring needed Bone marrow suppression Infection Liver function derangement Pneumonitis in case of methotrexate ```

Question 35

When do you prescribe biological agents?

Answer 35

Failure to respond to 2 DMARDs including methotrexate and DAS 28 STILL GREATER THAN 5.1 ON TWO SEPARATE OCCASIONS 4 WEEKS APART Methotrexate therapy is co-prescribed

Question 36

Steroids should only be used as bridging therapy and for flares only T/F

Answer 36

T