Rheumatoid Arthritis

Question 1

What is the treatment for newly diagnosed RA?

Answer 1

DMARD + Steroids for symptoms relief in the meantime

E.g. Methotrexate and Prednisolone

DMARDs should be started as soon as possible as this improves long term outcomes

Question 2

What important monitoring needs to be done for RA?

Answer 2

Bone marrow suppression- FBC
Liver toxicity- LFTs
Pulmonary fibrosis/Pneumonitis- Baseline CXR

Question 3

When should biologics be considered for the treatment of RA?

Answer 3

Failure to respond to at least two DMARDs including methotrexate

Question 4

What biologics are used to treat RA?

Answer 4

Anti TNF- Adalimumab, Entarcept, Infliximab

Anti-B Cell- Rituximab

Question 5

Name some DMARDs

Answer 5

Methotrexate
Sulfasalazine
Hydroxychloroquine

Question 6

What must be checked for before starting patients on Anti- TNF?

Answer 6

TB Status-

As TNF maintains the granulomas in latent TB.

Question 7

What are some adverse effects of methotrexate?

Answer 7

Marrow suppression
Liver toxicity
Pulmonary fibrosis
Pneumonitis

Question 8

Can methotrexate be used in pregnancy?

Answer 8

No it can’t it is teratogenic

Women should avoid pregnancy for at least three months after treatment has stopped

Question 9

Can methotrexate be used by men trying to get pregnant?

Answer 9

No it should be stopped for at least three months before trying, contraception should therefore be used for at least 3 months after.

Question 10

How often is methotrexate given?

Answer 10

Once weekly

Folic acid is given in between dose

Question 11

What is the strength of a single methotrexate tablet?

Answer 11

2.5mg

Starting dose is 7.5mg and titrate up

Question 12

What drugs might methotrexate interact with?

Answer 12

Trimethoprim or cotrimoxazole

High dose aspirin (as may reduce renal excretion)

Question 13

What needs to be checked before starting someone on azathioprine?

Answer 13

Thiopurine Methyltransferase (TPMT)

Deficiency predisposes to azathioprine related pancytopenia

Question 14

What are some adverse effects of azathioprine?

Answer 14

Marrow suppression
N+V
Pancreatitis
Increased risk of non-melanoma skin cancer

TPMT deficiency may lead to pancytopenia and so this should be checked.

Question 15

What are some X-ray changes seen in rheumatoid arthritis?

Answer 15

Periarticular erosions
Soft tissue swelling
Joint deformity

Question 16

What HLAs has RA been linked to?

Answer 16

HLA DR1 and DR4

Question 17

What causes RA?

Answer 17

Autoimmune attack of the synovial membrane

Question 18

What is the joint distribution of RA?

Answer 18

Symmetrical

MCPs and PIPs commonly affected as well as larger joints- knee, hip, shoulder

Question 19

What are the symptoms of RA?

Answer 19

Pain
Swelling
Reduced ROM
Morning stiffness- that improves after 30 minutes

Non-specific = Fever, fatigue, weight loss

Question 20

What is a dangerous place for RA to develop?

Answer 20

Atlantoaxial joint- which could lead to C spine instability

Question 21

What are some extra-articular manifestations of RA?

Answer 21

Rheumatoid nodules
Pulmonary fibrosis
Pleural effusions
Pericarditis
Pericardial effusion
Carpal tunnel syndrome

Question 22

What is felty syndrome?

Answer 22

RA + Neutropenia + Splenomegaly

Question 23

What blood tests should be done for RA?

Answer 23

ESR, CRP

RF, Anti-CCP (Highly specific)

Question 24

What deformities are seen in RA?

Answer 24

Ulnar deviation
Z Thumb
MCP subluxation
Swan Neck deformity
Boutonniere deformity

Question 25

What tool is used to measure disease activity in RA?

Answer 25

DAS-28

Question 26

What should be given in an RA flare?

Answer 26

Analgesia and steroids Methylprednisolone is more potent and better for this.

Question 27

What surgical procedures may be carried out in RA?

Answer 27

Less common now due to DMARDS Joint fusions Stabilising the C-Spine Joint replacements

Question 28

What is the management of RA?

Answer 28

Starting DMARDs early is associated with better outcomes. For a first presentation start DMARD (Methotrexate often 1st) and steroids to reduce sx

Question 29

When are biologics considered?

Answer 29

Failure to control disease activity and symptoms with at least two DMARDs

Question 30

What are some biologics used in the treatment of RA?

Answer 30

Anti-TNF e.g. Entarcept, Adalimumab, Infliximab Anti B Cell/Anti CD20- Rituximab IL-1 and IL-6 Inhibition (pro-inflammatory cytokines) e.g. Toclizumab

Question 31

What are some side effects of biologic therapies?

Answer 31

``` Risk of reactivation of latent TB Infection as immunosuppressed Hypersensitivity reactions Hepatitis B Increased risk of skin cancers with immunosuppression ```

Question 32

Where is the main risk of mortality in RA patients?

Answer 32

Cardiovascular disease Esp MI and stroke. Check risks and protective medicines e.g. statins, anti-hypertensives.