Rheumatoid Arthritis

Question 1

longstanding complication of RA with sensation of head falling off dropattacks and painless paresthesias of hands and feet

Answer 1

C1-C2 subluxation Can have inflammation that leads to attenuation of transverse ligament that normally limits posterior motion of odontoid process of C2 vertebrae.

Question 2

Pre op testing

Answer 2

Get flexion and extension XR of neck prior to surgery in case of C1-C2 subluxation atlantoaxial subluxation (important for intubation)

Question 3

If abnormal XR of neck in RA pt, order what test next?

Answer 3

MRI, if significant subluxation get surgery

Question 4

preferred therapy for RA (or initial monotherapy)

Answer 4

methotrexate weekly

Question 5

How to measure RA disease activity?

Answer 5

CDAI or clinical dx activity index

Question 6

maximum dose for methotrexate

Answer 6

methotrexate 25 mg weekly

Question 7

how to titrate methotrexate in patients with RA

Answer 7

CDAI score, development of joint damage by radiography or U/S (sees erosions earlier than XR)

Question 8

Is prednisone useful in tx of RA

Answer 8

Helpful if used WITH methotrexate but long term side effects are large not helpful if primary therapy

Question 9

What is the role of NSAIDs in RA?

Answer 9

helpful in treating pain and swelling but not disease modifying and doesn’t slow pregoression of dx. Only used for temporary symptom control while methotrexate or other therapies work

Question 10

Do we use mychophenolate mofetil in RA?

Answer 10

no, not a DMARD and no benefit compared to placebo

Question 11

Prognostic factors for erosive RA

Answer 11

positive anti CCP antibody and RA

early development of multiple joint inflammation

radiographic erosions

severe functional limitations

lower socioeconomic status and less education

elevated ESR and CRP persistent

joint inflammation >12 weeks

Question 12

people who have anti CCP antibodies and have higher titers with RA mean

Answer 12

they probably will have poor funcitonal outcomes and more radiographic progression so should be on a more aggressive DMARD compared to other pts to treat their RA

Question 13

clinical features of RA?

Answer 13

insidious onset, multiple joint pain,

stiffness and swelling morning stiffness lasting hours,

improves with activity

small joints PIP MCP MTP but no DIP

can see monoarthritis in knees and elbows (which occurs later)

Question 14

what is seen on physical exam with pt who has RA?

Answer 14

affected joints are tender, swollen, limited ROM.

tenosynovitis of palms (trigger finger)

rheumatoid nodules (on elbows)

cervical joint can lead to spine subluxation

Question 15

Lab imaging results for RA pts

Answer 15

positive anti CCP

high IgM RF

high ESR and CRP

XR with soft tissue swelling and joint space narrowing and boney erosions.

Question 16

can RA serology be negative and still have disease

Answer 16

yes. diagnosis is based on a point system so if number of joints, ESR/CRP are high, clinical history and physical exam are concerning can treat like RA. Serology can be negative in early disease.

Question 17

If RA patient is unable to tolerate methotrexate or doesn’t improve on methotrexate alone what do you give?

Answer 17

TNF alpha inhibitor (check tuberculin test prior to starting)

Question 18

when do we give rituximab in the treatment of RA?

Answer 18

third line tx

in pts who are resistant to usual DMARD therapy (methotrexate or combo with TNF alpha inhibitor)

Question 19

when do we use sulfasalazine and hydroxychloroquine for RA

Answer 19

for mild disease or in combination with methotrexate in highly active RA dx.

not used alone for moderate to severe dx.

Question 20

when would you get orthopedic surgery evaluation for RA?

Answer 20

• when have joint pain because of severe functional disability and impending tendon rupture.
• when there’s been longstanding RA and functional limitations not explained by inflammatory aspect of dx. If ESR and CRP are neg and no joint effusions or tenderness but has severe joint dx.

However total joint replacement and soft tissue release and joint fusion only lasts about 10-15 years after.

Question 21

who should we avoid TNF alpha inhibitors in?

Answer 21

CHF pts.

Could use cautiously in NYHA class 1 and 2 but absolutely contraindicated in 3 and 4.

Question 22

neck pain radiating to occipital region, slow progressive quadriparesis, painless sensory deficits in hands or feet and respiratory dysfunction (vertebral artery compression)

Answer 22

clinical features of rheumatoid cervical myelopathy

Question 23

signs of RA cervical myelopathy

Answer 23

protruding anterior arch of atlas, scioliosis with loss of cervical lordosis upper motor neuron signs (spastic paresis, hyperreflexia and Babinski sign) and Hoffman sign

Question 24

Risk factors for cervical subluxation related to RA

Answer 24

late onset RA< elevated C reactive protein, rapidly progressive peripheral joint dx and early subluxation of peripheral joints.

Question 25

why do we see cervical subluxation of C1-C2?

Answer 25

because this is the only joint that has synovial membrane. There can be synovitis with erosions that destroys adjacent ligaments anchoring C1 and C2 causing eventual subluxation of C1 relative to C2 most often anteriorly.

Question 26

Best imaging study to order to see if there's suspected subluxation

Answer 26

get spinal MRI to visualize the cervical spine for spinal cord compression, boney erosions and synovitis.

Question 27

patients who have subluxation without signs of core compression should be treated

Answer 27

medically with neck collars and close monitoring of neck prevention

Question 28

pts who have subluxation with signs of cord compression need

Answer 28

surgery for spinal stabilization

Question 29

methotrexate toxicity presentation

Answer 29

stomatitis and megaloblastic anemia or small oral ulcers that are non healing

Question 30

how long does stomatitis last and what are its effects

Answer 30

can persist for days to weeks and can interfere with eating and lead to premature discontinuation of MTX

Question 31

how what supplement should be given with MTX

Answer 31

give folic acid 1mg/day with dose increase to 5mg/day based on symptoms. Folic acid improves stomatitis and toxicity from MTX

Question 32

if someone doesn't improve with folic acid and is on MTX and has stomatitis what to do next?

Answer 32

need to discontinue MTX

Question 33

common side effects of MTX

Answer 33

**fever,** rash in once a week MTX fever can be caused by MTX but needs to be excluded. **GI complaints:** are nausea/ upset stomach and can be relieved by PPI or H2 blockers **non healing ulcers and stomatitis.**

Question 34

what kind of rash is associated with MTX

Answer 34

rash is punctuate and macular which affects extremities but spares the trunk. usually will fade by the following week's MTX dose.

Question 35

life threatening toxicities with MTX are:

Answer 35

hepatocellular toxicity, or worsening hepatotoxicity in setting of viral hepatitis, pulmonary damage, myelosuppression and nephrotoxicity

Question 36

what should be ordered on a pt who is going to get MTX

Answer 36

needs a CXR and a viral hepatitis panel prio to initiation

Question 37

What labs should be followed in pts who get MTX:

Answer 37

CMP (liver and Cr), albumin, CBC with diff.

Question 38

Prognosis of seronegative RA pts

Answer 38

have a somewhat less aggressive course

Question 39

treatment of RA is with: Role NSAIDs for acute flairs and treatment of RA

Answer 39

disease modifying antirheumatic agents NSAIDS **only provide pain relief** but **_don't actually prevent long term joint damage and functional impairment with RA_** **_Prednisone_** may have some disease modifying effect and are often paired with methotrexate or others. Often used to rapidly improve RA symptoms while waiting for long term DMARDs to be come effective.

Question 40

1st line DMARDs are

Answer 40

hydroxychloroquine, **methotrexate,** sulfasalazine, leflunomide most often people use methotrexate but can use other agents single agent. _Leflunomide_ is used when methotrexate is not tolerated. _hydroxychloroquine_ (lease potent) is used early in dx when dx activity score is low

Question 41

synovitis, systemic inflammation, chronic symmetrical polyarticular joint pain and stiffness and elevated CRP and ESR

Answer 41

RA features

Question 42

adverse effects of MTX

Answer 42

**hepatotoxicity stomatitis** **pulmonary fibrosis** **cytopenia -** folate deficiency rash GI-N/V can see nephrotoxicity non classically works as an antifolate metabolite _doesn't cause peripheral neuropathy_

Question 43

lefluomide adverse effects

Answer 43

**hepatotoxicity,** **fetal abnormalities** **cytopenia** **rarely it causes peripheral neuropathy** can see **HTN** pyrimidine synthesis inhibitor (often used when methotrexate is not tolerated)

Question 44

hydroxychloroquine adverse effects

Answer 44

**Hepatotoxicity,** **stomatitis,** **hemolytic anemia** **can see QT prolongation** with this TNF and IL-1 suppressor long term side effects is **irreversible damage to the retina** - need _eye exam at initiation of med_ and then **5 years after that**.

Question 45

sulfasalazine adverse effects

Answer 45

**hepatotoxicity,** **stomatitis,** **hemolytic anemia** **can see TEN and** **crystal induced AKI** Acts as TNF and IL-1 suppressor

Question 46

TNF inhibitors (adalimumab, certolizumab, etancercept, golimumab, infliximab) side effects

Answer 46

infection, demyelination, CHF malignancy Need to screen for TB and hep B and C prior to starting. can potentially cause a SLE drug induced dx and a increased risk for lymphoma. used in many diseases like **RA, psoriasis, psoriatic arthritis, ankylosing spondylitis, and Behcet's dx.**

Question 47

ACR classification for diagnosis of RA:

Answer 47

symptoms \>6 weeks inflammatory arthritis \>3 joints positive RF or anti CCP elevated ESR/CRP exclusion of other similar conditions: psoriatic arthritis, acute viral polyarthritis, polyarticular gout or CPPD dx, SLE)

Question 48

can see marginal erosion of joints in RA

Answer 48

see underlying erosive RA

Question 49

what is the Felty syndrome?

Answer 49

this is RA with splenomegaly and leukopenia seen with long established RA and has a positive RF

Question 50

treatment of Rheumatoid arthritis

Answer 50

Question 51

If there's a positive TST or positive interferon gamma release assay prior to starting a TNF-alpha inhibitor in a RA pt what do you do?

Answer 51

need to treat for latent TB prior to starting TNF antagonist therapy

Question 52

Before starting a TNF alpha inhibitor what vaccine would you give to a 50 year old woman with RA

Answer 52

give them the **recombinant herpes zoster vaccine** **recombinant** - inactivated vaccine However the 2019 _made no comment on if we can safely give recombinant vaccine to someone_ with TNF alpha inhibitor. Ok to **give recombinant vaccine with someone who is on methotrexate.**

Question 53

side effect of leflunomide is

Answer 53

Major toxicity are: **severe hypertension** **fetal toxicity** **hepatoxocity** - discontinue if there's LFTs elevation regardless of symptoms. DMARD that stops pyrimidine synthesis considered 1st line agent for RA and can be used with conjunction with biologic or non biologic DMARDs.

Question 54

felty syndrome is associated with:

Answer 54

neutropenia and splenomegaly happens in people who have **severe untreated RA** and they are at risk for serious bacterial infection, lower extremity ulceration, lymphoma and vasculitis.

Question 55

RA eye involvement:

Answer 55

most common symptom is **dry eyes** (_keratoconjunctivitis sicca_) if they also have **dry mouth + dry eyes** = secondary Sjogren's from RA Less common is **episcleritis -** inflammation of **superficial scleral vessels** **Scleritis** = inflammation of **deep scleral vessels. is vision threatening as** there's thinning of sclera and can have _perforation._ **keratitis -** corneal inflammation and can be ulcerative which iccurs at the periphery of corena **corneal melt -** severe keratitis both scleritis and keratitis need **immediate referral to ophthlamologist.**

Question 56

pleural effusion of RA

Answer 56

see pleural effusions which are exudative and large see low glucose and low pH low complement levels and elevated levels of total protein, RF, and LDH

Question 57

what causes majority of RA death?

Answer 57

CAD and atherosclerotic heart dx interstitial lung dx.

Question 58

pts who get pregnant and have RA often

Answer 58

2/3 will undergo remission of RA 1/3 will stay the same or get worse.

Question 59

Rheumatoid medications that are absolutely contraindicated in pregnancy

Answer 59

**methotrexate** - _STOP 3 months_ prior to pregnancy **leflunomide** - *extremely tetraogenic* - **need cholestyramine to remove drug from body** and needs to be followed with drug level **mycophenolate mofetil** - _STOP 3 months_ prior to pregnancy

Question 60

Rheumatoid medications that are safe to use in pregnancy:

Answer 60

hydroxychloroquine sulfasalazine tylenol not teratogenic

Question 61

Medications that are "iffy" and only should be used in pregnancy if benefit outweighs the risk and technically should be avoided:

Answer 61

NSAIDs glucocorticoids colchicine opioids tramadol azathioprine cyclosporine cyclophosphamide TNF alpha inhibitors all the gout drugs.