#2: RA

Question 1

RA Risk Factors: (5)

Answer 1

1- genetic tendency (HLA DR4 genotype; first degree relative increases risk 2-3x)
2- infx (mycoplasma, EBV, rubella)
3- Female and sex hormones (pregnancy and OCs are protective)
4- Smoking
5- Parental HX of substance abuse

Question 2

Describe a typical RA pt? (4)

Answer 2

1- race (MC native american)
2- sex (MC in female)
3- age (peaks at 35-50 yo)
4- Fam HX

Question 3

The presence of RF may increase the risk for these DZ manifestations: (3)

Answer 3

• extra-articular DZ (aka systemic SXS)
• rheumatoid nodules
• severe erosive esophagitis

Question 4

Positivity for anti-CCP antibodies indicates an increased risk for: (2)

Answer 4

1- higher likelihood of erosive esophagitis

2- worse prognosis overall

Question 5

RA DX Criteria and score to DX:

Answer 5

1- joint involvement
2- serology tests
3- SXS duration
4- acute-phase RX test result
---- 6/10

Question 6

Before TX with DMARD or prednisone >20 mg/day, pts should have the following tests done: (6)

Answer 6

1- CBC
2- Chem panel
3- CRP/ESR
4- LFTS
5- Viral Hep Panel
6- TB tests: IGRA/PPD, plus CXR if risk factors

Question 7

Biologics C/I in these types of pts: (7)

Answer 7

1- TB
2- Fungal infx
3- Chronic HBV
4- Chronic HCV
5- CHF 3
6- CHF 4
7- Cancer in the last 5 yrs

Question 8

When is prednisone given in TX for RA? (3)

Answer 8

1- acute flare of RA
2- new onset RA and wks prior to DMARD takes effect
3- maximal medical TX and pt cannot take another DMARD

Question 9

These vaccinations should be given prior to DMARD TX: (6)

Answer 9

1- PCP
2- influenza
3- HPV
4- HZV
5- HAV
6- HBV

Question 10

Pts started on biologics need to be tested for these 3 conditions:

Answer 10

1- endemic fungal infx (histoplasmosis)
2- TB
3- Viral hep

Question 11

Initial DMARD of choice

Answer 11

MTX

– if poor TX response at >6 mos. then add non-bx DMARD

Question 12

Felty’s generally develops in pts w. RA who have these 3 characteristics:

Answer 12

1- RF seropositive
2- >10 yr RA DZ
3- extra-articular manifestations (systemic SXS)

Question 13

Felty’s SXS Triad:

Answer 13

1- splenomegaly
2- neutropenia
3- RA

Question 14

Steroid SE in RA TX: (4)

Answer 14

1- osteoporosis worsening
2- HTN
3- Hyperglycemia
4- weight gain

Question 15

NSAID C/I: (8)

Answer 15

1- CKD
2- DDI w. warfarin 
3- Elderly pts
4- Failure: Decompensated HF
5- GI bleed
6- HTN
7- HX of PUD
8- Liver DZ
Caution: DM and ACE/ARB

Question 16

MTX reversal agent:

Answer 16

Leucovorin

Question 17

TNF agents safety concerns: (8)

Answer 17

1- Surgery: hold biologics 2-4 wks before and skip one dose after surgery (esp hip/knee TR)
2- Significant Liver DZ: caution w. active dz
3- SLE autoab’s:
–SXS: rash, arthritis, photosensitivity
–Positive: dsDNA and ANA
–stop drug to improve
4- HF: esp w. infliximab
C/I: NYHA C3 (SXS at rest) and C4 (SXS w. minimal activity)
5- HX of cancer: caution if ca tx in last 5 yr
6- Pregnancy: okay up until conception
7- Opportunistic infx: always screen PPD and Quantiferon prior to starting
—aspergillus, PCP, and histoplasmosis
8- Demyelinating DZ: GB, MS increased risk, so caution if fam hx