2: Rheumatoid arthritis

Question 1

What is the prevalence of rheumatoid arthritis in the population?

Answer 1

1%

Question 2

What is early RA?

Answer 2

RA discovered <2 years after onset

Question 3

What is advanced RA?

Answer 3

RA discovered >2 years after onset of symptoms

often irreversible changes will have occured at this point

Question 4

What is the definition of RA?

Answer 4

SYMMETRICAL inflammatory arthritis affecting PERIPHERAL JOINTS

Question 5

RA is (symmetrical / asymmetrical).

Answer 5

symmetrical

Question 6

Which joints are affected by RA?

Answer 6

Peripheral joints

1st and 2nd cervical joints

Question 7

RA, if left untreated, can lead to irreversible joint damage and deformities which cause ___ ___ ___.

Answer 7

loss of function

Question 8

Which sex is more likely to develop RA?

Answer 8

Females

Question 9

Mutations in which gene causes RA?

Answer 9

HLA-DR4

Question 10

Which lifestyle factor has an association with RA?

Answer 10

Smoking

Question 11

Which structure, lining the inside of synovial joints and tendon sheathes, is affected in RA?

Answer 11

Synovium

Question 12

RA affects any ___ joint.

Answer 12

synovial

Question 13

Which joints of the hand are affected by RA?

Answer 13

MCP joints

PIP joints

Question 14

Which joints of the hand aren’t affected by RA?

Answer 14

DIP joints

Question 15

Which spinal joints are affected by RA?

Answer 15

C1 and C2

Question 16

Inflammatory mediators released during synovitis cause joint ___.

Answer 16

damage

Question 17

Why does bone erode in RA?

Answer 17

Osteoclasts activated during inflammatory response

Question 18

Which immune cells are activated in RA?

Answer 18

Pretty much all of them

Question 19

What name is given to hypertrophic, inflamed synovium found in joints of RA patients?

Answer 19

Pannus

Question 20

In RA, antigen ___ cells present antigens to __ cells which go on to activate other immune cells and cause inflammation.

Which chemicals are released by immune cells and further the inflammatory response?

Answer 20

presenting, T cells

cytokines

Question 21

Apart from the hand joints themselves, what other structures are affected in RA?

Answer 21

Tendon sheathes

called tenosynovitis

Question 22

What other lesion are inflamed tendon sheathes mistaken for?

Answer 22

Ganglion cysts

Question 23

When is the ideal time to treat RA?

Answer 23

First 3 months following onset of symptoms

Question 24

Are RA patients always positive for rheumatoid antibodies?

Answer 24

No

Question 25

RA is an example of a **(monoarthritis / polyarthritis)**.

Answer 25

**polyarthritis**

Question 26

90% of RA diagnoses are based on ___ and \_\_\_.

Answer 26

**history** **examination**

Question 27

What are the symptoms of RA?

Answer 27

**Pain** **Swelling** **Prolonged morning stiffness** lasting \> 30 minutes

Question 28

In blood tests of patients with RA, what is commonly raised?

Answer 28

**Inflammatory markers** as it's an inflammatory disease

Question 29

Which joints tend to be involved in RA?

Answer 29

**Any synovial joints, but** small joints of hands and feet (symmetrically)

Question 30

Which joints, if eliciting pain when squeezed, should raise suspicion of RA?

Answer 30

**MCP joints** **MTP joints**

Question 31

Patients presenting with recurrent trigger finger should be suspected of having what?

Answer 31

**RA**

Question 32

What is carpal tunnel syndrome?

Answer 32

**Compression of MEDIAN NERVE causing peripheral pins and needles** can be caused by synovitis compressing nerve in RA

Question 33

What is palindromic rheumatism?

Answer 33

**Comes and goes in episodes**

Question 34

Tenosynovitis tends to affect the **(flexor / extensor)** tendons.

Answer 34

**extensor**

Question 35

# Loss of function Patients with a poor __ \_\_ should be suspected of having RA.

Answer 35

**poor grip strength**

Question 36

What are the two autoantibodies associated with RA?

Answer 36

**Rheumatoid factor** **Anti-CCP antibodies**

Question 37

Which class of antibody is rheumatoid factor?

Answer 37

**IgM**

Question 38

The ___ of rheumatoid factor is quite poor.

Answer 38

**sensitivity**

Question 39

Even though rheumatoid factor and anti-CCP antibody are raised in patients with RA, does their absence rule it out?

Answer 39

**No** some patients have RA without any autoantibodies

Question 40

The more RA antibodies present, the **(better / worse)** the prognosis.

Answer 40

**worse prognosis**

Question 41

Anti-CCP antibody is associated with what?

Answer 41

**Smoking**

Question 42

In the initial stages of RA, X-rays will be **\_\_\_**.

Answer 42

**normal**

Question 43

In untreated RA, osteoclasts erode the bone causing \_\_\_.

Answer 43

**osteopenia** reduced bone density

Question 44

Why are X-rays of the hands and feet a baseline investigation for RA even if there may be no visible changes?

Answer 44

**Cheap and reproducible, 10% of X-rays will have changes** **You've got an image to compare later X-rays to**

Question 45

What scan is used to identify erosions and make treatment changes?

Answer 45

**Ultrasound**

Question 46

What is the gold standard scan for RA, but is less commonly used due to its cost? What can you see on it in addition to bone?

Answer 46

**MRI scan** **Tendons** and **soft tissue swelling**

Question 47

What scoring system is used for disease activity in RA?

Answer 47

**DAS 28** counts the 28 joints most commonly affected (sparing the DIPs, which aren't affected)

Question 48

The lower the DAS28 score, the **(better / worse)** the prognosis for the patient.

Answer 48

**better**

Question 49

What drugs are used to treat RA?

Answer 49

**NSAIDs** **Steroids** **DMARDs** **Biologic agents**

Question 50

What are disease modifying drugs for RA?

Answer 50

**Drugs which reduce the activity of immune cells**

Question 51

What is the most commonly used disease modifying drug?

Answer 51

**Methotrexate**

Question 52

Steroids are used liberally as a **bridge** between NSAIDs and \_\_\_. Why?

Answer 52

**disease modifying drugs** e.g methotrexate DMARDs take weeks - months to start working

Question 53

How are steroids administered in patients with RA?

Answer 53

**Orally** **Intramuscularly / intra-articularly**

Question 54

How often do RA patients take methotrexate?

Answer 54

**Weekly**

Question 55

Why must the use of DMARDs be monitored?

Answer 55

**Loads of side effects**

Question 56

What is an important pulmonary side effect of methotrexate?

Answer 56

Causes **pneumonitis** (inflammation of the lungs) ## Footnote ***NOT pulmonary fibrosis***

Question 57

If patients fail to respond to NSAIDs, steroids and DMARDs, what other drugs can be used to try and treat RA?

Answer 57

**Biologic agents** i.e monoclonal antibodies

Question 58

What do biologic agents do?

Answer 58

**Block various parts of inflammatory pathway** e.g TNF, T cells, B cells...

Question 59

The use of biologic agents makes patients prone to \_\_\_.

Answer 59

**infection**

Question 60

Which organism can **re-activate** due to the use of biologic agents?

Answer 60

**Mycoplasma tuberculosis**

Question 61

Which disease, amongst many others, must patients be screened for before commencing the use of biologic agents?

Answer 61

**TB**

Question 62

Patients on biologic agents must avoid which type of vaccine?

Answer 62

**Live attenuated**

Question 63

Untreated RA will result in hand and foot \_\_\_.

Answer 63

**deformities**

Question 64

Untreated RA causes joints to **(sublux / dislocate)**.

Answer 64

**sublux**