Orthopaedics & Rheumatology\ Rheumatoid Arthritis

Question 1

What is the pathogenesis of rheumatoid arthritis (RA)?

Answer 1

Autoimmune disorder involving chronic inflammation of the synovial lining of joints and destruction of the surrounding joint architecture

Question 2

RA typically affects what gender and age group of patients?

Answer 2

Females between 30 and 55 years old

Question 3

What is the typical presentation of RA?

Answer 3

• Pain and swelling of the hands and feet
• fatigue
• morning stiffness

Question 4

What are the most common joints involved in RA?

Answer 4

• MCP and PIP joints of the fingers
• IP joints of the thumbs
• wrists, MTP joints

Question 5

Is the typical joint distribution in RA symmetric or asymmetric?

Answer 5

Symmetric

Question 6

What criteria are used in the diagnosis of RA?

Answer 6

Four of the following seven criteria must be satisfied for diagnosis:

1. Morning stiffness for 6 weeks
2. Arthritis of three or more joint areas simultaneously for 6 weeks
3. Arthritis of hand joints for 6 weeks
4. Symmetric arthritis
5. Rheumatoid nodules
6. Positive serum rheumatoid factor
7. Characteristic radiographic changes in the hands

Question 7

How does a joint affected by RA look on x-ray?

Answer 7

Joint space narrowing and bony erosions

Question 8

What percentage of patients with RA are RF positive?

Answer 8

85%

Question 9

What are the classic hand deformities associated with chronic RA?

Answer 9

• Ulnar deviation of the hands
• swan neck or Boutonniere deformities of the fingers

Question 10

Describe the swan neck deformity.

Answer 10

PIP hyperextension with distal interphalangeal (DIP) flexion

Question 11

Describe the Boutonniere deformity.

Answer 11

PIP hyperflexion with DIP hyperextension

Question 12

What are the extra-articular (systemic) manifestations of RA?

Answer 12

• Interstitial lung disease
• pericardial effusions
• ocular manifestations

Question 13

How is disease activity assessed in a patient with chronic RA?

Answer 13

• Symptoms
• functional status
• degree of joint and extra-articular involvement
• radiographic changes

Question 14

What laboratory tests are used to follow the degree of synovial inflammation?

Answer 14

• Erythrocyte sedimentation rate (ESR)
• C-reactive protein (CRP) levels

Question 15

What is the goal of treatment of RA patients?

Answer 15

• Early identification and treatment of active disease to prevent permanent destruction of joints

Question 16

Describe the effectiveness of analgesics for treatment of RA.

Answer 16

Used for pain control but no effect on disease progression

Question 17

Describe the effectiveness of NSAIDS for treatment of RA.

Answer 17

Have both analgesic and anti-inflammatory properties but no effect on disease outcome

Question 18

Describe the effectiveness of Glucocorticoids for treatment of RA

Answer 18

Effective relief of joint pain and inflammation with possible delay of joint erosions

Question 19

The effectiveness of Disease modifying anti-rheumatic drugs (DMARDs), for example, Methotrexate in the treatment of RA

Answer 19

Decreases disease activity, but limited by side effects

Question 20

The effectivenss of Antitumor necrosis factor alpha-antibody agents (etanercept, infliximab, adalimumab)

Answer 20

Powerful anti-inflammatory effects

Question 21

What are the side effects of chronic glucocorticoid use?

Answer 21

• Cushingoid features
• peptic ulcers
• cataracts
• osteoporosis
• hyperglycemia
• hypertension
• immunosuppression

Question 22

What are the classic cushingoid features?

Answer 22

• Truncal obesity
• buffalo hump
• moon face
• weight gain

Question 23

How much calcium and vitamin D should patients on chronic glucocorticoids take to help prevent osteoporosis?

Answer 23

• 1000-1500 mg of calcium
• 400-800 IU of vitamin D daily
• by diet or supplementation

Question 24

What is the mechanism of action of methotrexate?

Answer 24

• Structural analogue of folic acid
• competitively binds to dihydrofolate reductase
• impairing DNA/RNA synthesis and decreasing cellular proliferation

Question 25

What are the side effects of methotrexate use?

Answer 25

• Hepatotoxicity
• pulmonary toxicity
• myelosuppression
• nephrotoxicity
• aphthous ulcers

Question 26

If a patient is on methotrexate, how often should you check liver function tests (LFT)?

Answer 26

Every 4-8 weeks

Question 27

If a patient is on methotrexate, how do you monitor for and help prevent myelosuppression?

Answer 27

• Full blood count (FBC) every 4-8 weeks
• prescribe folic acid 1 mg PO