RA

Question 1

Causes of arthritis plus nodules

Answer 1

Rheumatoid arthritis (seropositive)
SLE - rare
Rheumatic fever (Jaccoud’s arthritis) - very rare
Amyloid arthropathy - mos usuallywith multiple myeloma

Question 2

DDx of a deforming symmetrical chronic polyarthropathy

Answer 2

RA
Psoriatic arthropathy & other seronegative spondyloarthtopathies
Chronic tophaceous gout (rarely symmetrical)
SLE (usually but not always non-deforming)

Question 3

Changes on X-ray of RA

Answer 3

Soft tissue swelling
Symmetrical joint space narrowing (OA causes asymmetrical narrowing) & erosions
Juxta-articular osteoporosis
Marginal joint erosions

Question 4

DDx of a raised ESR in RA

Answer 4

Active disease
Amyloidosis
Infection
Sjögren’s syndrome

Question 5

Risk factors for destructive disease in RA

Answer 5

High-titre RF or positive anti-CCP
Constitutional symptoms 
Insidious onset
Erosions early on X-ray 
Rheumatoid nodules early
HLA-DR4

Question 6

Methotrexate SE

Answer 6

Rash
Abnormal LFTs (transaminases)
Leukopenia
Thrombocytopenia 
Interstitial lung disease 
Should NOT be given to pts with glucose-6-phosphate dehydrogenase deficiency

Question 7

Side effects & precautions for use of biological agents

Answer 7

Local reaction at injection site
Infusion reactions - nausea, flushing, headache, palpitations
Delayed infusion reactions - fatigue, rash, arthralgia, myalgia
Increased risk of serious infection (Listeria & salmonella)
Reactivation of TB
Contraindicated for patients with active hepatitis B or C
Contraindicated for patients receiving immunosuppression
Live vaccines are contraindicated
Possible increased risk of non-melanoma skin cancers
Not recommended in pregnancy

Question 8

Routine assessment of patients with RA

Answer 8

Fatigue
Morning stiffness 
Weight loss 
Functional limitations 
Acute-phase reactants (ESR, CRP)

Question 9

Main indications for steroid use in RA

Answer 9

New or uncontrolled disease as a bridge until suppressive treatment with slower acting DMARDs becomes effective
Vasculitis complications
Chronic low dose treatment (may be justifiable in the elderly)
Local steroid injections for acute involvement of a joint

Question 10

Reduction in life expectancy in RA

Answer 10

Reduced by up to 7 years due to
- increased risk of GI bleeding
- increased risk of infection
- threefold increased risk of atherosclerosis
NB use of methotrexate has been shown to halve excess mortality, including that from cardiovascular disease