Rheumatoid arthritis

Question 1

Rheumatoid arthritis is a chronic systemic inflammatory disease that causes persistent (?) joint synovitis (inflammation of the synovial membrane) typically of the small joints of the hands and feet, although any synovial joint can be affected.

Answer 1

symmetrical

Question 2

Rheumatoid arthritis is a chronic systemic inflammatory disease that causes persistent symmetrical joint (?) (inflammation of the synovial membrane) typically of the small joints of the hands and feet, although any synovial joint can be affected.

Answer 2

synovitis

Question 3

What is the definition of synovitis?

Answer 3

Inflammation of the synovial membrane

Question 4

Rheumatoid arthritis is a chronic systemic inflammatory disease that causes persistent symmetrical joint synovitis (inflammation of the synovial membrane) typically of the (small/large?) joints of the hands and feet, although any synovial joint can be affected.

Answer 4

small

Question 5

What is the name of the rare form of inflammatory arthritis which causes attacks of joint pain and swelling similar to rheumatoid arthritis, but the joints return to normal in between attacks?

Answer 5

Palindromic rheumatism

Patients with palindromic rheumatism may later develop rheumatoid arthritis

Question 6

What is the first-line treatment in patients with newly diagnosed active rheumatoid arthritis?

Answer 6

Monotherapy with a conventional DMARD
- Oral methotrexate, leflunomide or sulfasalazine

Hydroxychloroquine sulfate, a weak conventional DMARD, is an alternative in patients with mild rheumatoid arthritis or those with palindromic rheumatism

Question 7

When should you start treatment with a DMARD in patients with newly diagnosed active rheumatoid arthritis?

Answer 7

As soon as possible, ideally within 3 months of onset of persistent symptoms

Question 8

Conventional DMARDs have a (fast/slow?) onset of action and can take 2–3 months to take effect.

Answer 8

Slow

Consider short-term bridging treatment with a corticosteroid (by oral, intramuscular, or intra-articular administration) when starting treatment with a new conventional DMARD to provide rapid symptomatic control, while waiting for the new DMARD to take effect.

Question 9

Conventional DMARDs have a slow onset of action and can take (?) months to take effect.

Answer 9

2-3

Consider short-term bridging treatment with a corticosteroid (by oral, intramuscular, or intra-articular administration) when starting treatment with a new conventional DMARD to provide rapid symptomatic control, while waiting for the new DMARD to take effect.

Question 10

What should you also prescribe when starting a patient with newly diagnosed active rheumatoid arthritis with a conventional DMARD?

Answer 10

Short-term bridging corticosteroid

To provide rapid symptomatic control while waiting for the new DMARD to take effect

Question 11

What should be given to rapidly decrease inflammation during flare-ups of rheumatoid arthritis?

Answer 11

Short-term corticosteroids

Question 12

If treatment target (remission or low disease activity) for rheumatoid arthritis has not been achieved despite dose escalation on conventional DMARDs, what is the next step in management?

Answer 12

Offer combination therapy with additional conventional DMARDs
(oral methotrexate, leflunomide, sulfasalazine or hydroxychloroquine sulfate)

Question 13

What drugs are considered for monotherapy with conventional DMARDs in the treatment of rheumatoid arthritis? (3)

Answer 13

Methotrexate
Leflunomide
Sulfasalazine

Hydroxychloroquine sulfate is a week conventional DMARD and is an alternative in patients with mild rheumatoid arthritis or those with palindromic rheumatism

Question 14

What are the drugs that are considered when treating rheumatoid arthritis with combination therapy of conventional DMARDS? (4 conventional DMARDs to choose from)

Answer 14

Methotrexate
Leflunomide
Sulfasalazine
Hydroxychloroquine sulfate

Question 15

What are the three treatment options if there has been an inadequate response to combination therapy with conventional DMARDs for the treatment of rheumatoid arthritis?

Answer 15

1. Tumour necrosis factor (TNF) alpha inhibitor
2. Biological DMARD (abatacept, sarilumab or tocilizumab)
3. Targeted synthetic DMARD (baricitinib, filgotinib, tofacitinib or upadactinib)

Question 16

Adalimumab, certolizumab pegol, etanercept, golimumab, or infliximab are all examples of which class of drug?

Answer 16

Tumour necrosis factor (TNF) alpha inhibitors

Question 17

Abatacept, sarilumab, or tocilizumab are all examples of which class of drug?

Answer 17

Biological DMARDs

Question 18

Baricitinib, filgotinib, tofacitinib, or upadacitinib are all examples of which class of drug?

Answer 18

Targeted synthetic DMARDs

Question 19

Methotrexate, leflunomide, sulfasalazine, or hydroxychloroquine sulfate are all examples of which class of drug?

Answer 19

Conventional DMARDs

Question 20

Which treatment is an option for patients with severe active rheumatoid arthritis who have had an inadequate response to, or are intolerant of other DMARDs, including at least one TNF alpha inhibitor?

Answer 20

Rituximab + methotrexate

Question 21

What is the last resort treatment for rheumatoid arthritis that should only be used if all other treatments options (including biological and targeted synthetic DMARDs) have been offered?

Answer 21

Long-term corticosteroid use

Question 22

Patients with active rheumatoid arthritis should be monitored (1?) until the treatment target (either remission or low disease activity) has been achieved, and all patients with rheumatoid arthritis should be reviewed (2?)

Answer 22

1. Monthly

2. Annually

Question 23

What is the treatment target for rheumatoid arthritis?

Answer 23

Disease remission
OR
Low disease activity if remission cannot be achieved

Question 24

What additional short-term pain relief should be considered for control of pain and stiffness associated with rheumatoid arthritis? (2)

Answer 24

NSAID
or
Selective COX-2 inhibitor

Patients should be offered a PPI to minimise associated GI adverse effects

Question 25

When is surgery considered an option in the treatment of rheumatoid arthritis? (4)

Answer 25

1. Drug treatment has failed to adequately manage persistent pain due to joint damage or other identifiable soft tissue causes 2. Worsening of joint function, 3. Progressive deformity 4. Persistent localised synovitis

Question 26

What are the two indications for the use of abatacept?

Answer 26

Moderate-to-severe active rheumatoid arthritis (specialist use only) Active psoriatic arthritis (specialist use only) Abatacept is a biological DMARD

Question 27

What is the contraindication for the use of the biological DMARD, abatacept?

Answer 27

Severe infection Caution: do not initiate until active infections are controlled

Question 28

For how long must a patient taking the biological DMARD abatacept ensure effective contraception?

Answer 28

During treatment and for 14 weeks after last dose

Question 29

What class of drug is abatacept?

Answer 29

Biological DMARD

Question 30

What class of drug is adalimumab?

Answer 30

TNF alpha inhibitor

Question 31

What are the contraindications for the use of the TNF alpha inhibitor adalimumab?

Answer 31

Moderate or severe heart failure | Severe infections

Question 32

For how long must a patient taking the TNF alpha inhibitor adalimumab ensure effective contraception?

Answer 32

During treatment and for at least 5 months after last dose

Question 33

What does a patient need to be screened for prior to starting treatment with TNF alpha inhibitor adalimumab?

Answer 33

Tuberculosis (TB) (active and latent)

Question 34

What needs to be monitored for in a patient taking the TNF alpha inhibitor adalimumab?

Answer 34

1. Infection (before, during and or 4 months after treatment) 2. Non-melanoma skin cancer before and during treatment 3. Pre-existing or developing central demyelinating disorders (before and at regular intervals during treatment)

Question 35

(?) is metabolised to mercaptopurine.

Answer 35

Azathioprine

Question 36

Azathioprine is metabolised to (?).

Answer 36

mercaptopurine

Question 37

Is azathioprine commonly used in the treatment of rheumatoid arthritis?

Answer 37

No Due to the availability of newer, more effective drugs Azathioprine is an older conventional DMARD

Question 38

What are the common side effects of the older conventional DMARD azathioprine? (5)

Answer 38

``` Bone marrow depression (dose-related) Infection Leucopenia Pancreatitis Thrombocytopenia ```

Question 39

If a transplant patient taking the older conventional DMARD azathioprine falls pregnant, should they stop taking azathioprine?

Answer 39

NO Transplant patients immunosuppressed with azathioprine should not discontinue it on becoming pregnant. However, there have been reports of premature birth and low birth-weight following exposure to azathioprine, particularly in combination with corticosteroids. Spontaneous abortion has been reported following maternal or paternal exposure.

Question 40

What does a patient need to be screened for prior to starting treatment with the older conventional DMARD azathioprine?

Answer 40

Thiopurine methyltransferase (TPMT) activity The enzyme thiopurine methyltransferase (TPMT) metabolises thiopurine drugs (azathioprine, mercaptopurine, tioguanine); the risk of myelosuppression is increased in patients with reduced activity of the enzyme, particularly for the few individuals in whom TPMT activity is undetectable.

Question 41

Why does thiopurine methyltransferase (TPMT) activity need to be screened prior to starting treatment with the older conventional DMARD azathioprine?

Answer 41

Increased risk of myelosuppression in patients with reduced activity of TPMT

Question 42

Name three drugs in which you should measure thiopurine methyltransferase (TPMT) activity prior to starting therapy?

Answer 42

Azathioprine Mercaptopurine Tioguanine Seek specialised advice for those with reduced or absent TPMT activity

Question 43

What do you need to monitor for in a patient taking the older conventional DMARD azathioprine? (3)

Answer 43

1. Toxicity 2. FBC weekly for first 4 weeks, then reduce to at least every 3 months 3. Signs of myelosuppression

Question 44

What class of drug is baricitinib?

Answer 44

Targeted synthetic DMARD Baricitinib selectively and reversibly inhibits the Janus-associated tyrosine kinases JAK1 and JAK2.

Question 45

What are the two indications for the use of the targeted synthetic DMARD baricitinib?

Answer 45

Moderate-to-severe active rheumatoid arthritis | Moderate-to-severe atopic eczema

Question 46

What is an uncommon but important side effect of the targeted synthetic DMARD baricitinib that will lead to permanent discontinuation if it occurs?

Answer 46

VTE

Question 47

What should be screened for prior to starting treatment with the targeted synthetic DMARD baricitinib? (2)

Answer 47

Tuberculosis (TB) | Viral hepatitis

Question 48

What class of drug is certolizumab pegol?

Answer 48

TNF alpha inhibitor

Question 49

What are the contraindications to the use of the TNF alpha inhibitor certolizumab pegol? (2)

Answer 49

Moderate to severe heart failure | Severe active infection

Question 50

What needs to be screened for prior to starting treatment with the TNF-alpha inhibitor certolizumab pegol?

Answer 50

Tuberculosis (TB)

Question 51

Is ciclosporin commonly used in the treatment of rheumatoid arthritis?

Answer 51

NO No longer used commonly due to the availability of newer, more effective drugs

Question 52

(?) inhibits production and release of lymphokines, thereby suppressing cell-mediated immune response.

Answer 52

Ciclosporin

Question 53

Pomelo juice is predicted to (1?) ciclosporin exposure. Purple grape juice is predicted to decrease ciclosporin exposure.

Answer 53

1. increase

Question 54

Pomelo juice is predicted to increase ciclosporin exposure. Purple grape juice is predicted to (1?) ciclosporin exposure.

Answer 54

1. decrease

Question 55

(?) juice is predicted to increase ciclosporin exposure. Purple grape juice is predicted to decrease ciclosporin exposure.

Answer 55

Pomelo

Question 56

Pomelo juice is predicted to increase ciclosporin exposure. (?) juice is predicted to decrease ciclosporin exposure.

Answer 56

Purple grape

Question 57

What class of drug is etanercept?

Answer 57

TNF alpha inhibitor

Question 58

What is the contraindication for the use of the TNF alpha inhibitor etanercept?

Answer 58

Active infection

Question 59

For how long must a patient taking the TNF alpha inhibitor etanercept ensure effective contraception?

Answer 59

During treatment and for 3 weeks after last dose

Question 60

What should be screened for prior to starting treatment with the TNF alpha inhibitor etanercept?

Answer 60

Tuberculosis (TB)

Question 61

What needs to be monitored for during treatment with the TNF alpha inhibitor etanercept?

Answer 61

Skin cancer Monitor for skin cancer before and during treatment, particularly in those at risk (including patients with psoriasis or a history of PUVA treatment).

Question 62

What class of drug is filgotinib?

Answer 62

Targeted synthetic DMARD Filgotinib is a selective inhibitor of the Janus-associated tyrosine kinase JAK1.

Question 63

What is the only indication for the use of the targeted synthetic DMARD filgotinib?

Answer 63

Rheumatoid arthritis

Question 64

What are the contraindications for the use of the targeted synthetic DMARD filgotinib? (5)

Answer 64

1. Absolute lymphocyte count less than 0.5 x 10^9 cells/litre 2. Absolute neutrophil count less than 1 x 10^9 cells/litre 3. Haemoglobin less than 8 g/dL 4. Serious infection (active) 5. Tuberculosis (active)

Question 65

For how long must a female patient taking the targeted synthetic DMARD filgotinib ensure effective contraception?

Answer 65

During treatment for at least 1 week after stopping treatment

Question 66

What must a male patient be warned about prior to starting treatment with the targeted synthetic DMARD filgotinib?

Answer 66

Potential risk of reduced fertility or infertility No effects on female fertility have been observed in animal studies

Question 67

What needs to be screened for prior starting treatment with the targeted synthetic DMARD filgotinib? (2)

Answer 67

Tuberculosis (TB) | Viral hepatitis

Question 68

What class of drug is golimumab?

Answer 68

TNF alpha inhibitor

Question 69

What are the two contraindications for the use of the TNF-alpha inhibitor golimumab?

Answer 69

Moderate or severe heart failure | Severe active infection

Question 70

What pre-treatment is required prior to starting therapy with the TNF-alpha inhibitor golimumab?

Answer 70

Tuberculosis (TB)

Question 71

What are the three indications for the use of the weak conventional DMARD hydroxychloroquine sulfate?

Answer 71

Active rheumatoid arthritis Systemic and discoid lupus erythematosus Dermatological conditions caused or aggravated by sunlight

Question 72

(drug?) is a weak conventional DMARD

Answer 72

Hydroxychloroquine sulfate

Question 73

Hydroxychloroquine sulfate is a (?) conventional DMARD

Answer 73

weak

Question 74

Hydroxychloroquine sulfate is a weak (?)

Answer 74

conventional DMARD

Question 75

What needs to be monitored regularly in a patient taking hydroxychloroquine sulfate?

Answer 75

Opthalmological examination (monitoring for retinopathy) Recommendations: - baseline examination (fundus photography and spectral domain optical coherence tomography) within 6-12 months of treatment initiation - Annual monitoring if taken hydroxychloroquine for > 5 years - Annual monitoring may be commenced before 5 years of treatment if additional risk factors

Question 76

What are the common side effects of hydroxychloroquine sulfate? (9)

Answer 76

``` Abdominal pain Appetite decreased Diarrhoea Emotional lability Headache Nausea Skin reactions Vision disorders Vomiting ```

Question 77

What is an uncommon side effect of hydroxychloroquine sulfate that must be monitored for?

Answer 77

Retinopathy

Question 78

If a patient with rheumatoid arthritis taking hydroxychloroquine becomes pregnant, do you need to stop this antimalarial drug?

Answer 78

No, if the rheumatic disease is well controlled But advised to avoid using during pregnancy

Question 79

To avoid excessive dosage in (?) patients, the dose of hydroxychloroquine should be calculated on the basis of ideal body-weight.

Answer 79

obese

Question 80

To avoid excessive dosage in obese patients, the dose of hydroxychloroquine should be calculated on the basis of (?).

Answer 80

ideal body weight

Question 81

What class of drug is infliximab?

Answer 81

TNF alpha inhibitor

Question 82

What are the two contraindications for the use of the TNF-alpha inhibitor infliximab?

Answer 82

Moderate to severe heart failure | Severe infections

Question 83

Why must resuscitation equipment be available for immediate use during the infusion of the TNF-alpha inhibitor infliximab?

Answer 83

Risk of hypersensitivity reactions All patients should be observed carefully for 1–2 hours after infusion and resuscitation equipment should be available for immediate use (risk of hypersensitivity reactions).

Question 84

What pre-treatment screening is required before starting a patient on the TNF-alpha inhibitor infliximab?

Answer 84

Tuberculosis (TB)

Question 85

What class of drug is leflunomide?

Answer 85

Conventional DMARD

Question 86

What are the two indications for the use of the conventional DMARD leflunomide?

Answer 86

Moderate-to-severe active rheumatoid arthritis | Active psoriatic arthritis

Question 87

What are the three contraindications for the use of the conventional DMARD leflunomide?

Answer 87

Serious infection Severe hypoproteinaemia Severe immunodeficiency

Question 88

The conventional DMARD leflunomide has a (long/short?) half-life

Answer 88

long

Question 89

Which potentially life-threatening side effect of leflunomide (conventional DMARD) usually occurs in the first 6 months of treatment?

Answer 89

Hepatotoxicity

Question 90

Leflunomide (conventional DMARD): Effective contraception essential during treatment and for at least (1?) years after treatment in women and at least (2?) months after treatment in men (plasma concentration monitoring required; waiting time before conception may be reduced with washout procedure

Answer 90

1. 2 years | 2. 3 months

Question 91

What pre-treatment screening is required prior to starting a patient on the conventional DMARD leflunomide in women?

Answer 91

Pregnancy (must be excluded)

Question 92

What monitoring is required during treatment with the conventional DMARD leflunomide? (3)

Answer 92

FBC LFTs BP

Question 93

Due to the long half-life of leflunomide (conventional DMARD), what two things can be given to aid drug elimination in case of serious adverse effects or before starting another DMARD (washout period)?

Answer 93

Colestyramine OR Activated charcoal

Question 94

What class of drug is methotrexate?

Answer 94

Conventional DMARD Methotrexate inhibits the enzyme dihydrofolate reductase, essential for the synthesis of purines and pyrimidines.

Question 95

Methotrexate inhibits the enzyme (?), essential for the synthesis of purines and pyrimidines.

Answer 95

dihydrofolate reductase

Question 96

Methotrexate inhibits the enzyme dihydrofolate reductase, essential for the synthesis of (?) and (?).

Answer 96

Purines | Pyrimidines

Question 97

(?) inhibits the enzyme dihydrofolate reductase, essential for the synthesis of purines and pyrimidines.

Answer 97

Methotrexate

Question 98

What are the indications for the use of the conventional DMARD methotrexate? (4)

Answer 98

1. Severe Crohn's disease (including maintenance of remission) 2. Moderate to severe active rheumatoid arthritis 3. Neoplastic diseases 4. Severe psoriasis unresponsive to conventional therapy

Question 99

How often is a dose of methotrexate given in autoimmune conditions?

Answer 99

once weekly

Question 100

What are the contraindixcations for the use of the conventional DMARD methotrexate?

Answer 100

Active infection Ascites Immunodeficiency syndromes Significant pleural effusions

Question 101

What can you give to reduce the mucosal and GI side-effects of methotrexate?

Answer 101

Folic acid Give folic acid to reduce side-effects. Folic acid decreases mucosal and gastrointestinal side-effects of methotrexate and may prevent hepatotoxicity; there is no evidence of a reduction in haematological side-effects.

Question 102

What may be the first sign of GI toxicity in a patient taking methotrexate?

Answer 102

Ulcerative stomatitis | Withdraw treatment

Question 103

How long does a patient require effective contraception when taking and stopping methotrexate?

Answer 103

During treatment and for at least 6 months after treatment in MEN and WOMEN

Question 104

Can a mother breastfeed while taking methotrexate?

Answer 104

NO Present in milk

Question 105

What pre-treatment screening is required before starting treatment with methotrexate? (3)

Answer 105

Exclude pregnancy FBC LFTs

Question 106

What needs to be monitored regularly in a patient taking methotrexate?

Answer 106

FBC Renal function LFTs Every 1-2 weeks until therapy stabilised, thereafter every 2-3 months

Question 107

Patients taking methotrexate must be advised to report all symptoms and signs suggestive of (?)

Answer 107

Infection Especially sore throat

Question 108

Treatment with (?) may be required in acute toxicity of methotrexate

Answer 108

folinic acid (as calcium folinate)

Question 109

Is penicillamine commonly used in the treatment of rheumatoid arthritis?

Answer 109

No Due to the availability of newer, more effective drugs

Question 110

(?) aids the elimination of copper ions in Wilson's disease (hepatolenticular degeneration)

Answer 110

Penicillamine

Question 111

Penicillamine aids the elimination of (?) in Wilson's disease (hepatolenticular degeneration).

Answer 111

copper ions

Question 112

Penicillamine aids the elimination of copper ions in (?) (hepatolenticular degeneration).

Answer 112

Wilson's disease

Question 113

What class of drug is sarilumab?

Answer 113

Biological DMARD Sarilumab is a recombinant human monoclonal antibody that specifically binds to interleukin-6 receptors and blocks the activity of pro-inflammatory cytokines.

Question 114

What pre-treatment screening is required before starting a patient on the biological DMARD sarilumab?

Answer 114

Tuberculosis (TB)

Question 115

What class of drug is sulfasalazine?

Answer 115

Conventional DMARD And an aminosalicylate

Question 116

What are the indications for the use of sulfasalazine? (3)

Answer 116

Ulcerative colitis Active Crohn's disease Active rheumatoid arthritis

Question 117

What needs to be monitored in a patient taking sulfasalazine? (3)

Answer 117

FBC Renal function Liver function

Question 118

What class of drug is tocilizumab?

Answer 118

Biological DMARD

Question 119

What class of drug is tofacitinib?

Answer 119

Targeted synthetic DMARD Tofacitinib selectively inhibits the Janus-associated tyrosine kinases JAK1 and JAK3.

Question 120

What class of drug is upadacitinib?

Answer 120

Targeted synthetic DMARD Upadacitinib is a selective and reversible inhibitor of the Janus-associated tyrosine kinase JAK1.