Rheumatoid arthritis

Question 1

What is RA?

Answer 1

Autoimmune condition that causes chronic inflammation of the synovial lining of the joints, tendon sheaths and bursa that improves with activity

Question 2

1) Is RA normally symmetrical or asymmetrical?
2) Does RA normally impact 1 or multiple joints?
3) In which sex is it more common in?

Answer 2

1) Symmetrical
2) Multiple joints
3) Females

Question 3

Name 1 of the genetic associations of RA

Answer 3

• HLA DR4
• HLA DR1

Question 4

1) What is the commonest autoantibody in RA?
2) What does this autoantibody target?
3) What does targeting of this autoantibody cause?
4) RF can be any class of ig, but what is it most commonly?
5) What autoantibody is more sensitive and specific than RF for RA?
6) How can anti-CCP antibodies give an indication that a patient will go on to develop rheumatoid arthritis at some point?
7) Which of these is a marker of poor prognosis?

Answer 4

1) Rheumatoid factor (RF)
2) Fc portion of the IgG antibody
3) Activation of the immune system against the patient’s own IgG causing systemic inflammation
4) IgM
5) Cyclic citrullinated peptide antibodies (anti-CCP antibodies)
6) Often pre-dates the development of RA
7) Anti CCP

Question 5

1) What are the 3 key symptoms of RA?
2) Name 2 joints that are commonly impacted
3) Name 2 systemic symptoms

Answer 5

1) Pain, swelling, stiffness
2) Small joints of the hands and feet, typically the wrist, ankle, MCP and PIP joints in the hands, but also larger joints i.e. shoulder and. knee
3) Fatigue, weight loss, flu like illness, muscles aches and weakness

Question 6

Name 2 features of a patient’s hands that have RA

Answer 6

• Z shaped deformity to the thumb
• Swan neck deformity (hyperextended PIP with flexed DIP)
• Boutonnieres deformity (hyperextended DIP with flexed PIP)
• Ulnar deviation of the fingers at the knuckle (MCP joints)

Question 7

Name 3 extra-rheumatological manifestations of RA

Answer 7

• Pulmonary fibrosis with pulmonary nodules (Caplan’s syndrome)
• Bronchiolitis (inflammation causing small airway destruction)
• Felty’s syndrome (RA, neutropenia and splenomegaly)
• Secondary Sjogren’s Syndrome (AKA sicca syndrome)
• Anaemia of chronic disease
• CVD
• Episcleritis and scleritis
• Rheumatoid nodules
• Lymphadenopathy
• Carpal tunnel syndrome
• Amyloidosis

Question 8

Name 2 aspects of the investigation in RA

Answer 8

• X-ray - every patient with suspected RA
• RF and anti-CCP antibodies
• Raised CRP and ESR
• Clinical picture

Question 9

Management (1)
1) What medication is given for RA flares?
2) What is the initial management of RA?
3) As for disease modifying anti-rheumatic drugs, name 2 of the first line monotherapy drugs
4) What anti rheumatic drug is considered the mildest anti rheumatic?

Answer 9

1) Corticosteroids
2) Methotrexate + short course corticosteroid
3) Methotrexate, leflunomide or sulfasalazine
4) Hydroxychloroquine

Question 10

Management [Biological therapies] (2)
0.5) What investigation is done before initiating biologics for RA, and why?
1) Name an anti-TNF that may be used in RA
2) Name an anti-CD20 that may be used in RA
3) Name an Anti-IL6 that may be used in RA
4) Name an anti-IL6 receptor that may be used in RA
5) Name a JAK inhibitor that may be used in RA

Answer 10

0.5) X-ray to check for TB as biologics can cause reactivation
1) Adalimumab, infliximab, etanercept, golimumab and certolizumab pegol
2) Rituximab
3) Sarilumab
4) Tocilizumab
5) Tofacitinib, baricitinib

Question 11

How is methotrexate toxicity managed?

Answer 11

Folinic acid

Question 12

Name a possible xray feature in RA

Answer 12

Early = loss of joint space, juxta articular osteoporosis, soft tissue swelling
Late = Periarticular erosions, subluxation