Rheumatoid Arthritis

Question 1

Rheumatoid Arthritis (RA)

Answer 1

one of the most common inflammatory
arthritides.
○ Chronic (>6 weeks)
○ Systemic (articular and extra-articular manifestations)
○ Symmetric involvement

Question 2

Etiology of RA

Answer 2

The exact cause of RA remains unknown; however, there are several influences that are
factors that are suspected in the development of RA
● Genetic factors: HLA-DR4, HLA-DR1 (lesser extent)
● Environmental factors: smoking
● Autoantibodies: Rheumatoid factor (RF) and/or anti-citrullinated protein (ACPA/CCP)
autoantibodies

Question 3

Pathophysiology of RA

Answer 3

These factors/stresses likely cause modifications peptides at mucosal surfaces, such as the
lung, gut, oral cavity, and synovial membranes. The synovial membranes become inflamed and
proliferate forming a pannus (proliferation of the synovium) that invades bone, cartilage, and
ligaments and leads to damage and deformities.
Autoantibodies can be found in sera years (e.g. up to 6-10 years) before clinical symptoms
occur. This suggests that initiating events (environmental, genetic factors, etc) may cause a
complex interaction between the innate and adaptive immune systems

Question 4

Family history and RA

Answer 4

● Several rheumatic disorders have a strong genetic basis and tend to cluster in
families. Asking about family history of rheumatic diseases can help to build a
diagnosis.

Question 5

Onset and course of RA

Answer 5

● RA symptoms tend to have subacute onset (occurring over weeks to months)
and is usually > 6 weeks.

Question 5

Clinical Presentation of RA

Answer 5

● Patients suspected of RA may have recurrent low grade fevers, chills, night
sweats, and weight loss
● Stiffness in or around the joints may be noted (e.g. 1 hour before improvement)
● It is important to differentiate between Arthralgia (joint pain) and Arthritis
(joint inflammation). RA is an inflammatory arthritis (presence of synovitis).

Question 5

Suspicion for RA is indicated by the presence of _____, or inflammation of
synovial membranes

Answer 5

synovitis,

Question 6

Articular Manifestation distribution of RA

Answer 6

● Distribution in early disease: the wrists, metacarpophalangeal (MCP) joints,
proximal interphalangeal (PIP) joints of the hands, interphalangeal joints of the
thumbs, metatarsophalangeal (MTP) joints of the feet
● Distribution in late disease: larger joints like the ankles, knees, elbows,
shoulder
● Less common involvement: temporomandibular and sternoclavicular joints
● Nearly always spared: distal interphalangeal joints and thoracolumbar spine

Question 7

Articular Manifestations - Joint
Deformities in RA

Answer 7

Fusiform swelling
Boutonniere deformity
Swan-neck deformity
Ulnar deviation of fingers
Hitchhiker thumb
“Piano key” ulnar head
Cock-up toe deformities
Hallux valgus (Bunion):

Question 8

______: synovitis of PIP joints
which causes them to appear
spindle-shaped.

Answer 8

Fusiform swelling

Question 9

______: flexion of the PIP
and hyperextension of the DIP joint, caused
by weakening of the central slip of the
extrinsic extensor tendon and a palmar
displacement of the lateral bands

Answer 9

Boutonniere deformity

Question 10

______: contraction of the flexors (intrinsic muscles) of the MCPs which results in flexion contracture of the MCP joint, hyperextension of PIP, and flexion of the DIP join

Answer 10

Swan-neck deformity

Question 11

______: subluxation of
MCP joints results from weakening of the
extensor carpi ulnaris leading to radial
deviation of the wrist causing all finger tendons
to pull the fingers ulnarly with power grasp

Answer 11

Ulnar deviation of fingers

Question 12

______: hyperextension of IP joint
with flexion of MCP and exaggerated
adduction of first metacarpal. Causes inability
to pinch

Answer 12

Hitchhiker thumb

Question 13

______: secondary to
destruction of ulnar collateral ligament
leading to a floating ulnar styloid.

Answer 13

“Piano key” ulnar head

Question 14

______: dorsal
subluxations of the MTPs

Answer 14

Cock-up toe deformities

Question 15

It is important to note that ______ can
be present with RA and may be seen on PE

Answer 15

osteoarthritis
● Heberden’s nodes affecting the DIP
joints
● Bouchard’s nodes affecting the PIP
joints

Question 16

Extra-articular Manifestations of RA

Answer 16

Rheumatoid Nodules (Subcutaneous)
the most common (currently)
extra-articular manifestation
Sjogren’s Syndrome (Secondary) is also
common

Question 17

Diagnostic Labs for RA

Answer 17

Autoantibodies:
● Rheumatoid Factor (RF), anti-CCP (CCP)
Inflammatory markers:
● Erythrocyte Sedimentation Rate (ESR), C-Reactive Protein (CRP)
Adjunct labs:
● CBC, CMP
● ANA by IFA, Comprehensive ANA panel, Chronic Hepatitis Panel (Hepatitis C
and Hepatitis B)
● With consideration: Uric Acid, CPK, SPEP

Question 18

Labs for RA diagnosis

Answer 18

● Labs
○ RF, CCP, ESR, CRP
● Imaging
○ X-ray, US, MRI
● Joint fluid aspiration testing
In rare instances a synovial
biopsy will be used in the
diagnosis of RA.

Question 18

Anti-Malondialdehyde-Acetaldehyde Antibody (MAA) and RA

Answer 18

● This new autoantibody is associated with the development of RA
similar to RF and CCP
● Elevations of MAA are associated with high levels of CCP
○ Elevations in CCP are associated with the development of RA
■ Months up to 18 years per some literature
○ Elevations in MAA are associated with the development of RA
■ 2-3 years prior

Question 19

known risk factors for the development of RA

Answer 19

● Smoking, Silica
○ PTSD and RA (Vets being exposed to “burn pits” while during
active duty have been see to develop RA)

Question 20

Synthetic / Traditional DMARDs

Answer 20

● Methotrexate (MTX)*
● Leflunomide (Arava)*
● Sulfasalazine*
● Azathioprine (Imuran)
● Hydroxychloroquine (Plaquenil)*
● Cyclosporine
● Minocycline

Question 21

Biologic and Small Molecule DMARDs

Answer 21

● Infliximab (Remicade)
● Adalimumab (Humira)*
● Etanercept (Enbrel)
● Golimumab (Simponi / Simponi Aria)
● Certolizumab (Cimzia)
● Abatacept (Orencia)
● Tocilizumab (Actemra)
● Sarilumab (Kevzara)
● Rituximab (Rituxan)
● Tofacitinib (Xeljanz)
● Anakinra (Kineret)

Question 22

If an inflammatory arthritis (the presence of synovitis) is identified with
suspicion for RA, _____ may be used
for symptomatic relief and also to aid in diagnosis.

Answer 22

low dose prednisone (10-15 mg, rarely 20 mg)

Question 23

After adequate follow up testing in performed (RF, CCP, appropriate adjunct
labs, baseline x-rays of hands and feet) ____ therapy is then started.

Answer 23

low dose Methotrexate (MTX)

Question 24

____ can be used in moderate to severe Rheumatoid Arthritis where
biologics cannot be given, or insufficient insurance coverage, and can be as
effective as the addition of MTX + Biologic in certain patients

Answer 24

Triple therapy

Question 25

TNF Inhibitors / Blockers

Answer 25

● Adalimumab (Humira)
● Infliximab (Remicade, Renflexis)
● Etanercept (Enbrel)
● Golimumab (Simponi / Simponi Aria)
● Certolizumab (Cimzia)

Question 26

MTX therapy and alcohol

Answer 26

Alcohol Use:
○ Avoided in patients using MTX as concomitant use can irritate the liver
■ Patients that cannot give up alcohol should be started on a different
therapy.

Question 27

RA: The “FLARE”

Answer 27

At any time during the treatment of rheumatoid arthritis, even if the disease is very
well controlled, patients may experience a “flare” of their disease. This can
represent increased disease activity. Symptoms can be severe and can last days
to weeks. Manifestations of a flare include:
● Synovitis
● Heat to the joint
● Joint pain
● Increased stiffness
● Difficulty performing activities of daily living

Question 28

While patients are waiting to be seen by Rheumatology for RA, appropriate
pharmaceutical therapy can be used until more effective treatment can be implemented:

Answer 28

● NSAIDs (meloxicam, diclofenac, celebrex) if there are no contraindications
○ This is more preferable to prednisone due to masking symptoms.
● A trial of burst and taper low dose prednisone (10 mg daily, or 15 mg
daily with larger joint involvement)
○ Leaving a patient on chronic steroid treatment for several weeks or months is not recommended

Question 29

_____ is high on the differential on any patient on an immunosuppressant therapy like Methotrexate, Humira, etc

Answer 29

Infection