Rheumatoid arthritis

Question 1

What is rheumatoid arthritis?

Answer 1

an autoimmune condition that causes chronic inflammation in the synovial lining of joints, tendon sheaths and bursa

Question 2

Describe the typical distribution of RA across the body

Answer 2

typically affects multiple small joins symmetrically across both sides of the body (symmetrical polyarthritis)

Question 3

Give 4 risk factors for RA:

Answer 3

1) female sex
2) smoking
3) obesity
4) family history

Question 4

What is the most common gene associated with RA?

Answer 4

HLA DR4

Question 5

Name two autoantibodies associated with RA:

Answer 5

1) Rheumatoid factor (RF)
2) Anti-cyclic citrullinated peptide antibodies (anti-CCP)

Question 6

Describe the pathophysiology of rheumatoid factor in RA:

Answer 6

Rheumatoid factor targets the Fc portion of IgG causing an immune system response that results in systemic inflammation

Question 7

Which are more sensitive and specific to RA testing, rheumatoid factor or anti-CCP autoantibodies?

Answer 7

anti-CCP autoantibodies

Question 8

What are the 3 key presentations of RA?

Answer 8

1) pain
2) stiffness
3) swelling

Question 9

Name the 4 most commonly affected joints in RA:

Answer 9

1) metacarpophalangeal joints
2) proximal interphalangeal joints
3) wrist
4) metatarsophalangeal joints

Question 10

Give two findings found on palpation of a joint affected by RA:

Answer 10

1) tenderness
2) boggy synovial thickening

Question 11

True or false: RA rarely affects the DIP joints

Answer 11

true (a good differentiating factor from OA)

Question 12

What is palindromic rheumatism?

Answer 12

where patients have spontaneous episodes of joint pain, stiffness and swelling affecting only a few joints for a few days before completely resolving without treatment

Question 13

Give 4 hand signs seen in advanced RA:

Answer 13

1) Z-shaped deformity of the thumb
2) Swan neck deformity
3) Boutonniere deformity
4) ulnar deviation of the fingers at the MCP joint

Question 14

Describe a swan neck deformity:

Answer 14

hyperextension of the PIP joint and flexion at the DIP

Question 15

Describe a boutonniere deformity:

Answer 15

hyperextension of DIP and flexion of PIP

Question 16

What life threatening manifestation of RA affects the spine?

Answer 16

atlantoaxial subluxation

Question 17

Describe how atlantoaxial subluxation can lead to a medical emergency: (2)

Answer 17

1) RA causes synovitis and damage to the ligaments around the odontoid peg of C2, allowing it to shift within C1
2) subluxation of this joint can compress the spinal cord

Question 18

Give 4 extra-articular manifestations of RA:

Answer 18

1) Sjogren’s syndrome
2) Rheumatoid nodules
3) Anaemia of chronic disease
4) Felty’s syndrome

Question 19

What are the two presentations seen in Sjogren’s syndrome?

Answer 19

dry eyes and dry mouth

Question 20

What are rheumatoid nodules?

Answer 20

firm, painless lumps found on the hands and elbows

Question 21

Name the three conditions seen in Felty’s syndrome:

Answer 21

1) RA
2) neutropenia
3) splenomegaly

Question 22

Name 5 investigations that may be performed by a rheumatologists following RA referral:

Answer 22

1) rheumatoid factor blood test
2) anti-CCP blood test
3) inflammatory markers bloods (CRP, ERP)
4) X-rays for bone changes
5) CT/MRI (if findings are unclear)

Question 23

Give 4 X-ray findings associated with RA:

Answer 23

1) periarticular osteopenia (weakened bone at the joint surfaces)
2) boney erosion
3) soft tissue swelling
4) joint destruction and deformity

Question 24

What scoring system assesses 28 joints to monitor RA and treatment response?

Answer 24

The Disease Activity Score 28 Joints (DAS28)

Question 25

What treatment can initially be used to relieve symptoms in RA whilst waiting to see a rheumatologist?

Answer 25

1) short term steroids
2) NSAIDs

Question 26

What DMARD is given for mild RA/ palindromic rheumatism?

Answer 26

hydroxychloroquine

Question 27

Give the 3 long-term DMARD treatment plans for RA:

Answer 27

1) monotherapy (methotrexate, lefunomide, sulfasazine)
2) combination therapy with multiple cDMARDs
3) biologic therapies with methotrexate

Question 28

Name 4 cDMARDs:

Answer 28

1) azathioprine
2) ciclosporin
3) cyclophosphamide
4) mycophenolate

Question 29

What does cDMARD stand for?

Answer 29

conventional disease modifying anti-rheumatc drugs

Question 30

Give two biologics that inhibit TNF:

Answer 30

1) infliximab
2) adalimumab

Question 31

What is the mechanism of rituximab?

Answer 31

monoclonal antibody against CD20 on B cells

Question 32

Name 2 biologics that act to inhibit IL-6:

Answer 32

1) tocilizumab
2) sarilumab

Question 33

Name 2 biologics that act to inhibit JAK:

Answer 33

1) Tofacitinib
2) upadactinib

Question 34

Name a biologic that inhibits T cell continuation:

Answer 34

abatacept

Question 35

Give 3 general side effects of biologic use:

Answer 35

1) immunosuppression
2) increased risk of certain cancers (e.g. shin)
3) reactivation of latent TB

Question 36

Describe the mechanism of methotrexate:

Answer 36

inhibits folate production

Question 37

True or false: methotrexate cannot be taken during pregnancy

Answer 37

true (folate interference)

Question 38

Give 3 side effects of methotrexate:

Answer 38

1) bone marrow suppression
2) leukopenia
3) highly teratogenic

Question 39

Give two side effects of leflunomide:

Answer 39

1) hypertension
2) peripheral neuropathy

Question 40

Describe the mechanism of leflunomide:

Answer 40

interferes with the production of pyrimidine and so acts as an immunosuppressant

Question 41

Give 2 side effects of sulfasalazine:

Answer 41

1) orange urine
2) reversible male infertility (low sperm count)

Question 42

Describe the mechanism of hydroxychoroquine:

Answer 42

interferes with toll-like receptors, disrupting antigen presentation

Question 43

Give 3 side effects of hydroxychloroquine:

Answer 43

1) retinal toxicity
2) hair bleaching
3) blue-grey skin pigmentation