rheumatoid arthritis

Question 1

extraarticular manifestations of RA

Answer 1

neurologic: cervical myelopathy
hematologic: anemia of chronic disease, neutropenia, splenomegaly, Felty’s syndrome, large granular lymphocyte leuukemia, lymphooma
GI: vasculitis
skeletal: osteoporosis
ocular: ketaoconjunctivitis sicca, episcleritis, scleritis
oral: xerostomia, periodontitis
pulmonary: pleural effusions, pulmonary nodules, interstitial lung disease, pulmonary vasculitis, organizing pneumonia
cardiac: pericarditis, ischemic heart disease, myocarditis, cardiomyopathy, arrhythmia, mitral regurgitation
renal: membranous nephropathy, secondary amyloidosis
endocrine: hypoandrogenism
skin: rheumatoid nodules, purpura, pyoderma gangrenosum

Question 2

nodules in RA

Answer 2

subcutaneous nodules, common
found in skeleton subject to repeat trauma (forearm, sacral prominence, Achilles); also lungs, pleura, pericardium, or peritoneum
- nodules typically benign, although can be ass w/ infection, ulceration and gangrene

Question 3

secondary Sjögren’s syndrome

Answer 3

found in RA

• presence of keratocnjunctivitis sicca (dry eye)
• xerostomia (dry mouth)

Question 4

pulmonary complications of RA

Answer 4

• most common: pleural disease (exudative pleural effusions)
• can also develop interstitial lung disease

Question 5

cardiac complications of RA

Answer 5

• pericarditis
• cardiomyopathy (from myocarditis, CAD, or diastolic dysfunction)
• mitral regurg

Question 6

vasculitis in RA

Answer 6

• seen in longstanding disease, + RF, and hypocomplementemia
• overall, rare
• petechiae, purpura, digital infarcts, gangrene, livedo reticularis

Question 7

hematologic complications in RA

Answer 7

• normochromic, norrmocytic anemia that corresponds to inflammation (ESR, CRP)
• platelets may be elevated as acute phase reactant

Question 8

risk of cancer in RA

Answer 8

• increased risk of lymphoma, usually diffuse large B-cell lymphoma

Question 9

conditions associated with RA

Answer 9

1. CVD (higher CAD, atherosclerosis, CHF)
2. osteoporosis (inflammation –> generalized bone loss; also steroids and immobility)
3. hypoandrogenism: low testosterone may play people at greater risk of RA, or RA may cause low testosterone

Question 10

environmental factors contributing to RA

Answer 10

smoking

? EBV

Question 11

criteria for diagnosing RA

Answer 11

joint involvement, serology, acute-phase reactants, duration of symptoms

Question 12

RF vs anti-CCP

Answer 12

both have sensitivity ~80%

anti-CCP has sensitivity off 95%

Question 13

utility of synovial fluid analysis in RA

Answer 13

confirms inflammatory arthritis (as opposed to OA) and excluding infection or crystal-induced arthritis

Question 14

remission in RA

Answer 14

10% of pts will undergo spontaneous remission w/i 6 months (usually seronegative pts)

Question 15

categories of RA treatment

Answer 15

1. NSAIDs
2. glucocorticoids (prednisone, methylpred)
3. conventional DMARDs
4. biologic DMARDs

Question 16

NSAIDs for RA

Answer 16

analgesic and anti-inflammatory effect

chronic use should be minimized because of side effects (gastritis, PUD, renal dysfunction)

Question 17

glucocorticoids for RA

Answer 17

1. achieve rapid control before DMARDs kick in
2. management of acute disease flares
3. chronic administration for those unresponsive to DMARDs

Question 18

side effects of glucocorticoids and prevention

Answer 18

osteoporosis, PUD

bisphosphonate for any pt getting >5mg/d for more than 3 months

Question 19

what makes a DMARD? examples of conventional DMARDs

Answer 19

ability to slow or prevent structural progression of RA

• hydroxychloroquine, sulfasalazine, methotrexate, leflunomide
• delayed onset of action til 6-12 wks

Question 20

first choice DMARD + mechanism of action

Answer 20

methotrexate

- stimulates adenosine release from cells, producing an anti-inflammatory effect

Question 21

side effects + monitoring of hydroxychloroquine

Answer 21

serious: irreversible retinal damage, cardiotoxicity, blood dyscrasia
common: nausea, diarrhea, headache, rash
monitoring: eye exams every year

Question 22

side effects and monitoring of sulfasalazine

Answer 22

serious: granulocytopenia, hemolytic aneemia (with G6PD deficiency)
common: nausea, diarrhea, headache
monitoring: CBC ~monthly

Question 23

side effects and monitoring of methotrexate

Answer 23

serious: hepatotoxicity, myelosuppression, infection, interstitial pneumonitis, pregnancy category X
common: nausea, diarrhea, stomatitis / mouth ulcers, alopecia, fatigue
monitoring: CBC, Cr, LFTs

Question 24

side effects and monitoring of leflunomide

Answer 24

serious: hepatotoxicity, myelosuppression, infection, pregnancy category X
common: alopecia, diarrhea
monitoring: CBC, Cr, LFTs

Question 25

types of biologic DMARDs

Answer 25

1. anti-TNF agents (infliximab, etanercept, adalimunab, golimumab, certolizumab)
2. abatacept: CD28 receptor antagonist
3. anakinra: IL-1 receptorr antagonist
4. rituximab: antibody against CD20
5. tocilizumab: antibody against IL-6

Question 26

approach to treatment of RA

Answer 26

1. methotrexate alone
2. combinations: methotrexate, sulfasalazine, and hydroxychloroquine (triple therapy); methotrexate and leflunomide; methotrexate and biologic

Question 27

articular signs of RA

Answer 27

symmetric
wrists, MCP and PIP to start 
flexor tendon tenosynovitis 
swan-neck deformity
butonniere deformity
Z-line deformity