Rheumatoid Arthritis

Question 1

Define rheumatoid arthritis.

Answer 1

Autoimmune disease causing a symmetrical, small joint, inflammatory polyarthropathy

Question 2

Describe the clinical features of RA in the joints. (5)

Answer 2

Joint inflammation (synovitis)
Spongy swelling of joints
Joint effusion
Small joint distribution
Hand deformities

Question 3

Which joints are especially affected by RA? (3)

Answer 3

Small joints, esp.

Metacarpophalangeal joints (MCPs)
Proximal interphalangeal joints (PIPs)

Question 4

List 5 types of hand deformity seen in RA.

Answer 4

Ulnar deviation
Muscle wasting
Z-thumb
Boutonniere deformity (fixed flexion of PIP, fixed extension of the DIP)
Swan-neck deformity (fixed extension of PIP, fixed flexion of DIP)

Question 5

List 11 features of RA outside of joints.

Answer 5

Rheumatoid nodules
Stroke
Ischaemic heart disease
Lymphoma
Scleritis
Compression  myelopathy
Pulmonary fibrosis
Serositis 
Anaemia
Amyloidosis
Peripheral neuropathy

Question 6

What is RA caused by?

Give 2 examples.

Answer 6

Genetic predisposition, e.g.

• HLA DR4
• Shared epitope (HLA-DRB1)

Question 7

List 4 risk factors for RA.

Answer 7

Mediterranean diet (loads of omega 3/fatty fish)
Smoking
Infections
Microbiome

Question 8

What investigations would you do for RA? (3)

Answer 8

Bloods
X-ray
DAS28 score

Question 9

What blood tests you would you do for RA? (4)

Answer 9

FBC
CRP/ESR
Rheumatoid factor (autoantibody against Fc component of other antibodies)
Anti-CCP antibodies (ACPA)

Question 10

What are the features of RA on x-ray? (6)

Answer 10

Soft tissue swelling
Juxta-articular osteopenia 
Decreased joint space
Bony erosions
Subluxation
Carpal destruction

Question 11

What is Felty’s syndrome?

Answer 11

RA + splenomegaly + neutropenia

Question 12

How would you measure the severity of RA?

Describe this system. (4)

Answer 12

DAS28 (disease activity score)

Takes into account:

• Number of swollen joints (out of 28)
• Number of tender joints (out of 28)
• Bloods (esp. CRP/ESR)
• Patient’s opinion of their general health from very good to very bad

Question 13

Describe the results of the DAS28 scale.

Answer 13

5.1+ - active disease
<3.2 - low disease activity
<2.6 - remission

Question 14

How would you treat RA? (7)

Answer 14

Analgesia
Corticosteroids
DMARDs
Anti-TNF drugs
Multi-disciplinary team 
Occupational therapy
Surgery

Question 15

What sort of analgesia would you give in RA? Give some examples of this time of painkiller.

Answer 15

NSAIDs, e.g.

• Ibuprofen
• Diclofenac

Question 16

List 5 side effects of NSAIDs.

Answer 16

Gastritis
GI/duodenal ulceration 
Renal impairment
Bronchospasm
LFT derangement

Question 17

Give 3 examples of DMARDs.

Answer 17

Methotrexate
Sulfasalazine
Hydroxychloroquine

Question 18

List 7 side effects of DMARDs.

Answer 18

Increased susceptibility to infection
Headache
GI ulceration
Rash
Abnormal FBC, U&Es, LFTs
Pneumonitis
Retinal disease

Question 19

List the important pharmacokinetics/dynamics of DMARDs. (4)

Answer 19

Slow acting (2-3 months before effect)
Requires regular blood monitoring
Requites annual optic screening
Requires flu and pneumococcal vaccines

Question 20

Give 5 examples of anti-TNF drugs.

Answer 20

Infliximab
Etanercept
Adalimumab
Certolizumab
Golimumab

Question 21

List 5 side effects of anti-TNF drugs.

Answer 21

Increased susceptibility to infection (esp. reactivation of TB)
Pulmonary fibrosis
Increased risk of malignancy
Demyelination disorders
Anti-drug antibodies

Question 22

Apart from anti-TNF drugs, which other biologic therapies can be used for RA? (4)

Answer 22

Rituximab (anti-B cell)
Tocilizumab (anti-IL6)
Abatacept (co-stimulation blockade)
Tofactinib (JAK/STAT inhibition)

Question 23

Who is in the MDT for RA? (6)

Answer 23

Physiotherapist
Occupational therapist
Specialist nurses
Podiatry
Orthotics
GP