Rheumatoid arthritis

Question 1

What part of a joint is affected in a degenerative joint disorder e.g. osteoarthritis?

Answer 1

Hyaline cartilage (degeneration, wearing with age)

Question 2

What part of a joint is affected in an inflammatory joint disorder e.g. RA?

Answer 2

Synovium of the joint

Question 3

What condition is characterised by a build up of crystal in the joints i.e. crystal arthropathy?

Answer 3

Gout

Question 4

Which bacteria commonly causes septic arthritis?

Answer 4

Streptococcal

Question 5

Name 3 viral infections that can cause inflammatory arthritis

Answer 5

Hep B

Hep C

Rubella (German measles)

Question 6

Which cells in a joint capsule secrete synovial fluid?

Where can they be found?

Answer 6

Synovocytes

Synovium (serous membrane)

Question 7

Give 2 purposes of synovial fluid

Answer 7

Metabolite exchange medium

Lubricant for synovial joints

Question 8

Where are T cells made?

Answer 8

Cortex of the thymus gland

Question 9

What virus causes glandular fever?

Answer 9

Epstein-Barr virus (EBV)

Question 10

Which HLA gene is connected with RA?

Answer 10

HLA-DR4

Question 11

Which autoimmune diseases are associated with HLA-DQ2?

Answer 11

T1DM

Coeliac disease

Question 12

What are rheumatoid factors?

Answer 12

IgM autoantibodies directed against the Fc fragment of immunoglobulin G (IgG).

Question 13

Which autoantibody are rheumatoid factors made from?

Answer 13

IgM

Question 14

Which autoantibody to rheumatoid factors fight against?

Answer 14

IgG

Question 15

Why is rheumatoid factor not good at diagnosing joint pain?

Answer 15

10-25% false positives in over 70s

If patient comes in with joint pain, RF will not diagnose RA.

Question 16

What are some common clinical features in RA?

Answer 16

Young-middle aged females (20-50)

Pain and stiffness in joints

Gradual or sudden onset

Usually symmetrical, hands, feet, other joints

Often FH

Smoking increases the risk

Question 17

When is stiffness most profound in RA?

Answer 17

In the mornings when they’re ‘trying to get going’

Question 18

What are the 3 S’s for inflammatory arthritis?

Answer 18

Stiffness - early morning for more than 30 mins

Swelling - usually hand joints

Squeezing - painful to squeeze joint

Question 19

Which joints are most commonly affected in RA?

Answer 19

Metacarpal/metatarsal-phalangeal joints of hands and feet

Question 20

What features can be seen in the hand in RA?

List them in order of disease progression

Answer 20

Ulnar deviation of fingers + metacarpal-phalangeal subluxation

Swan neck deformities

Boutonniere deformities

Question 21

Why can RA cause nerve compression?

Answer 21

C1/C2 atlantoaxial subluxation - involvement of these vertebrae can put pressure on the spinal cord

Question 22

What is the classic positional presentation of pericarditis?

Answer 22

Sitting forward eases pain

Lying back decreases pain

Pericarditis can be a complication of RA and present as ACS with potentially no ECG changes

Question 23

Which cytokine produced by the T-cell mediated immune response destroys articular cartilage and bone?

Answer 23

IL-1

Question 24

In late disease, the synovium can get inflamed and proliferate. When this starts to invade surrounding tissues, what is the structure called?

Answer 24

Pannus

Very vascular structure, invades bones and cartilage

Question 25

What blood results would you expect in RA?

Answer 25

Anaemia (normocytic normochromic), anaemia of chronic diseases ESR/cRP: moderately raised Immunology: Anti-CCP - +ve in 60% RA patients ALP - raised Albumin - decreased

Question 26

If ALP is raised alongside bilirubin, GGT or ALT, what does this suggest?

Answer 26

That the raised ALP is coming from the liver, showing liver damage

Question 27

If ALP is raised alongside calcium and phosphate, what does this suggest?

Answer 27

That the raised ALP is coming from the bone

Question 28

What would an iron deficiency anaemia look like on a blood test?

Answer 28

Microcytic (low MCV)

Question 29

What would a B12 deficiency aneamia look like on a blood test?

Answer 29

Macrocytic

Question 30

Which 2 substances can effect the ESR?

Answer 30

Fibrinogen (levels increase in inflammation) Immunoglobulins

Question 31

What changes could be seen in an Xray of someone with RA?

Answer 31

Soft tissue swelling Joint space narrowing Erosions Subluxation Deformity Juxta-articular osteopenia (reduced bone density next to the swelling)

Question 32

What 2 drugs are given in combination treatment of RA?

Answer 32

Sulphasalazine Methotrexate

Question 33

What is the MoA of sulphasalazine? What other drug is in this family?

Answer 33

Aminosalicylates Anti-inflammatory, ?COX inhibition Mesalazine

Question 34

What is the MoA of methotrexate? What other drug is in this family?

Answer 34

Inhibits the enzyme dihydrofolate reductas which inhibits DNA synthesis. This reduces lymphocyte proliferation Azothiprine

Question 35

What corticosteroid can be used short term to treat arthritis?

Answer 35

Prednisolone

Question 36

Why are corticosteroids (prednisolone) useful in RA? Think MoA

Answer 36

General immunosurpressors Reduced transcription of cytokines e.g. IL-1 and IL-2 This reduces the proliferation of T helper cells (involved in autoimmunity)

Question 37

How often is methotrexate given?

Answer 37

Once weekly

Question 38

Name some side effects of methotrexate

Answer 38

Teratogenic (attacks any rapidly dividing cells) Tiredness (signs of anaemia) GI side effects - mouth ulcers, diarrhoea Hair loss Increased risk of infections

Question 39

Name 2 monoclonal antibodies used in the treatment of RA

Answer 39

Infliximab Rituximab

Question 40

What is the MoA of infliximab?

Answer 40

Binds and blocks proinflammatory function of TNF-alpha Anti-TNFa

Question 41

What is the MoA of rituximab?

Answer 41

Anti-CD20 on B cells

Question 42

How are infliximab and rituximab administered?

Answer 42

IV infusion