Rheumatoid Arthritis

Question 1

Which susceptibility genes are there for RA

Answer 1

HLA DR4

PTPN22

Question 2

Which environmental factors can lead to RA

Answer 2

Smoking
Gut microbiome
Viruses e.g EBV

Question 3

Describe citrullination

Answer 3

When argenine is converted to citrulline 
Loss of immune tolerance 
So gets picked up by APC 
And recognised as foreign 
Ab made by B cells against it 
So self antibodies are made

Question 4

What does the combination of susceptibility genes and environmental factors lead to

Answer 4

Epigenetic modification
E.g formation of immune complexes and RF
Altered citrullination of proteins
Breakdown of immune tolerance

Question 5

Which cytokines do infiltrating T cells release

Answer 5

IFN gamma

IL-17

Question 6

What is the effect of T cells releasing cytokines

Answer 6

Recruit macrophages
Releasing further cytokines
Leading to synovial inflammation

Question 7

Which cytokines do infiltrating macrophages release

Answer 7

IL-6
IL-1
TNF alpha

Question 8

Which B cell has a pathogenic role in RA

Answer 8

CD20 +

Question 9

What is the role of B cells in RA

Answer 9

Produce autoantiboeis

Question 10

What is pannus

Answer 10

Thick, swollen synovial membrane with granulation tissue

Question 11

What does pannus do

Answer 11

Damages cartilage

Erodes bone

Question 12

What is neoangiogenesis

Answer 12

Formation of new blood vessels

Question 13

What is the purpose of neoangiogenesis in RA

Answer 13

Provude nutrients to hypertrophic synovium

Question 14

What angiogenic factors are released in RA

Answer 14

IL-8

Ve GF

Question 15

What mediates cartilage destruction

Answer 15

Proteases released by activated synovial cells

Question 16

What is bone destruction mediated by

Answer 16

Osteoclasts

Which are activated by RANKL

Question 17

What is RANKL produced by

Answer 17

ActivatedT cells

Question 18

What is RF

Answer 18

IgM antibody that targets the Fc domain of self IgG antibodies

Question 19

What is RA

Answer 19

Chronic autoimmune disease characterised by peripheral symmetrical arthritis and other systemic features

Question 20

What is used to classify RA

Answer 20

EULAR/ACR criteria

Question 21

What EULAR/ACR score gives a definite Dx

Answer 21

6 or more

Question 22

RF for RA

Answer 22

Female 
4th 5th decade
HLA DR4 
PTPN22
Smoking

Question 23

Symptoms of RA

Answer 23

Pain 
Morning stiffness >30 mins 
Poor function 
Decreased ROM 
Joint inflammation 
Extra-articular involvement

Question 24

Signs of RA

Answer 24

Swelling 
Tenderness
Decreased ROM 
Redness
Heat
Typically symmetrical 
Typically peripheral (hands)

Question 25

X-ray signs of RA

Answer 25

``` Periarticular osteoporosis Soft tissue swelling Bone erosion Decreased joint space Subluxation ```

Question 26

1st line Rx RA

Answer 26

NSAIDs

Question 27

2nd line Rx RA

Answer 27

DMARDs Methotrexate Sulfasalazine

Question 28

3rd line Rx RA

Answer 28

Biologicals TNF alpha IL-1 inhibitors Anti-B cell therapy

Question 29

Which anti-B cell therapy can be used

Answer 29

CD20 e.g Rituximab

Question 30

4th line Rx for RA

Answer 30

Steroids

Question 31

Are steroids recommended as a single therapy

Answer 31

No

Question 32

SE of steroids

Answer 32

``` Skin thinning Hyperglycaemia Hypertension Osteoporosis Increased risk of infection ```

Question 33

Ix for RA

Answer 33

``` RF Anti-CCP CRP ESR X-ray USS ```

Question 34

Extra-articular manifestations Lungs

Answer 34

Interstitial fibrosis Peluritis RA nodules

Question 35

Cardiac features

Answer 35

Pericarditis IHD Pericardial effusion

Question 36

Eye manifestations

Answer 36

Scleritis Episclerotiis Keratoconjunctivitis 2ndry Sjogrens

Question 37

Kidney manifestations

Answer 37

Amyloidosis

Question 38

Other manifestations RA

Answer 38

Carpal tunnel Splenomegaly (felty snydrome) Myositis

Question 39

Which DAS indicates remission

Answer 39

<2.4

Question 40

Which DAS score indicates eligibility for biological therapy

Answer 40

>5.1

Question 41

Who is methotrexate CI in

Answer 41

Pregnant women