Rheumatoid Arthritis

Question 1

what is RA?

Answer 1

an autoimmune symmetrical inflammatory arthritis

Question 2

what gene mediates RA

Answer 2

HLA DR4

Question 3

pathophysiology of RA development

Answer 3

IgG forms against cartilage – rheumatoid factor (IgM antibody) forms in response to IgG – synovitis – pannus + joint destruction

Question 4

what is pannus

Answer 4

deposits in the synovial membrane - inflamed, spongy synovium

Question 5

what gender is RA more common in

Answer 5

3x more common in females

Question 6

most specific antibodies in RA

Answer 6

anti-CCP - worse prognosis if present

Question 7

what joints are most commonly affected by RA

Answer 7

small joints of hands + feet - MCP - PIP - MTP

Question 8

what joints of hands + feet does RA typically spare

Answer 8

thumb + 1st MTP

Question 9

what is tenosynovitis?

Answer 9

inflammation of synovium that surrounds a tendon - affects flexors in RA

Question 10

what deformities may be seen in longstanding disease

Answer 10

ulnar deviation dorsal wrist subluxation boutonniere + swan neck deformities

Question 11

difference between boutonniere and swan neck deformities

Answer 11

boutonniere causes flexion at PIP

swan neck causes flexion DIP

Question 12

when are symptoms of RA worse

Answer 12

worse in the morning with >30 mins stiffness

• improves as day goes on

Question 13

systemic symptoms of RA

Answer 13

fatigue

fever

weight loss

Question 14

skin manifestations of RA

Answer 14

Rheumatoid nodules

Pyoderma gangrenosum

Erythema nodosum

Question 15

what nerve entrapment is common in RA

Answer 15

Carpal tunnel syndrome

• compression of median nerve
• pain/numbness in thumb, index + middle finger

Question 16

what eye conditions are associated with RA

Answer 16

Keratoconjunctivitis Sicca - dryness of conjunctiva

Scleritis - painful red eye + gradual vision decrease

Episcleritis - non-painful red eye

Question 17

what cardiac valve disease is associated with RA

Answer 17

mitral regurgitation

• pansystolic blowing murmur
• best heard at apex
• radiates to axilla

Question 18

features of rheumatoid lung disease

Answer 18

Pulmonary fibrosis

Pleural effusion

methotrexate pneumonitis

Question 19

RA, RF +ve, splenomegaly and neutropenia

classical of what syndrome?

Answer 19

Felty’s syndrome

Question 20

XRAY findings in RA

Answer 20

Juxta-articular osteoporosis

Periarticular erosions

Subluxation

Loss of joint space

Question 21

what scoring system is used for RA

Answer 21

DAS 28

• disease activity score that assesses 28 joints

Question 22

What DAS score indicates severe active disease

Answer 22

>5.1

Question 23

What DAS score indicates remission

Answer 23

<2.6

Question 24

what inflammatory markers may be raised in RA

Answer 24

ESR

CRP

Question 25

1st line treatment for RA

Answer 25

Methotrexate (DMARD) + short course prednisolone as bridging therapy

Question 26

how is methotrexate taken

Answer 26

oral, once a week

Question 27

what is given along side methotrexate in RA

Answer 27

Folic acid

Question 29

is methotrexate safe in pregnancy

Answer 29

NO

• stop 3 months before trying to conceive

Question 30

what must be monitored on methotrexate + why

Answer 30

LFTS - risk of liver cirrhosis

FBC - risk of myelosuppresion

Question 31

resp side effect of methotrexate

Answer 31

pneumonitis

Question 32

2nd line DMARD

Answer 32

Sulfasalazine (aminosalicylate)

Question 33

when would use of TNF-inhibitors be considered

Answer 33

inadequate response to 2 DMARDS, including methotrexate

Question 34

examples of TNF inhibitors

what condition do they increase risk of reactivating?

Answer 34

etanercept

infliximab

• reactivation of TB

Question 35

How are flares of RA managed

Answer 35

oral or IM steroids

Question 36

what drug must you be cautious in prescribing in patient with an aspirin allergy

Answer 36

sulfasalazine