Rheumatoid Arthritis

Question 1

What is rheumatoid arthritis?

Answer 1

Autoimmune condition causing chronic inflammation of the synovial lining of the joint, tendon sheaths and bursa

Question 2

What genes are associated with RA?

Answer 2

HLA-DR4

HLA-DR1

Question 3

Triggers for RA

Answer 3

Smoking
Infection
Trauma

Question 4

Presentation of RA

Answer 4

Symmetrical, polyarthritis of the small joints of the hands and feet
Joint pain (worse at rest or inactivity)
Joint swelling (boggy)
Joint stiffness (>30mins in morning)

Question 5

What joints are affected in RA?

Answer 5

Wrist, ankle, MCPs, PIPs, knees, shoulders, elbows

Question 6

What joint deformities can be seen in RA?

Answer 6

Ulnar deviation
Swan neck deformity
Boutonniere deformity
Z-shaped thumb

Question 7

What is swan neck deformity?

Answer 7

Hyperextension at PIP with flexion at DIP

Question 8

What is boutonniere deformity?

Answer 8

Flexion at PIP with hyperextension at DIP

Question 9

Autoantibodies in RA

Answer 9

RF

Anti-CCP

Question 10

XR findings in RA

Answer 10

Joint destruction and deformity
Soft tissue swelling
Periarticular osteopenia
Boney erosions

Question 11

Extra-articular manifestations of RA

Answer 11

LOTS
Pulmonary fibrosis with pulmonary nodules (Caplan’s syndrome)
Bronchiolitis obliterans (inflammation causing small airway destruction)
Felty’s syndrome (RA, neutropenia and splenomegaly)
Secondary Sjogren’s Syndrome (AKA sicca syndrome)
Anaemia of chronic disease
Cardiovascular disease
Episcleritis and scleritis
Rheumatoid nodules
Lymphadenopathy
Carpel tunnel syndrome
Amyloidosis

Question 12

1st line treatment for RA

Answer 12

Monotherapy
Methotrexate 
Leflunomide
Sulfasalazine
Hydroxychloroquine

Question 13

2nd line treatment for RA

Answer 13

Any 2 of 
Methotrexate 
Leflunomide
Sulfasalazine
Hydroxychloroquine
Used in combination

Question 14

3rd line treatment for RA

Answer 14

Tried combination therapy of 2 DMARDS and still has a DAS28 score >5.1
Methotrexate + biologic (usually TNF-inhibitor)

Question 15

4th line treatment for RA

Answer 15

Methotrexate + rituximab

Question 16

Which DMARDs are safe in pregnancy?

Answer 16

Sulfasalazine

Hydroxychloroquine

Question 17

Biologics used in RA

Answer 17

Anti-TNF (adalimumab, infliximab, etanercept, golimumab and certolizumab pegol)
Anti-CD20 on B cells (rituximab)
Anti-IL6 (sarilumab)
Anti-IL6 receptor (tocilizumab)
JAK inhibitors (tofacitinib and baricitinib)

Question 18

Side effects of methotrexate

Answer 18

Teratogenic

Pulmonary fibrosis

Question 19

Side effects of leflunomide

Answer 19

Hypertension and peripheral neuropathy

Question 20

Side effect of sulfasalazine

Answer 20

Male infertility (reduces sperm count)

Question 21

Side effects of hydroxychloroquine

Answer 21

Nightmares and reduced visual acuity

Question 22

Side effects of anti-TNF medications

Answer 22

Reactivation of TB or hepatitis B

Question 23

Side effects of rituximab

Answer 23

Night sweats and thrombocytopenia

Question 24

When is surgery used for treatment of RA?

Answer 24

For controlling pain and maintaining function in resistant disease

Question 25

What are the components of the DAS28 score and what is it used for?

Answer 25

Monitor disease activity over time
Tender joint count
Swollen joint count
CRP/ESR
Patients own assessment of their disease activity