Rheumatoid Arthritis

Question 1

associated alleles with ra

Answer 1

• hla drb1
• ptpn22
• padi4

Question 2

pathophysio of ra

Answer 2

read

Question 3

pathological hallmarks of ra

Answer 3

• synovial inflammation and proliferation
• focal bone erosions
• thinning or articular cartilage

Question 4

what is a pannus

Answer 4

mass of edematous synovium, inflammatory cells, granulation tissue, and fibroblasts

Question 5

classic clinical picture

Answer 5

chronic inflammatory symmetric polyarthritis

Question 6

inflammatory features

Answer 6

• tender, warm, swollen
• morning stiffness
• symmetric

Question 7

joints involved

Answer 7

• small joints of hands and feet
• wrists, metacarpal phalangeal joints, pip
• flexor tendon tenosynovitis
• dips spared

Question 8

ra specific deformities

Answer 8

• ulnar deviation
• boutonniere deformity
• swan neck deformity
• zigzag deformity
• “piano key movement” of ulnar styloid

Question 9

natural history

Answer 9

• early: metatarsophalangeal joint pain
• ankle and mid-tarsal region
• atlantoaxial of cervical spine
• late: large joints (knees and shoulders)

Question 10

most common extra articular symptoms

Answer 10

• weight loss
• fever
• fatigue
• malaise
• depression

Question 11

risk factors for systemic inolvement

Answer 11

• cigarette smoking
• early onset of significant physical disability
• (+) rf or anti-ccp antibodies

Question 12

common hematologic manifestation

Answer 12

• anemia of chronic disease

- felt’s syndrome: neutropenia, splenomegaly, nodular rheumatoid arthritis

Question 13

renal and cardiac manifestation

Answer 13

• membranous nephropathy
• secondary amyloidosis
• ischemic heart disease

Question 14

differentials for ra

Answer 14

• infectious/ viral arthritis (chikungunya, dengue, hep b)
• sle
• psoriatic arthritis
• other ct/ autoimmune diseases

Question 15

t/f sle results in erosions and irreversible deformities

Answer 15

false

Question 16

ra vs osteoarthritis

Answer 16

read

Question 17

clinical findings in oa

Answer 17

• short morning stiffness, worsened by effort
• bouchard’s nodes
• heberden’s nodes
• (-) rf and anti-ccp

Question 18

serology

Answer 18

• rf: negative in first year
• acpa
• elevated esr and crp

Question 19

synovial fluid analysis

Answer 19

• 5,000-50,000 wbc/ul with neutrophilic predominance
• decreased string sign
• most useful for confirming inflammatory arthritis or execluding infection

Question 20

plain xray findings

Answer 20

• periarticular osteopenia or no changes

- soft tissue swelling, symmetric joint space loss, subchondral erosions

Question 21

mri findings

Answer 21

• early detection

- greatest sensitivity for synovitis and joint effusions

Question 22

uts and doppler

Answer 22

• detect more erosions

- detect synovitis and increased vascularity (= inflammation)

Question 23

2010 acr/eular classification for ra

Answer 23

joint: 1 large, 2-10 large, 1-3 small, 4-10 small, >10

serology
acute phase reactants (crp and esr)
duration (6 wks)

6 = definite ra

Question 24

approach to treatment

Answer 24

read

Question 25

remission

Answer 25

• tender joint count less/= 1
• swollen joint count less/= 1
• crp less/= 1
• patient global assessment less/= 1

OR simplified DAI less/= 3.33

Question 26

factors for improved outcome

Answer 26

• methrotrexate = toc for early ra

- combination dmard > methotrexate

Question 27

pharmacologic treatment

Answer 27

• nsaids
• glucocorticoids
• dmards
• biological dmards

Question 28

glucocorticoids

Answer 28

• low to moderate doses before dmard therapy

- high dose for severe

Question 29

risks to chronic glucocorticoids

Answer 29

• osteoporosis
• infection
• cushing’s
• gastritis

Question 30

dmards

Answer 30

• methotrexate
• leflunomide
• hydroxychloroquine
• sulfasalaizine
• others

Question 31

biological dmards

Answer 31

• tnf: infliximab, adalimumab, goli, certolizu, etanercept
• cd28/cd80/cd86: abatacept
• ccd20: rituximab
• il6: tocilizumab, sarilumab
• jak: tofacitinib, barcitinib

Question 32

contraindications for tnf targeting

Answer 32

• chronic infection (hep b/c)

- class 3/4 heart failure

Question 33

___ have spontaneous remission within 6 mos

Answer 33

10%

Question 34

clinical course

Answer 34

• majority have persistent and progressive disease

- 2x higher mortality (ischemic heart disease, infection)

Question 35

risk factors for shortened lifie expectance

Answer 35

• systemic extraarticular involvement
• low functional capacity
• low socioeconomic status
• low education
• chronic prednisone use