Rheumatoid Arthritis Dx and Tx

Question 1

What is the most common polyarthritis?

Answer 1

• Rheumatoid arthritis; RA (connective tissue disease)

Question 2

What are the connective tissue disorders in order of most to least common?

Answer 2

• RA
• SLE
• systemic sclerosis
• poly/dermatomyositis
• vasculitis
• sjogren’s syndrome
• overlap (MCTD)
• undifferentiated CTD

Question 3

What type of appearance will you see in the digits in a pt with RA?

Answer 3

• fusiform swelling and hyperpigmentation of the joints of the HANDS (mainly wrist, MCPs and PIPs) and FEET (MTPs and dorsum of foot).

Question 4

What is RA?

Answer 4

• progressive, systemic, inflammatory disorder of unknown etiology.
• characterized by symmetric synovitis, joint erosions, and multisystem extra-articular manifestations.

Question 5

Where does the pathogenesis begin in RA?

Answer 5

• in the lining of the joint SYNOVIUM

Question 6

What is the genetic predisposition to develop RA?

Answer 6

• HLA-DR4 (chromosome 6)

Question 7

Do more men or women get RA?

Answer 7

• women

Question 8

What is the age of onset of RA?

Answer 8

20-45

Question 9

What is the most common extra-articular manifestation of RA?

Answer 9

• anemia

Question 10

What specific factor will you see on serology with RA?

Answer 10

• rheumatoid factor

Question 11

What virus can mimic RA?

Answer 11

• Parvovirus B-19

* usually involving a school teacher

Question 12

What should be on your DDx for RA?

Answer 12

• thyroid
• infection
• osteoarthritis
• gout
• seronegative spondylitis
• PMR
• rheumatic fever

Question 13

Will pts with RA often have subcutaneous nodules?

Answer 13

• YES

Question 14

What is Caplan’s syndrome?

Answer 14

• pneumoconiosis of the lungs with RA

Question 15

When you’re sending your pt for a joint replacement with RA, what should you always do?

Answer 15

• do a cervical spine x ray to make sure there isn’t a C1/2 subluxation

Question 16

What are the extra-articular manifestations of RA?

Answer 16

• anemia
• nodules
• lymphadenopathy
• pleural effusion with low glucose
• Raynaud’s
• Sjogren’s
• cardiac

Question 17

What lab data will you see in RA?

Answer 17

• anemia (80%)
• Rheumatoid factor (85%)
• anti-CCP
• ANA
• elevation of ESR
• group II synovial fluid
• polyclonal gammopathy

Question 18

What is rheumatoid factor?

Answer 18

• IgM directed against Fc portion of IgG.

Question 19

What is anti-cyclic citrullinated peptide antibody (Anti-CCP)?

Answer 19

• citrullinated peptides, which are autoantigenic targets produced in synovial joints.
• detected by ELISA

Question 20

What are the x-ray findings of RA?

Answer 20

• soft tissue swelling
• juxtaarticular osteopenia
• symmetrical (both sides of the joint) joint space narrowing
• erosions

Question 21

When does the most significant damage occur to the joints in RA?

Answer 21

• in the initial 1-2 years of disease

* treat aggressively and early.

Question 22

What are the goals of therapy?

Answer 22

• control disease activity
• alleviate pain
• maintain function for essential daily activities
• slow progression

Question 23

What non-pharmacologic management is involved in RA?

Answer 23

• REST
• exercise (stretching, muscle conditioning)
• diet/weight control

Question 24

What drugs do we use to treat RA?

Answer 24

1. NSAIDs

2. DMARDs (hydroxychloroquine, methotrexate, leflunomide, sulfasalzaine, gold, penicillamine, TNF-alpha inhibitors).

Question 25

What can we use methotrexate for in rheumatology?

Answer 25

• RA
• psoriatic arthritis
• reactive arthritis
• poly/dermatomyositis

Question 26

*** What is the drug of choice for RA?

Answer 26

• METHOTREXATE

Question 27

Does combination therapy work better for RA?

Answer 27

YES:

• MTX + SSZ
• triple tx
• MTX + TNF

Question 28

Before using TNF-alpha inhibitors to treat RA, what test must always be done first?

Answer 28

• PPD for TB

Question 29

What is tofacitinib?

Answer 29

• inhibitor of janus kinase (JAK) enzymes.