Rheumatoid Arthritis (RA)

Question 1

What is the pathogenesis of rheumatoid arthritis (RA)?

Answer 1

1. Autoimmune attack causes synovitis in synovial joints and tendons causing pain
2. Pannus (inflamed joint capsule) forms damages the joint/tendon
3. This can progress to tendon rupture or joint instability

Question 2

How does rheumatoid arthritis (RA) present?

Answer 2

More common in women

Symmetrical pain/swelling of small joints in hands and feet

Question 3

What are the hand deformities associated with rheumatoid arthritis (RA)?

Answer 3

Swan-neck deformity (hyperextended PIPJ, flexed DIPJ)

Boutonniere deformity (flexed PIPJ, hyperextended DIPJ)

Z-shaped thumb (flexed MCPJ, hyperextended DIPJ)

Ulnar deviaton

Question 4

What autoantibodies are associated with rheumatoid arthritis (RA)? Which is more specific?

Answer 4

Rheumatoid factor (RF)

Anti-cyclic-citrininated protein (anti-CCP)

Anti-CCP has much higher specificity and it the preferred test (positive anti-CCP means than you are very likely to have rheumatoid arthritis)

Question 5

What can be seen on XR in rheumatoid arthritis (RA)?

Answer 5

In early disease:

• nothing

In late disease:

• Loss of joint space
• Erosions
• Periarticular osteopenia (loss of bone density around joints)
• soft tissue swelling
• Subluxation/gross malalignment

Question 6

What scoring system is used to diagnose rheumatoid arthritis (RA)?

Answer 6

EULAR/ACR score

Question 7

What scoring system is used to track rheumatoid arthritis (RA) disease activity?

What are the different levels of disease activity?

Answer 7

DAS28

Remission - <2.6
Low - 2-7-3.2
Moderate - 3.3-5.1
High - >5.1

Question 8

What class of drugs are the mainstay of management of rheumatoid arthritis (RA).

Name 3.

Answer 8

Disease modifying anti-rheumatic drugs (DMARDs)

Methotrexate
Sulphalazine
Hydroxychloroquine

Question 9

What is the purpose of DMARDs in the management of rheumatoid arthritis (RA)?

Answer 9

Prevent disease progression

Question 10

What is the first line DMARD?

Answer 10

Methotrexate (MTX)

Question 11

What drugs should be taken alongside methotrexate (MTX) and why?

Answer 11

Folic acid (MTX is anti-folate agent)

Contraception (MTX is teratogenic)

Question 12

How long do DMARDs take to work? What is done to manage symptoms in the time where they don’t work?

Answer 12

6-8 weeks

Steroids are used and gradually withdrawn as DMARDs take effect

Question 13

What is the goal regarding the timing of starting DMARD therapy?

Answer 13

Start DMARDs within 3 months of symptom onset

Question 14

What blood tests are done regularly for patients on DMARDs and why?

Answer 14

LFT, FBC

DMARDs are hepatotoxic

Question 15

What would you do with a patient on methotrexate who wanted to get pregnant?

Answer 15

Tell them it is damaging to unborn baby

Change prescription to sulphasalazine

Advise patient not to get pregnant and continue taking contraception for 3 months after stopping methotrexate to ensure all methotrexate is out of body

Question 16

When is sulphasalazine indicated for rheumatoid arthritis (RA)?

Answer 16

If methotrexate doesn’t reduce DAS28

In women with rheumatoid arthritis wanting to get pregnanct

Question 17

What are some side effects of DMARDs?

Answer 17

Increased infection risk

Allergic pneumonitis (methotrexate)

Hepatotoxicity

Question 18

When are biologic agents (e.g. ritixumab) indicated for rheumatoid arthritis (RA)?

Answer 18

DAS28 > 5.1 (high disease activity)

Despite treatment with 2 DMARDs including methotrexate

Question 19

What are patients on biologic agents for rheumatoid arthritis (RA) at risk from developing?

Answer 19

Infection (particularly tuberculosis)

Question 20

What can trigger rheumatoid arthritis (RA)?

Answer 20

Smoking, infection, stress

Question 21

What gene is rheumatoid arthritis (RA) associated with?

Answer 21

HLA-DR4