Rheumatology

Question 1

Arteries affected by GCA

Answer 1

1. External carotid branches (temporal and occipital arteries)
2. Ophthalmic
3. Vertebral
4. Distal subclavian and axillary arteries
5. Thoracic aorta

Question 2

4 distinct clinical presentation of GCA

Answer 2

80% - cranial GCA (headache, jaw claudication, scalp tenderness)
Symptomatic LVV (claudication/pulseless limb )with or without cranial signs 9%
Systemic symptoms in 9% or inflammatory response
Isolated PMR with vasculitis on imaging 2%

Question 3

What GCA patients are more likely to have large vessel involvements?

Answer 3

Younger patient
Less likely to present with headaches
Less likely to have positive temporal artery biopsy
Lower risk of visual loss
Requires higher dose of steroids, and are at higher risk of relapse

Question 4

What proportion of GCA patients have normal ESR?

Answer 4

4%

Question 5

Sensitivity for biopsy in:

Temporal artery biopsy

Answer 5

70-90% in cranial GCA

However this drops to 52% in large vessel GCA (therefore imaging is particularly useful in large vessel GCA)

Question 6

Best imaging modality to diagnose large vessel GCA

Answer 6

1. FDG-PET - sensitivity and specificity of 90% and 98% respectively
2. CT angiogram
3. MR cranial arteries
4. USS temporal arteries

Question 7

Role of aspirin in GCA

Answer 7

Aspirin suppresses interferon gamma in mouse models of GCA

6 observational studies showed protection against ischaemic events - OR 0.3

Rates of visual loss, other ischaemic complications in patients on steroids with addition of aspirin, without the risk of increased bleeding risk

Question 8

Role of methotrexate in GCA

Answer 8

MTX 15mg/week reduced risk of first relapse by 35% and second relapse by 51%
Reduction in mean cumulative dose of prednisolone

Question 9

Effectiveness of tocilizumab in GCA

Answer 9

IL-6 monoclonal antibody

Sustained remission of around 50% in patients given weekly/2 weekly tocilizumab compared to 14-18% in prednisone and placebo group

Also cumulative median prednisone dose over 52 weeks was lower in the tocilizumab group

Question 10

What are the three mandatory criteria for 2012 ACR-EULAR criteria for PMR?

Answer 10

1. Age >50 years
2. Aching in both shoulders
3. Abnormal CRP and/or ESR

Question 11

Long term disease specific risk of GCA

Answer 11

Increased risk of development of aortic aneurysms, ascending more than descending
Increased risk 5 years after the GCA diagnosis

Question 12

Why do we start with high dose steroid therapy in GCA? (ie, >40mg/day)

Answer 12

Patients receiving an initial oral prednisone dose of greater than 40mg/day were more likely to reach a dose of <5mg/day and discontinue steroids than patients initially receiving <40mg/day without an increase in observed adverse effects.

Question 13

What does presence of RF indicate?

Answer 13

Predicts severe disease course
Stronger correlation with extraarticular manifestations such as ILD and vasculitis
Increases the likelihood of clinically significant response to rituximab after railed TNF inhibitor therapy

Question 14

What is a rheumatoid factor?

Answer 14

Autoantibodies directed against the Fc portion of the human IgG, found in 75-80% of RA patients at some time during the course of disease

Question 15

Predictors of progressive joint damage in RA

Answer 15

1. Anti-CCP

2. Raised inflammatory markers