Rheumatology - Rheumatoid Arthritis

Question 1

What are the risk factors for rheumatoid arthritis?

Answer 1

Women
Middle age
Smoking
Obesity
HLADR4 gene

Question 2

What antibodies are present in RA?

Answer 2

Rheumatoid factor
Anti-CCP

Question 3

Where does the rheumatoid factor autoantibody target?

Answer 3

Fc portion of IgG

Causes immune activation against IgG

Most often IgM

Question 4

What antibody is more specific and sensitive?

Answer 4

Anti-CCP

Often present before patient affected by RA

Question 5

How does RA present?

Answer 5

Pain
Stiffness
Swelling

Symmetrical distal polyarthritis

Question 6

What joints are most affected in RA?

Answer 6

MCP
PIPs
Wrist
MTP

Question 7

What is present on palpation of joints affected by RA?

Answer 7

Tenderness
Synovial thickening

Boggy feeling

Question 8

What are the hand signs in RA?

Answer 8

Z-shaped deformity
Swan neck deformity
Boutonniere deformity
Ulnar deviation

Question 9

What causes boutonniere deformity?

Answer 9

Tear in central slip of extensor components at PIP

Central slip connects middle phalanx to PIP

Lateral bands go around PIP and connect to distal phalanx

Hyperextension of DIP
Flexion of PIP

Question 10

What causes swan neck deformity?

Answer 10

Tear of central slip in flexor

Hyperflexion of DIP
Extension of PIP

Question 11

What are some extra-articular manifestations of RA?

Answer 11

Episcleritis
Keratitis
Cataracts
Retinopathy
Felty’s syndrome
Anaemia of chronic disease
Carpal tunnel syndrome

Question 12

What is atlantoaxial subluxation?

Answer 12

Synovitis and damage to ligaments around the peg

Can cause spinal cord compression

MRI

Question 13

How is RA diagnosed?

Answer 13

RF
Anti-CCP
CRP and ESR
X-rays
USS or MRI to detect synovitis

Question 14

What are the x-ray changes of RA?

Answer 14

Periarticular osteopenia
Boney erosions
Soft tissue swelling
Joint destruction and deformity

Question 15

What scoring systems are used for RA?

Answer 15

HAQ
Disease Activity Score 28 joints

Question 16

What is used to monitor treatment of RA?

Answer 16

CRP
DAS28

Question 17

What can be used at initial presentation of RA?

Answer 17

Short-term steroids

Question 18

How is RA treated?

Answer 18

1. Monotherapy with methotrexate, leflunomide or sulfasalazine
2. Combination treatment with multiple cDMARDS
3. Biologic therapies alongside methotrexate

Question 19

What happens to RA in pregnancy?

Answer 19

Can improve symptoms

Some women may get a symptom flare

Hydroxychloroquine and sulfasalazine can be used in pregnancy

Folic acid is required with sulfasalazine

Question 20

What are the different categories of biological DMARDS?

Answer 20

TNF inhibitors
- Infliximab
- Adalimunab

Anti-CD20 on B cells
- Rituximab

Question 21

What are the main side effects of :
- Methotrexate
- Leflunomide
- Sulfasalazine
- Hydroxychloroquine
- Anti-TNF medications
- Rituximab

Answer 21

Methotrexate
Interferes with folate metabolism
Need once weekly folic acid 5mg

• Bone marrow suppression and leukopenia

Leflunomide
Interferes with production of pyrimidine

• Hypertension and peripheral neuropathy

Sulfasalazine
- Orange urine
- Reduces sperm count

Hydroxychloroquine
Targets Toll-like receptors disrupting antigen presentation and increasing pH in lysosomes

• Retinal toxicity
• Blue-grey skin pigmentation
• Hair bleaching

Anti-TNF
- Reactivates TB

Rituximab
- Night sweats
- Thrombocytopenia