RA

Question 1

Definition of RA?

Answer 1

Chronic autoimmune synovitis causing erosive, symmetric inflammatory polyarthritis.

Question 2

Typical joint pattern in RA?

Answer 2

Symmetric MCP, PIP, MTP > wrists; DIPs usually spared.

Question 3

Morning stiffness clue for RA?

Answer 3

≥60 minutes, improves with activity.

Question 4

Most specific antibody for RA?

Answer 4

Anti-CCP (ACPA).

Question 5

Sensitivity vs specificity: RF vs anti-CCP?

Answer 5

RF more sensitive; anti-CCP more specific (~95%).

Question 6

Seronegative RA?

Answer 6

RA can exist without RF/anti-CCP positivity.

Question 7

Key genetic risk in RA?

Answer 7

HLA-DRB1 ‘shared epitope’ (e.g., HLA‑DR4).

Question 8

Environmental trigger?

Answer 8

Smoking (↑ citrullination); periodontal disease (P. gingivalis).

Question 9

Pathogenic cytokines?

Answer 9

TNF‑α > IL‑6 > IL‑1 drive synovitis and pannus.

Question 10

Classic RA deformities?

Answer 10

Ulnar deviation, swan‑neck, boutonnière, Z‑thumb.

Question 11

Extra‑articular RA lung disease?

Answer 11

Pleuritis, RA‑ILD, rheumatoid nodules.

Question 12

Cervical spine risk in RA?

Answer 12

Atlanto‑axial subluxation → image C‑spine pre‑intubation.

Question 13

Felty’s syndrome triad?

Answer 13

RA + splenomegaly + neutropenia.

Question 14

Caplan’s syndrome?

Answer 14

RA with pneumoconiosis → pulmonary nodules.

Question 15

Initial screening before DMARDs?

Answer 15

FBC, LFT, U&E, ESR/CRP, HBV/HCV/HIV, TB IGRA, chest imaging.

Question 16

Early imaging for RA?

Answer 16

MSK ultrasound (power Doppler) or MRI detects synovitis early.

Question 17

Late X‑ray findings?

Answer 17

Peri‑articular osteopenia, joint‑space loss, marginal erosions.

Question 18

Classification threshold?

Answer 18

ACR/EULAR 2010 score ≥6/10 = definite RA (supporting diagnosis).

Question 19

Treat‑to‑target goal?

Answer 19

Remission or low activity (e.g., DAS28 < 2.6).

Question 20

When to start DMARDs?

Answer 20

Within 3 months of symptom onset (as early as possible).

Question 21

First‑line csDMARD?

Answer 21

Methotrexate 15–25 mg weekly + folic acid 5 mg weekly.

Question 22

MTX monitoring frequency?

Answer 22

FBC/LFT/Cr every 4–8 weeks initially, then q3–6 months.

Question 23

MTX key contraindications?

Answer 23

Pregnancy, significant liver disease, eGFR <30, cytopenias.

Question 24

MTX key toxicities?

Answer 24

Pneumonitis (idiosyncratic), hepatotoxicity, cytopenia, teratogenic.

Question 25

Leflunomide caution in pregnancy?

Answer 25

Contraindicated; use cholestyramine washout if pregnancy desired.

Question 26

Hydroxychloroquine eye safety?

Answer 26

Baseline exam then screen every 5 years (earlier if high risk).

Question 27

Sulfasalazine fertility effect?

Answer 27

Reversible male infertility (oligospermia).

Question 28

Bridge therapy role?

Answer 28

Short Pred ≤10 mg daily while DMARD takes effect; taper early.

Question 29

If inadequate control at 3–6 months?

Answer 29

Use combo csDMARDs (e.g., MTX+SSZ+HCQ) or add bDMARD/tsDMARD.

Question 30

Pre‑biologic safety screen?

Answer 30

HBV, HCV, HIV, TB; update vaccines (influenza, pneumococcal, zoster).

Question 31

TNF inhibitor examples?

Answer 31

Etanercept, Adalimumab, Infliximab.

Question 32

TNF inhibitor cautions?

Answer 32

TB reactivation, serious infection, demyelination, worsened CHF.

Question 33

IL‑6 blocker examples?

Answer 33

Tocilizumab, Sarilumab.

Question 34

IL‑6 blocker adverse effects?

Answer 34

↑ LFTs/lipids, risk of diverticulitis/perforation.

Question 35

B‑cell therapy example and risk?

Answer 35

Rituximab; HBV reactivation, infusion reactions, hypogammaglobulinaemia.

Question 36

T‑cell costimulation blocker?

Answer 36

Abatacept; infection risk, caution in COPD.

Question 37

JAK inhibitor examples?

Answer 37

Tofacitinib, Baricitinib, Upadacitinib.

Question 38

JAK inhibitor key warnings?

Answer 38

↑ Zoster, VTE, MACE; use later‑line per PBS and counsel CV risk.

Question 39

PBS rule (Australia) to start biologic?

Answer 39

Failure of ≥2 csDMARDs over ≥6 months with active disease documented.

Question 40

JAK position in Australia?

Answer 40

After ≥2 csDMARDs and usually ≥1 bDMARD failure or contraindication.

Question 41

Vaccination tip with JAK/biologics?

Answer 41

Give zoster (Shingrix) and other vaccines before starting; avoid live vaccines on therapy.

Question 42

RA‑ILD DMARD choices?

Answer 42

Prefer Rituximab, Abatacept, or Mycophenolate; avoid MTX/Leflunomide if ILD significant.

Question 43

RA with heart failure?

Answer 43

Avoid TNF blockers; consider non‑TNF options.

Question 44

RA with recent malignancy?

Answer 44

Rituximab often preferred.

Question 45

Pregnancy‑compatible DMARDs?

Answer 45

Hydroxychloroquine, Sulfasalazine, Azathioprine; certolizumab if biologic needed.

Question 46

Absolute avoid in pregnancy?

Answer 46

Methotrexate, Leflunomide, JAK inhibitors.

Question 47

Non‑pharmacologic measures?

Answer 47

Exercise/physio, hand splints, smoking cessation, weight and CV risk control.

Question 48

Prognostic “bad signs” in RA?

Answer 48

High anti‑CCP/RF, early erosions, high CRP/ESR, extra‑articular disease, smoking, DRB1 epitope.

Question 49

OA vs RA quick discriminator?

Answer 49

OA: stiffness <30 min, no MCP synovitis; RA: stiffness ≥60 min, MCP/PIP swell.

Question 50

PsA vs RA quick clue?

Answer 50

PsA: DIP + nail pitting + dactylitis; RA spares DIPs, symmetric.

Question 51

csDMARD stands for?

Answer 51

Conventional synthetic DMARD (e.g., MTX, Leflunomide, SSZ, HCQ).

Question 52

bDMARD stands for?

Answer 52

Biologic DMARD (e.g., TNF, IL‑6 inhibitors, Rituximab, Abatacept).

Question 53

tsDMARD stands for?

Answer 53

Targeted synthetic DMARD (e.g., JAK inhibitors).

Question 54

MACE stands for?

Answer 54

Major Adverse Cardiovascular Events (MI, stroke, CV death).

Question 55

Why must Leflunomide be stopped immediately if pregnancy occurs, and how is it cleared safely?

Answer 55

Leflunomide’s active metabolite (teriflunomide) has a very long half-life (up to 2 months) due to enterohepatic recirculation, remaining teratogenic long after stopping. → Do cholestyramine washout (8 g TDS for 11 days or 4 g TDS for 11 days) to bind drug in bile and interrupt recirculation. → Confirm plasma teriflunomide < 0.02 mg/L before conception. Folate or passive waiting alone is unsafe. 🧠 Memory cue: “Le-full-life drug → flush with Cholestyramine.”

Question 56

What is the DAS-28 score and what defines remission in RA?

Answer 56

DAS-28 (Disease Activity Score – 28 joints) combines: • Tender joint count (28) • Swollen joint count (28) • ESR or CRP • Patient global assessment (VAS) Interpreted as: • < 2.6 → Remission • 2.6–3.2 → Low activity • 3.2–5.1 → Moderate activity • 5.1 → High activity 🎯 Treat-to-target: aim for DAS-28 < 2.6 (remission) or low activity with early csDMARD ± biologic escalation. 🧠 Memory cue: “28 joints, 2.6 target.”