Rheumatoid arthritis flashcards
16 high-yield MRCP Part 1 cards from the Intellect Medicos Rheumatology course. Try to answer each question before you open it — then study them properly with spaced repetition, which brings each card back just before you would forget it.
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Which HLA allele is most strongly associated with rheumatoid arthritis?
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HLA-DR4 (HLA-DR1 to a lesser extent).
Why? HLA-DR4 also marks a worse prognosis in RA.
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What is the strongest modifiable risk factor for developing rheumatoid arthritis?
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Smoking.
Why? Smoking increases the risk of seropositive RA and is linked to more severe disease, so cessation is part of management.
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A 42-year-old woman has 8 weeks of painful swelling of the MCP and PIP joints of both hands, with 90 minutes of morning stiffness. Following NICE, which blood test should be offered first?
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Rheumatoid factor.
Why? NICE NG100 advises testing RF first and considering anti-CCP antibodies if RF is negative. X-rays of the hands and feet are also requested.
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Which autoantibody is the most specific for rheumatoid arthritis and predicts erosive disease?
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Anti-CCP (anti-cyclic citrullinated peptide) antibody.
Why? Rheumatoid factor is sensitive but non-specific; anti-CCP is highly specific and high titres predict severe, erosive disease.
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Rheumatoid factor is an ______ antibody directed against the ______.
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IgM; Fc portion of IgG
Why? RF is not specific for RA: it is positive in almost all Felty's syndrome, about half of Sjögren's and infective endocarditis, and in mixed cryoglobulinaemia.
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According to NICE, which three features in suspected persistent synovitis should prompt URGENT rheumatology referral?
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Small joints of the hands or feet affected; more than one joint affected; or 3 months or longer between symptom onset and seeking advice.
Why? Early DMARD treatment in the "window of opportunity" limits joint damage, so any of these features triggers urgent referral.
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Which imaging does NICE recommend at diagnosis of RA as a baseline?
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X-rays of the hands and feet.
Why? Baseline films show existing erosions (a poor prognostic sign) and allow progression to be tracked.
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Name three plain X-ray findings of rheumatoid arthritis in the hand.
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Any three: periarticular osteopenia, marginal bony erosions, joint space narrowing, soft-tissue swelling, subluxation.
Why? Inflamed pannus destroys cartilage (joint space narrowing) and bare bone at the joint margins (erosions).
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In the NICE treat-to-target approach to active RA, what is measured monthly until the target is reached?
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CRP and a disease activity score (e.g. DAS28).
Why? The target is remission, or low disease activity if remission is not achievable; treatment is stepped up until the target is met.
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For mild or palindromic RA, which cDMARD may NICE consider as an alternative to the standard first-line options?
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Hydroxychloroquine.
Why? Hydroxychloroquine is a weaker DMARD but well tolerated, so it suits mild or palindromic disease.
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What is given to control symptoms while a newly started cDMARD takes effect in RA?
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A short course of glucocorticoids (oral, IM or intra-articular) as "bridging" therapy.
Why? cDMARDs take weeks to months to work; long-term steroids are avoided because of their side effects.
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A 68-year-old woman with long-standing rheumatoid arthritis is listed for a hip replacement under general anaesthesia. She mentions neck pain and occipital headaches. Which complication must be excluded before intubation?
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Atlantoaxial (C1–C2) subluxation — image the cervical spine first.
Why? Neck extension during intubation can cause cord compression and sudden death in unstable C1–C2 disease.
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A rheumatoid pleural effusion is an exudate with very ______, low pH and high LDH.
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low glucose
Why? The very low glucose is a classic exam discriminator from other exudates (empyema also has low glucose).
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Felty syndrome is the triad of rheumatoid arthritis, ______ and ______.
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splenomegaly; neutropenia
Why? It reflects severe, usually seropositive, long-standing RA and raises infection risk because of the neutropenia.
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Name three poor prognostic factors in rheumatoid arthritis.
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Any three: RF positive, anti-CCP positive, early erosions on X-ray, extra-articular disease (e.g. nodules), poor function at presentation, HLA-DR4, insidious onset.
Why? These features predict erosive progression and justify earlier, more aggressive treatment.
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Which hand joints are characteristically spared in rheumatoid arthritis?
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The distal interphalangeal (DIP) joints.
Why? RA affects MCP, PIP and MTP joints symmetrically. DIP involvement suggests osteoarthritis (Heberden's nodes) or psoriatic arthritis.