Rheumatology for MRCP Part 1

A 44-year-old woman has 4 months of pain and swelling in the small joints of both hands and wrists, with early-morning stiffness lasting two hours that eases through the day. The metacarpophalangeal joints are boggy and tender. Anti-cyclic citrullinated peptide antibody is strongly positive and CRP is raised. What is the most likely diagnosis?

1. Systemic lupus erythematosus An arthritis that does not erode bone, with problems in several organs and a positive ANA (antinuclear antibody) blood test. But joint-lining inflammation in small joints on both sides, with long morning stiffness and a positive anti-CCP antibody does not point to it.
2. Osteoarthritis Joint pain from wear that is worse with use, with only brief stiffness. Here, joint-lining inflammation in small joints on both sides, with long morning stiffness and a positive anti-CCP antibody points elsewhere.
3. Polymyalgia rheumatica Pain and stiffness in the shoulders and hips of an older patient. That does not match joint-lining inflammation in small joints on both sides, with long morning stiffness and a positive anti-CCP antibody.
4. Psoriatic arthritis Inflammatory arthritis with psoriasis, dactylitis (a whole finger or toe swollen like a sausage) and nail changes. It does not fit joint-lining inflammation in small joints on both sides, with long morning stiffness and a positive anti-CCP antibody.
5. Rheumatoid arthritis correct Correct. Joint-lining inflammation in small joints on both sides, with long early-morning stiffness and a strongly positive anti-CCP antibody, is rheumatoid arthritis.

The point: Rheumatoid arthritis is a long-term inflammatory arthritis that affects joints on both sides of the body at once. It usually attacks the small joints of the hands and feet, causing morning stiffness that lasts over an hour, and, left untreated, wears away the joint surfaces and causes deformity. Anti-cyclic citrullinated peptide (anti-CCP) antibody is the most specific blood marker for the disease. Together with rheumatoid factor, it predicts more joint damage. Inflammatory markers are usually raised, and x-rays can show thinning of the bone near the joint and erosions (small bites out of the bone). The disease can also affect organs beyond the joints: rheumatoid nodules (lumps under the skin), interstitial lung disease (scarring of the lungs), pericarditis (inflammation around the heart), scleritis and episcleritis (inflammation of the eye), Felty syndrome (an enlarged spleen with a low white cell count) and a higher risk of heart disease. Treatment starts with a conventional disease-modifying drug early, usually methotrexate first, given with folic acid. The aim is to treat to a target of remission or low disease activity, stepping up to a biologic or targeted synthetic drug, such as a TNF inhibitor, if that target is not reached. Methotrexate is teratogenic (harmful to a developing baby) and must be stopped before trying to conceive. It needs regular blood tests to check the full blood count and liver function, because it can suppress the bone marrow, damage the liver and, rarely, cause pneumonitis (lung inflammation). Short courses of corticosteroid bridge the gap in symptom control while a disease-modifying drug starts to work.

Source: British Society for Rheumatology — management of rheumatoid arthritis British Society for Rheumatology · tier 2, specialty society or college

A 44-year-old woman has 4 months of pain and swelling in the small joints of both hands and wrists, with early-morning stiffness lasting two hours that eases through the day. The metacarpophalangeal joints are boggy and tender. Anti-cyclic citrullinated peptide antibody is strongly positive and CRP is raised. What is the most appropriate management?

1. Escalation to a TNF inhibitor if the target is not met A biologic drug used when the first treatment does not work well enough. Here, joint-lining inflammation in small joints on both sides, with long morning stiffness and a positive anti-CCP antibody points elsewhere.
2. Methotrexate with folic acid as first-line disease-modifying therapy correct Correct. Methotrexate is the first-choice disease-modifying drug. It is started early, with folic acid, to stop joint damage.
3. A short course of corticosteroid to bridge symptoms Controls symptoms while the disease-modifying drug starts to work. It does not fit joint-lining inflammation in small joints on both sides, with long morning stiffness and a positive anti-CCP antibody.
4. Cardiovascular risk assessment and management Needed because ongoing inflammation raises the risk of heart disease. But joint-lining inflammation in small joints on both sides, with long morning stiffness and a positive anti-CCP antibody does not point to it.
5. Monitoring of full blood count and liver function Checks for methotrexate harming the bone marrow or liver. That does not match joint-lining inflammation in small joints on both sides, with long morning stiffness and a positive anti-CCP antibody.

The point: Rheumatoid arthritis is a long-term inflammatory arthritis that affects joints on both sides of the body at once. It usually attacks the small joints of the hands and feet, causing morning stiffness that lasts over an hour, and, left untreated, wears away the joint surfaces and causes deformity. Anti-cyclic citrullinated peptide (anti-CCP) antibody is the most specific blood marker for the disease. Together with rheumatoid factor, it predicts more joint damage. Inflammatory markers are usually raised, and x-rays can show thinning of the bone near the joint and erosions (small bites out of the bone). The disease can also affect organs beyond the joints: rheumatoid nodules (lumps under the skin), interstitial lung disease (scarring of the lungs), pericarditis (inflammation around the heart), scleritis and episcleritis (inflammation of the eye), Felty syndrome (an enlarged spleen with a low white cell count) and a higher risk of heart disease. Treatment starts with a conventional disease-modifying drug early, usually methotrexate first, given with folic acid. The aim is to treat to a target of remission or low disease activity, stepping up to a biologic or targeted synthetic drug, such as a TNF inhibitor, if that target is not reached. Methotrexate is teratogenic (harmful to a developing baby) and must be stopped before trying to conceive. It needs regular blood tests to check the full blood count and liver function, because it can suppress the bone marrow, damage the liver and, rarely, cause pneumonitis (lung inflammation). Short courses of corticosteroid bridge the gap in symptom control while a disease-modifying drug starts to work.

Source: British Society for Rheumatology — management of rheumatoid arthritis British Society for Rheumatology · tier 2, specialty society or college

A 44-year-old woman has 4 months of pain and swelling in the small joints of both hands and wrists, with early-morning stiffness lasting two hours that eases through the day. The metacarpophalangeal joints are boggy and tender. Anti-cyclic citrullinated peptide antibody is strongly positive and CRP is raised. What is the most appropriate definitive treatment?

1. A short course of corticosteroid to bridge symptoms Controls symptoms while the disease-modifying drug starts to work. That does not match joint-lining inflammation in small joints on both sides, with long morning stiffness and a positive anti-CCP antibody.
2. Treat-to-target review of disease activity correct Correct. Treatment follows a treat-to-target strategy, stepping up until remission or low disease activity is reached.
3. Cardiovascular risk assessment and management Needed because ongoing inflammation raises the risk of heart disease. It does not fit joint-lining inflammation in small joints on both sides, with long morning stiffness and a positive anti-CCP antibody.
4. Monitoring of full blood count and liver function Checks for methotrexate harming the bone marrow or liver. But joint-lining inflammation in small joints on both sides, with long morning stiffness and a positive anti-CCP antibody does not point to it.
5. Escalation to a TNF inhibitor if the target is not met A biologic drug used when the first treatment does not work well enough. Here, joint-lining inflammation in small joints on both sides, with long morning stiffness and a positive anti-CCP antibody points elsewhere.

The point: Rheumatoid arthritis is a long-term inflammatory arthritis that affects joints on both sides of the body at once. It usually attacks the small joints of the hands and feet, causing morning stiffness that lasts over an hour, and, left untreated, wears away the joint surfaces and causes deformity. Anti-cyclic citrullinated peptide (anti-CCP) antibody is the most specific blood marker for the disease. Together with rheumatoid factor, it predicts more joint damage. Inflammatory markers are usually raised, and x-rays can show thinning of the bone near the joint and erosions (small bites out of the bone). The disease can also affect organs beyond the joints: rheumatoid nodules (lumps under the skin), interstitial lung disease (scarring of the lungs), pericarditis (inflammation around the heart), scleritis and episcleritis (inflammation of the eye), Felty syndrome (an enlarged spleen with a low white cell count) and a higher risk of heart disease. Treatment starts with a conventional disease-modifying drug early, usually methotrexate first, given with folic acid. The aim is to treat to a target of remission or low disease activity, stepping up to a biologic or targeted synthetic drug, such as a TNF inhibitor, if that target is not reached. Methotrexate is teratogenic (harmful to a developing baby) and must be stopped before trying to conceive. It needs regular blood tests to check the full blood count and liver function, because it can suppress the bone marrow, damage the liver and, rarely, cause pneumonitis (lung inflammation). Short courses of corticosteroid bridge the gap in symptom control while a disease-modifying drug starts to work.

Source: British Society for Rheumatology — management of rheumatoid arthritis British Society for Rheumatology · tier 2, specialty society or college