Rheumatoid Arthritis

Rheumatology · Rheumatoid Arthritis 🎯 Practice these cards

RA classically involves the ____, ____, MTP (2–5), and wrist joints symmetrically, spares the ____ joints and thoracic/lumbar spine, but targets the ____ spine (especially C1–C2).

RA targets MCP, PIP, MTP (2–5), and wrist joints, typically symmetric, with morning stiffness ≥30–45 minutes that improves with activity. It SPARES the DIP joints (DIP disease usually means coexistent osteoarthritis) and the thoracic/lumbar spine — but involves the cervical spine, especially C1–C2 (atlantoaxial). Early signs: boggy palpable synovitis, positive MCP/MTP squeeze test, and inability to make a fist from flexor tenosynovitis.

  1. Rheumatology — "Rheumatoid Arthritis," Ch. 3, pp. 17–23. ACP, 2022.
  2. Harrison's 22e — Shah A, St. Clair EW. "Rheumatoid Arthritis," Ch. 370, pp. 2839–2854.
  3. Fraenkel L, et al. 2021 ACR Guideline for the Treatment of RA. Arthritis Care Res 2021;73(7):924–939.
  4. Smolen JS, et al. EULAR RA management recommendations: 2022 update. Ann Rheum Dis 2023;82(1):3–18.
  5. Studenic P, et al. ACR/EULAR remission criteria for RA: 2022 revision. Ann Rheum Dis 2022.
  6. U.S. FDA Drug Safety Communication, Dec 2021 — JAK inhibitors (ORAL Surveillance; N Engl J Med 2022;386:316–326).

RF is ~____% sensitive but only ~____% specific; anti-CCP has similar sensitivity but ~____% specificity and better predicts ____ disease.

Rheumatoid factor (usually IgM anti-Fc of IgG): ~70% sensitive, only ~85% specific (positive in hepatitis, endocarditis, aging). Anti-CCP (ACPA): ~70% sensitive, ~95% specific — and a better predictor of erosive disease. Both can predate clinical arthritis by years. 10–25% of RA is seronegative (generally better prognosis). ESR/CRP elevated in ~75%; anemia of inflammation and thrombocytosis are common.

  1. Rheumatology — "Rheumatoid Arthritis," Ch. 3, pp. 17–23. ACP, 2022.
  2. Harrison's 22e — Shah A, St. Clair EW. "Rheumatoid Arthritis," Ch. 370, pp. 2839–2854.
  3. Fraenkel L, et al. 2021 ACR Guideline for the Treatment of RA. Arthritis Care Res 2021;73(7):924–939.
  4. Smolen JS, et al. EULAR RA management recommendations: 2022 update. Ann Rheum Dis 2023;82(1):3–18.
  5. Studenic P, et al. ACR/EULAR remission criteria for RA: 2022 revision. Ann Rheum Dis 2022.
  6. U.S. FDA Drug Safety Communication, Dec 2021 — JAK inhibitors (ORAL Surveillance; N Engl J Med 2022;386:316–326).

A 2010 ACR/EULAR score of ≥____/10 classifies definite RA; the four domains are joints, ____, acute-phase reactants, and ____; erosions and nodules were ____ from the criteria.

Four domains: joint involvement (0–5; >10 joints incl. ≥1 small = 5), serology (neg 0 / low-positive 2 / high-positive >3× ULN = 3), acute-phase reactants (abnormal CRP or ESR = 1), duration (≥6 weeks = 1). Score ≥6/10 = definite RA. Requires ≥1 joint with definite clinical synovitis not better explained by another disease. Excludes DIP, 1st CMC, 1st MTP. Erosions and nodules were DROPPED from the older 1987 criteria to enable early classification.

  1. Rheumatology — "Rheumatoid Arthritis," Ch. 3, pp. 17–23. ACP, 2022.
  2. Harrison's 22e — Shah A, St. Clair EW. "Rheumatoid Arthritis," Ch. 370, pp. 2839–2854.
  3. Fraenkel L, et al. 2021 ACR Guideline for the Treatment of RA. Arthritis Care Res 2021;73(7):924–939.
  4. Smolen JS, et al. EULAR RA management recommendations: 2022 update. Ann Rheum Dis 2023;82(1):3–18.
  5. Studenic P, et al. ACR/EULAR remission criteria for RA: 2022 revision. Ann Rheum Dis 2022.
  6. U.S. FDA Drug Safety Communication, Dec 2021 — JAK inhibitors (ORAL Surveillance; N Engl J Med 2022;386:316–326).

The treat-to-target goal is remission or ____; reassess every ____ weeks. MTX is titrated to ____ mg/week with ____ acid; above ~15 mg/week switch to the ____ route.

Goal: remission or low disease activity (CDAI/DAS28/SDAI), reassessed every 12 weeks; treat-to-target reduces radiographic damage, CV risk, and work loss. Methotrexate is the anchor drug: titrate to 25 mg/week with folic acid; above ~15 mg/week switch to subcutaneous (oral absorption plateaus). MTX monotherapy achieves remission/LDA in 30–50%. TNF inhibitors are the most-used biologics — rapid onset, synergy with MTX, and slowed radiographic progression even with ongoing clinical activity. Triple therapy (MTX+HCQ+SSZ) ≈ MTX+TNFi for symptoms but not for radiographic progression.

  1. Rheumatology — "Rheumatoid Arthritis," Ch. 3, pp. 17–23. ACP, 2022.
  2. Harrison's 22e — Shah A, St. Clair EW. "Rheumatoid Arthritis," Ch. 370, pp. 2839–2854.
  3. Fraenkel L, et al. 2021 ACR Guideline for the Treatment of RA. Arthritis Care Res 2021;73(7):924–939.
  4. Smolen JS, et al. EULAR RA management recommendations: 2022 update. Ann Rheum Dis 2023;82(1):3–18.
  5. Studenic P, et al. ACR/EULAR remission criteria for RA: 2022 revision. Ann Rheum Dis 2022.
  6. U.S. FDA Drug Safety Communication, Dec 2021 — JAK inhibitors (ORAL Surveillance; N Engl J Med 2022;386:316–326).

Scleritis/corneal melt demands urgent ____ referral; suspected atlantoaxial subluxation requires cervical ____ views before intubation; the major cause of excess death in RA is ____ disease.

Scleritis or peripheral ulcerative keratitis (corneal melt) → immediate ophthalmology referral (can perforate). Suspected C1–C2 subluxation → cervical flexion/extension views BEFORE intubation or neck manipulation. RA pleural effusion: exudative, very low glucose/pH, low complement, mononuclear (neutrophils → think infection). ILD: radiologic in ~50%, clinically significant in ~10% (UIP pattern worst). Atherosclerotic CVD is the major cause of excess death — treat RA patients as high CV risk. Felty syndrome = neutropenia + splenomegaly in severe seropositive RA. Rheumatoid nodules in up to 30%.

  1. Rheumatology — "Rheumatoid Arthritis," Ch. 3, pp. 17–23. ACP, 2022.
  2. Harrison's 22e — Shah A, St. Clair EW. "Rheumatoid Arthritis," Ch. 370, pp. 2839–2854.
  3. Fraenkel L, et al. 2021 ACR Guideline for the Treatment of RA. Arthritis Care Res 2021;73(7):924–939.
  4. Smolen JS, et al. EULAR RA management recommendations: 2022 update. Ann Rheum Dis 2023;82(1):3–18.
  5. Studenic P, et al. ACR/EULAR remission criteria for RA: 2022 revision. Ann Rheum Dis 2022.
  6. U.S. FDA Drug Safety Communication, Dec 2021 — JAK inhibitors (ORAL Surveillance; N Engl J Med 2022;386:316–326).

After ORAL Surveillance, the FDA restricted JAK inhibitors to patients with inadequate response to ≥1 ____ blocker; Boolean 2.0 remission raised the PtGA threshold to ≤____ cm; the 2021 ACR guideline says to switch oral MTX to the ____ route before adding another DMARD.

(1) ORAL Surveillance → FDA boxed warning on ALL JAK inhibitors (tofacitinib, baricitinib, upadacitinib): ↑ MACE, malignancy, VTE, death; restricted to patients failing/intolerant of ≥1 TNF blocker; EMA: avoid in ≥65, smokers, CV/malignancy risk unless no alternative. (2) 2021 ACR guideline: switch oral → subcutaneous MTX before adding another DMARD; HCQ preferred for DMARD-naïve LOW activity; strongly minimize chronic glucocorticoids. (3) 2022 EULAR update: same JAKi risk stratification; rapid glucocorticoid taper. (4) Boolean 2.0 remission: PtGA threshold relaxed to ≤2 cm (TJC, SJC, CRP ≤1 unchanged); SDAI ≤3.3 / CDAI ≤2.8.

  1. Rheumatology — "Rheumatoid Arthritis," Ch. 3, pp. 17–23. ACP, 2022.
  2. Harrison's 22e — Shah A, St. Clair EW. "Rheumatoid Arthritis," Ch. 370, pp. 2839–2854.
  3. Fraenkel L, et al. 2021 ACR Guideline for the Treatment of RA. Arthritis Care Res 2021;73(7):924–939.
  4. Smolen JS, et al. EULAR RA management recommendations: 2022 update. Ann Rheum Dis 2023;82(1):3–18.
  5. Studenic P, et al. ACR/EULAR remission criteria for RA: 2022 revision. Ann Rheum Dis 2022.
  6. U.S. FDA Drug Safety Communication, Dec 2021 — JAK inhibitors (ORAL Surveillance; N Engl J Med 2022;386:316–326).

Tap a card to flip it.