An critical subject matter to understand as you put together for the Inner Medication Board or ABIM exam is Rheumatoid Arthritis.


In contrast to the identical-sounding ailment osteoarthritis (which was very last week’s disorder profile), rheumatoid arthritis (RA) is a issue that can wreck havoc further than the joint spaces. It is an autoimmune, systemic, serious, and inflammatory course of action. For the reason that it is an autoimmune sickness, a particular antibody will generally be present (continue to be tuned for the prognosis part). Antibodies have the skill to disseminate by means of the bloodstream to unique tissues and organs thus, earning the affliction systemic. Despite the fact that lots of organs can be harmed by RA, the synovial joints are generally afflicted. Being inflammatory in character, RA can element morning stiffness lasting for a longer time than 60 minutes, with accompanying inflammation, and joints that can be pink, warm, and tender to touch. If a synovial fluid evaluation is completed, the white blood mobile depend from the synovial fluid will be in the inflammatory variety of 5000-50,000 WBC/uL.

Despite the fact that no known induce exists for RA, quite a few industry experts consider that antigens cause an inflammatory reaction in vulnerable men and women. Using tobacco can enhance probabilities of building RA. The most effective recognized genetic mechanism for the enhancement of RA is the existence of HLA-DRB1 *0401 or HLA-DRB1 *0404. When genetically prone men and women have a putative antigen, the synovial macrophages act as antigen presenting cells via HLA-DR to activate T cells. Due to the fact RA is mostly a T mobile mediated situation, it is extremely unusual to see RA in HIV individuals whose T cells can be depleted. B cells release autoantibodies to the putative antigen, secrete professional-inflammatory cytokines, and can also act as antigen presenting cells. Although many cytokines are introduced or included the pathogenesis of RA, tumor necrosis variable alpha (TNF-alpha) is the most notorious and critical cytokine that initiates and perpetuates the inflammatory cascade in RA. Consequently, TNF-alpha inhibitors participate in a key purpose in the administration of this issue.

Diagnosis AND Clinical Features

As you get ready for the ABIM test, it is critical to fully grasp how a diagnosis of Rheumatoid Arthritis is built.

The prognosis of RA is equally scientific and primarily based on laboratory results. It is a serious, symmetrical, poly-articular, systemic ailment. 4 or much more of the pursuing diagnostic standards are essential for the diagnosis of rheumatoid arthritis:

DIP joint and the lower again are usually not involved with rheumatoid arthritis. The presence of anti-cyclic citrullinated peptide (anti-CCP) antibodies in the blood is pretty distinct (90-95%) for rheumatoid arthritis consequently, the existence of this antibody enhances the chance that an person has rheumatoid arthritis. Energetic ailment from the synovium can distribute and bring about added-articular manifestations.

These excess-articular manifestations can influence the heart resulting in constrictive pericarditis or myocarditis.

With lung involvement, pleural effusions, hypersensitivity pneumonitis, or interstitial fibrosis can create. When pleural effusion occurs due to the fact of rheumatoid arthritis, the effusion will be an exudative effusion with glucose concentrations ordinarily significantly less than 30 mg/dl from the effusion.

Individuals can build anemia of long-term sickness. With anemia of chronic disease, we can see regular to reduced iron stages, diminished TIBC level, and enhanced ferritin level.

Ulceration of the fingers and toes can come about secondary to vascular involvement, major to necrosis.

Foot drop or wrist drop can happen for the reason that of neuropathy. Patients can also develop carpal tunnel or tarsal tunnel syndrome from RA.

Eye involvement can direct to scleritis or episcleritis.

Pores and skin involvement will result in the most prevalent further-articular manifestation to take place: rheumatoid nodules.

If renal involvement takes place, it is generally at the late levels of RA. Patients can develop amyloid nephropathy or nephrotic syndrome. When rheumatoid arthritis influences C1-C2 degree of the cervical spine, it can guide to atlanto-odontoid subluxation. This subluxation can compress the vertebrobasilar artery system, which qualified prospects to syncopal indicators. With compression of the cervical spinal wire, there can be each motor and sensory compromise. If the lesion is either a lot less than 5 mm or the patient is asymptomatic, treatment method is typically not needed. On the other hand, if the lesion is both increased than or equal to 8 mm or the particular person has signs and symptoms, surgical decompression is necessary for cure.

Inadequate prognostic components for rheumatoid arthritis can greatest be recognized by dividing into 3 groups: joint involvement, lab results, and further-articular manifestations. With joint involvement, progressive synovitis (worsening inflammation or swelling) or joint space loss/erosions on x-ray suggest inadequate prognostic components. Lab findings of elevated rheumatoid factor, amplified ESR (indicating irritation), and existence of HLA-DR4 suggest weak prognostic variables. At last, one particular excess-articular manifestation that predicts poor prognostic factor is also the most common further-articular manifestation of RA as described above: rheumatoid nodules. An additional more-articular manifestation that predicts poor prognostic aspect is ulceration of fingers and toes thanks to vasculitis.


Management of disorders and ailments is a vital element of the Inner Medicine Board (ABIM) exam.

Management of RA is generally obtained by way of drugs. With moderate RA, remedy generally can be initiated with NSAIDS, sulfasalazine, or the anti-malarrial medicine hydroxychloroquine. When NSAIDS are utilised for administration of RA, they must be taken with meals and/or with proton pump inhibitors to reduce belly ulcers or gastritis from happening. Persons who have allergy symptoms to sulfa must not be presented sulfasalazine. People who are remaining addressed with hydroxychloroquine for RA really should bear recurrent eye exams as this medicine can induce macular injury, especailly with renal dysfunction.

If patient’s symptoms are not controlled with the above prescription drugs, then more therapy is warranted. Reasonable to significant rheumatoid arthritis can be managed with methotrexate, leflunomide, or steroids. When methotrexate is made use of for reasonable to critical RA, CBC and liver operate exams need to be monitored each six-eight months to detect early signals of anemia or hepatotoxicity. Also, methotrexate administration really should be accompanied by folic acid to prevent folate deficiency. Hypersensitivity pneumonitis and/or pulmonary fibrosis may final result from methotrexate use.

Leflunomide is also utilised to handle moderate to extreme RA. Leflunomide is teratogenic and aspect consequences contain myelosuppression, hepatotoxicity, rash, diarrhea, and alopecia.

Steroids are utilized to command the swelling connected with RA but must be avoided very long time period because of a negative side-influence profile, which includes hyperglycemia, hypertension, osteoporosis, and Cushing syndrome.

When these drugs do not control the discomfort involved with RA, then we bring out the “major guns” to assist manage RA. As TNF-alpha is a main professional-inflammatory cytokine associated in the pathogenesis of RA. As a result, TNF-alpha inhibitors can now be applied to command quite critical indications of RA. Just before initiating cure with TNF-alpha inhibitors, a PPD test wants to be done to make sure that a patient does not have pre-existing tuberculosis. Some of the most common TNF-alpha inhibitors that are applied are etanercept, infliximab, or adalimumab. If a person TNF-alpha inhibitor is not controlling RA symptoms, it really should be switched to another TNF-alpha inhibitor, which will normally assistance manage the signs or symptoms. Two or far more TNF-alpha inhibitors need to In no way be used concurrently as this mixture can compromise the essential inflammatory reaction to fight off infections.