Novel Therapies in Osteoarthritis — MCQs
Which drug used in treatment of rheumatoid arthritis acts by inhibition of T-cell proliferation?
All are true about osteoarthritis, except
Primary osteoarthritis affects all except:
Which is the drug of choice in Paget's disease?
Systemic factor which is responsible for bone remodeling :
Mrs. Katson, a 64-year-old obese woman with bilateral knee osteoarthritis, describes pain on most days and limiting pain at least 2 days per week. She has tried activity modification (walking less) without success. All of the following therapies have been shown to be efficacious EXCEPT:
Arrange the following cellular events of inflammation in the correct sequence: 1. Rolling 2. Cytokine-mediated integrin activation 3. Adhesion 4. Migration
Which of the following joints are commonly affected in osteoarthritis? I. First metatarsophalangeal joint II. Proximal interphalangeal joint III. Ankle joint IV. 5th and 6th cervical vertebrae joint Select the correct answer using the code given below :
Osteoarthritis is typically not seen in which of the following joints?
Frieberg's disease involves which of the following?
Novel Therapies in Osteoarthritis Indian Medical PG Practice Questions and MCQs
Question 1: Which drug used in treatment of rheumatoid arthritis acts by inhibition of T-cell proliferation?
- A. Anakinra
- B. Leflunomide (Correct Answer)
- C. Infliximab
- D. Etanercept
Explanation: ***Leflunomide*** - **Leflunomide** is a **pyrimidine synthesis inhibitor** that works by inhibiting the enzyme **dihydroorotate dehydrogenase** [1]. - This inhibition leads to a decrease in **de novo pyrimidine synthesis**, which is essential for **T-cell proliferation**, thereby exerting its immunomodulatory effects in **rheumatoid arthritis** [1], [2]. *Anakinra* - **Anakinra** is an **interleukin-1 receptor antagonist** that blocks the activity of **IL-1**, a pro-inflammatory cytokine. - It does not primarily act by inhibiting **T-cell proliferation**, but rather by modulating the inflammatory response. *Infliximab* - **Infliximab** is a **monoclonal antibody** that targets and neutralizes **tumor necrosis factor-alpha (TNF-α)**, a key cytokine in inflammation. - Its mechanism of action is primarily related to blocking **TNF-α activity**, not directly inhibiting **T-cell proliferation**. *Etanercept* - **Etanercept** is a **fusion protein** that acts as a **TNF-α receptor decoy**, binding to **TNF-α** and preventing it from interacting with its natural receptors. - Similar to infliximab, its main action is to inhibit **TNF-α**, rather than directly inhibiting **T-cell proliferation**.
Question 2: All are true about osteoarthritis, except
- A. Quadriceps atrophy (Correct Answer)
- B. MCP is spared
- C. Glucosamines are beneficial
- D. Loose bodies in the ankle joint
Explanation: ***Quadriceps atrophy*** - While muscle weakness can occur in osteoarthritis due to pain and disuse, **quadriceps atrophy** is not a universal or defining characteristic of the disease itself, nor is it consistently observed as a primary feature. - The statement implies that quadriceps atrophy is *always* true about osteoarthritis, which is incorrect as it's a potential consequence but not inherently present in all cases or a direct pathological feature. *MCP is spared* - The **metacarpophalangeal (MCP) joints** are typically spared in osteoarthritis, unlike in rheumatoid arthritis. - Osteoarthritis predominantly affects the **distal interphalangeal (DIP)** and **proximal interphalangeal (PIP)** joints of the hands, as well as the **carpometacarpal (CMC) joint of the thumb**. *Glucosamines are beneficial* - **Glucosamine sulfate** is a commonly used supplement in osteoarthritis, with some studies suggesting it may provide modest pain relief and slow cartilage degradation in certain patients. - While its efficacy is debated and not universally accepted as curative, many patients report subjective benefit, and it is considered a complementary therapy. *Loose bodies in the ankle joint* - **Loose bodies**, also known as joint mice, are fragments of cartilage or bone that can break off and float within the joint space. - These are a recognized complication of osteoarthritis, particularly in weight-bearing joints like the **ankle**, and can cause locking or catching sensations.
Question 3: Primary osteoarthritis affects all except:
- A. Metacarpophalangeal joint (Correct Answer)
- B. Hip Joint
- C. Distal interphalangeal joint
- D. Knee joint
Explanation: ***Metacarpophalangeal joint*** - The **metacarpophalangeal (MCP) joints** are typically spared in primary osteoarthritis, making their involvement a less common presentation. - Involvement of the MCP joints, particularly with significant inflammation, might suggest other conditions like **rheumatoid arthritis**. *Hip Joint* - The hip joint is a common site for primary osteoarthritis due to its **weight-bearing function** and susceptibility to mechanical stress. - Patients often experience **groin pain** and reduced range of motion, particularly internal rotation. *Distal interphalangeal joint* - The **distal interphalangeal (DIP) joints** are very commonly affected in primary osteoarthritis, leading to the formation of **Heberden's nodes**. - These nodes are bony enlargements that indicate osteophyte formation and cartilage loss. *Knee joint* - The knee joint is another frequently affected large joint in primary osteoarthritis, often presenting with **pain**, **stiffness**, and **crepitus**. - Its **weight-bearing role** contributes significantly to its vulnerability to degenerative changes.
Question 4: Which is the drug of choice in Paget's disease?
- A. Allopurinol
- B. Calcitonin
- C. Alendronate (Correct Answer)
- D. Steroids
Explanation: ***Alendronate*** - **Bisphosphonates** like alendronate are the **first-line treatment** for Paget's disease due to their potent antiresorptive inhibitory effect on **osteoclasts**. - They reduce bone turnover, bone pain, and the risk of complications such as **fractures** and **bone deformities**. *Allopurinol* - This drug is used to treat **gout** by inhibiting **xanthine oxidase** and reducing uric acid production. - It has no role in the management of Paget's disease, which is a disorder of abnormal bone remodeling. *Calcitonin* - Historically, calcitonin was used for Paget's disease, but its effectiveness is **less than bisphosphonates** and it is associated with more side effects. - It is now generally reserved for patients who **cannot tolerate bisphosphonates** or have severe renal impairment. *Steroids* - **Corticosteroids** are potent anti-inflammatory and immunosuppressive agents. - They are primarily used in conditions like **autoimmune disorders** or severe inflammatory diseases, and are **not indicated** for the treatment of Paget's disease.
Question 5: Systemic factor which is responsible for bone remodeling :
- A. Cytokines (e.g., IL-1, IL-6)
- B. Prostaglandin E2 (PGE2)
- C. PTH (Correct Answer)
- D. Transforming Growth Factor-beta (TGF-β)
Explanation: ***PTH*** - **Parathyroid hormone (PTH)** is a major systemic regulator of bone remodeling, primarily influencing **calcium and phosphate homeostasis**. - High levels of PTH, particularly prolonged or continuous elevation, stimulate **osteoclasts** directly or indirectly, leading to increased **bone resorption**. *Cytokines (e.g., IL-1, IL-6)* - These are primarily **local humoral factors** that regulate bone remodeling in a specific area, often in response to inflammation or injury. - While they can influence bone metabolism, their action is generally more localized, unlike the widespread systemic effects of PTH. *Prostaglandin E2 (PGE2)* - **PGE2** is another **local mediator** involved in bone remodeling, produced by various cells including osteoblasts and osteocytes. - It plays a role in both bone formation and resorption depending on concentration and context, but its effects are typically paracrine or autocrine rather than systemic endocrine control. *Transforming Growth Factor-beta (TGF-β)* - **TGF-β** is a potent **local growth factor** stored within the bone matrix and released during bone resorption. - It regulates proliferation and differentiation of osteoblasts and osteoclasts, primarily acting as a local regulator of bone formation and repair rather than a systemic hormone.
Question 6: Mrs. Katson, a 64-year-old obese woman with bilateral knee osteoarthritis, describes pain on most days and limiting pain at least 2 days per week. She has tried activity modification (walking less) without success. All of the following therapies have been shown to be efficacious EXCEPT:
- A. Glucosamine-chondroitin (Correct Answer)
- B. Glucocorticoid steroid intra-articular injections
- C. Acetaminophen
- D. Total joint arthroplasty
Explanation: ***Glucosamine-chondroitin*** - While widely used and marketed for osteoarthritis, numerous **large, well-designed clinical trials** have consistently shown that **glucosamine-chondroitin supplements** are **not more effective than placebo** in alleviating pain or improving function in osteoarthritis. - The American College of Rheumatology (ACR) and other major medical organizations **do not recommend** its use due to a lack of evidence of efficacy. *Glucocorticoid steroid intra-articular injections* - **Intra-articular corticosteroid injections** provide **short-term pain relief** [1] and reduce inflammation in patients with osteoarthritis, especially during flares. - They are a commonly used and effective treatment for **symptomatic knee osteoarthritis** [1], although repeated injections have potential risks and may not alter long-term disease progression. *Acetaminophen* - **Acetaminophen (paracetamol)** is often recommended as a **first-line oral analgesic** for mild to moderate pain in osteoarthritis due to its relatively favorable side effect profile compared to NSAIDs for long-term use. - It works by **inhibiting prostaglandin synthesis** primarily in the central nervous system, reducing pain perception. *Total joint arthroplasty* - **Total joint arthroplasty (TJA)**, particularly **total knee replacement**, is a highly effective surgical treatment for patients with **severe, end-stage osteoarthritis** [1] who have failed conservative therapies. - It significantly **reduces pain and improves functional outcomes** [1] and quality of life for the vast majority of patients.
Question 7: Arrange the following cellular events of inflammation in the correct sequence: 1. Rolling 2. Cytokine-mediated integrin activation 3. Adhesion 4. Migration
- A. 1,2,3,4 (Correct Answer)
- B. 3,4,1,2
- C. 2,1,4,3
- D. 4,1,2,3
Explanation: ***1,2,3,4*** - The correct sequence of cellular events for leukocyte recruitment during inflammation begins with **rolling** [1], followed by **cytokine-mediated integrin activation** [2], then firm **adhesion** to the endothelium [1], and finally **migration** (diapedesis) into the tissues [3]. - This step-by-step process ensures effective targeting of leukocytes to the site of injury or infection [1]. *3,4,1,2* - This sequence is incorrect as **adhesion** cannot occur before **rolling**, and **migration** is the final step after adhesion, not an early one. - **Cytokine-mediated integrin activation** must precede firm adhesion [1]. *2,1,4,3* - This order is incorrect because **rolling** (1) is the initial interaction that allows leukocytes to slow down on the endothelium [2], and it occurs before **cytokine-mediated integrin activation** (2) which strengthens the binding. - **Migration** (4) is also misplaced as it should be the last step after firm adhesion (3). *4,1,2,3* - This sequence is incorrect as **migration** (4) is the last step in the process, not the first. - **Rolling** (1) initiates the process by transiently interacting with endothelial cells, followed by activation and adhesion. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Inflammation and Repair, p. 87. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Migration in the tissues toward a chemotactic stimulus, pp. 86-87. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Inflammation and Repair, pp. 87-89.
Question 8: Which of the following joints are commonly affected in osteoarthritis? I. First metatarsophalangeal joint II. Proximal interphalangeal joint III. Ankle joint IV. 5th and 6th cervical vertebrae joint Select the correct answer using the code given below :
- A. I, II, III and IV
- B. I and II only
- C. III and IV only
- D. I, II and IV only (Correct Answer)
Explanation: ***I, II and IV only*** - **Osteoarthritis** commonly affects joints that bear significant weight or are subject to repetitive stress, such as the **first metatarsophalangeal joint**, **proximal interphalangeal joints**, and the **cervical spine**. - Degenerative changes in these joints, including cartilage loss and **osteophyte formation**, are characteristic findings in osteoarthritis. *I, II, III and IV* - While the first metatarsophalangeal joint, proximal interphalangeal joints, and cervical vertebrae are commonly affected, the **ankle joint** is typically spared in primary osteoarthritis. - Ankle involvement in osteoarthritis is usually secondary to **trauma** or inflammatory arthritis rather than primary degenerative change. *III and IV only* - This option misses the common involvement of the **first metatarsophalangeal joint** and **proximal interphalangeal joints**, which are frequently affected in osteoarthritis. - The ankle joint is less commonly involved in primary osteoarthritis compared to other load-bearing joints like the **knee** and **hip**. *I and II only* - This option incorrectly omits the **cervical vertebrae**, which are a very common site for osteoarthritis, often leading to neck pain and **radiculopathy**. - While the metatarsophalangeal and proximal interphalangeal joints are correct, the exclusion of the cervical spine makes this option incomplete.
Question 9: Osteoarthritis is typically not seen in which of the following joints?
- A. Ankle joints (Correct Answer)
- B. Knee joints
- C. Hip joints
- D. First metacarpophalangeal joint
Explanation: **Explanation:** Primary **Osteoarthritis (OA)** is a degenerative joint disease that characteristically affects weight-bearing joints and specific small joints of the hand. **Why Ankle Joints are the Correct Answer:** The **ankle (talocrural) joint** is remarkably resistant to primary osteoarthritis. This is due to the unique properties of ankle cartilage, which is thinner but has higher proteoglycan density and lower water content compared to the knee or hip, making it more resistant to compressive forces. While the ankle is a weight-bearing joint, OA here is almost always **secondary** (e.g., following intra-articular fractures, ligamentous instability, or rheumatoid arthritis) rather than primary/idiopathic. **Analysis of Incorrect Options:** * **Knee Joints:** The most common site for primary OA. It typically involves the medial compartment due to the mechanical axis of the lower limb. * **Hip Joints:** A major weight-bearing joint frequently affected by primary OA, often leading to total hip arthroplasty in elderly patients. * **First Metacarpophalangeal (MCP) Joint:** While OA commonly affects the **First Carpometacarpal (CMC)** joint (base of the thumb) and the **Distal Interphalangeal (DIP)** joints (Heberden’s nodes), the first MCP joint is also a recognized site for degenerative changes due to the high stresses of pinch and grip. **High-Yield Clinical Pearls for NEET-PG:** * **Nodal Distribution:** OA typically affects DIP joints (Heberden’s nodes) and PIP joints (Bouchard’s nodes). **MCP joints (except the 1st) and wrists are usually spared** (if involved, think Rheumatoid Arthritis). * **Radiological Hallmarks:** Joint space narrowing (asymmetrical), subchondral sclerosis, subchondral cysts, and osteophyte formation. * **Kellgren-Lawrence Grading:** The standard radiological classification system for OA severity. * **Eburnation:** A pathological feature where subchondral bone becomes polished and ivory-like due to complete loss of overlying cartilage.
Question 10: Frieberg's disease involves which of the following?
- A. Tibial tuberosity
- B. Calcaneal tuberosity
- C. 2nd metatarsal (Correct Answer)
- D. 5th metatarsal
Explanation: **Explanation:** **Freiberg’s disease** is an **osteochondrosis** (avascular necrosis) affecting the head of the metatarsal. It most commonly involves the **2nd metatarsal head (Option C)** because it is the longest and most rigid metatarsal, making it susceptible to repetitive microtrauma and excessive loading during the toe-off phase of gait. It is typically seen in adolescent girls and presents with pain, swelling, and limited range of motion at the metatarsophalangeal joint. **Analysis of Incorrect Options:** * **Option A (Tibial tuberosity):** This is the site for **Osgood-Schlatter disease**, a traction apophysitis caused by repetitive strain from the patellar tendon. * **Option B (Calcaneal tuberosity):** This is the site for **Sever’s disease**, an apophysitis of the calcaneus common in active children. * **Option D (5th metatarsal):** The base of the 5th metatarsal is the site for **Iselin’s disease** (apophysitis). While the 5th metatarsal is also prone to Jones fractures, it is not the classic site for Freiberg’s. **High-Yield Clinical Pearls for NEET-PG:** * **Demographics:** Most common in adolescent females (ratio ~3:1). * **Radiology:** Early stages show flattening and sclerosis of the metatarsal head; late stages show joint space narrowing and secondary osteoarthritis. * **Hierarchy of Involvement:** 2nd Metatarsal (most common) > 3rd Metatarsal > 4th Metatarsal. * **Management:** Conservative (activity modification, orthotics) is first-line; surgery (debridement or osteotomy) is reserved for refractory cases.
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