Rheumatology & Haematology — MCQs
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A 56-year-old man presents with sudden onset severe breathlessness 6 days following a right total knee replacement. CT pulmonary angiogram confirms bilateral pulmonary emboli. He has no previous history of venous thromboembolism. He weighs 82kg with normal renal function (eGFR 78 mL/min/1.73m²). He was receiving prophylactic low molecular weight heparin postoperatively. What is the most appropriate initial anticoagulation management?
A 29-year-old woman presents with fatigue and pallor. She has menorrhagia and no other medical history. Blood tests reveal: Hb 87 g/L, MCV 71 fL, ferritin 8 mcg/L, serum iron 6 micromol/L (normal 10-30), transferrin saturation 12% (normal 20-50%), total iron-binding capacity (TIBC) 82 micromol/L (normal 45-70). She is commenced on oral ferrous sulfate 200mg three times daily. When should her full blood count be rechecked to assess treatment response?
A 38-year-old woman with no significant past medical history presents with bilateral hand and wrist pain for 5 months. Examination reveals synovitis of the metacarpophalangeal joints bilaterally and both wrists. Blood tests show: CRP 34 mg/L, ESR 42 mm/hr, rheumatoid factor negative, anti-CCP antibodies negative. Hand X-rays show soft tissue swelling only with no erosions. What is the most appropriate classification of her condition?
A 64-year-old woman presents to the emergency department with severe pain and swelling of her right first metatarsophalangeal joint. She has a history of chronic kidney disease stage 3b (eGFR 42 mL/min/1.73m²) and hypertension treated with ramipril and bendroflumethiazide. Joint aspiration reveals negatively birefringent crystals. Her serum urate is 0.52 mmol/L. What is the most appropriate immediate management?
A 51-year-old woman with early rheumatoid arthritis has been on methotrexate 20mg weekly for 8 months with good disease control (DAS28 score 2.4). She now presents with progressive painless swelling of her left elbow over 3 weeks, with no history of trauma. The joint is non-tender with a large effusion but no warmth or erythema. Her inflammatory markers are normal. What pathological process best explains this presentation?
A 47-year-old man presents with a 3-month history of progressive fatigue and exertional dyspnoea. He has a history of Crohn's disease managed with azathioprine. Blood tests reveal: Hb 94 g/L, MCV 108 fL, WCC 3.2 × 10⁹/L, platelets 145 × 10⁹/L, reticulocyte count 45 × 10⁹/L. Blood film shows hypersegmented neutrophils. What is the most likely underlying mechanism for his anaemia?
A 34-year-old woman with newly diagnosed seropositive rheumatoid arthritis is started on methotrexate. She asks about the monitoring requirements for this medication. Which of the following represents the correct initial monitoring schedule for methotrexate therapy?
A 66-year-old man is investigated for macrocytic anaemia. Blood tests show: Hb 89 g/L, MCV 118 fL, WCC 4.2 × 10⁹/L, platelets 156 × 10⁹/L, reticulocytes 18 × 10⁹/L, serum B12 95 ng/L (normal 200-900), serum folate 18 μg/L (normal 4-20), bilirubin 42 μmol/L (unconjugated), LDH 890 U/L. Blood film shows macrocytes, polychromasia, and spherocytes. What is the most likely diagnosis?
A 44-year-old woman with psoriatic arthritis affecting her hands and feet has had inadequate response to methotrexate and leflunomide. She develops new-onset blurred vision and eye pain. Ophthalmology diagnoses acute anterior uveitis. What is the most appropriate next step in managing her arthritis?
A 52-year-old woman diagnosed with immune thrombocytopenia (ITP) 18 months ago has been managed with intermittent corticosteroids. Her platelet count has gradually declined to 25 × 10⁹/L despite prednisolone 40mg daily for 3 weeks. She has easy bruising but no active bleeding. She has had her spleen previously removed following trauma 15 years ago. What is the most appropriate next treatment option?
Rheumatology & Haematology UK Medical PG Practice Questions and MCQs
Question 51: A 56-year-old man presents with sudden onset severe breathlessness 6 days following a right total knee replacement. CT pulmonary angiogram confirms bilateral pulmonary emboli. He has no previous history of venous thromboembolism. He weighs 82kg with normal renal function (eGFR 78 mL/min/1.73m²). He was receiving prophylactic low molecular weight heparin postoperatively. What is the most appropriate initial anticoagulation management?
- A. Commence rivaroxaban 15mg twice daily for 3 weeks, then 20mg once daily
- B. Commence apixaban 10mg twice daily for 7 days, then 5mg twice daily (Correct Answer)
- C. Commence treatment-dose low molecular weight heparin with warfarin overlap, target INR 2-3
- D. Commence dabigatran 150mg twice daily immediately
- E. Commence unfractionated heparin infusion with monitoring of APTT ratio
Explanation: ***Commence apixaban 10mg twice daily for 7 days, then 5mg twice daily***- **Apixaban** is a recommended first-line direct oral anticoagulant (DOAC) for acute pulmonary embolism (PE), particularly for **provoked PE** like post-surgical cases, allowing for oral monotherapy from the outset.- The correct loading dose for acute PE in patients with normal renal function is **10mg twice daily for 7 days**, followed by the maintenance dose of **5mg twice daily**.*Commence rivaroxaban 15mg twice daily for 3 weeks, then 20mg once daily*- While **rivaroxaban** is also a first-line DOAC for PE, its recommended loading regimen involves **15mg twice daily for 21 days**, which differs from apixaban's shorter 7-day loading period.- This patient's clinical situation and current guidelines favor the rapid initiation and established efficacy of apixaban's 7-day loading phase in many protocols.*Commence treatment-dose low molecular weight heparin with warfarin overlap, target INR 2-3*- The combination of **low molecular weight heparin (LMWH)** and **warfarin** is an older standard of care that requires an initial parenteral agent and then careful INR monitoring to achieve therapeutic levels.- Current guidelines typically favor **DOACs** over Vitamin K antagonists (like warfarin) for most VTE patients due to their better safety profile (e.g., lower bleeding risk) and greater convenience.*Commence dabigatran 150mg twice daily immediately*- **Dabigatran** is a DOAC, but it is not approved for immediate initiation in acute VTE; it requires a **5-10 day lead-in period of parenteral anticoagulation** (e.g., LMWH) before oral administration.- Starting dabigatran immediately would leave the patient inadequately anticoagulated during the critical acute phase of the pulmonary embolism.*Commence unfractionated heparin infusion with monitoring of APTT ratio*- **Unfractionated heparin (UFH) infusion** is typically reserved for specific high-risk scenarios, such as patients with **severe renal impairment** (eGFR <15-30 mL/min), hemodynamically unstable PE, or when a rapid reversal might be necessary for intervention.- This patient has normal renal function (eGFR 78 mL/min) and is not described as hemodynamically unstable, making the complexity of UFH with **APTT monitoring** unnecessary.
Question 52: A 29-year-old woman presents with fatigue and pallor. She has menorrhagia and no other medical history. Blood tests reveal: Hb 87 g/L, MCV 71 fL, ferritin 8 mcg/L, serum iron 6 micromol/L (normal 10-30), transferrin saturation 12% (normal 20-50%), total iron-binding capacity (TIBC) 82 micromol/L (normal 45-70). She is commenced on oral ferrous sulfate 200mg three times daily. When should her full blood count be rechecked to assess treatment response?
- A. After 1 week to assess for reticulocytosis
- B. After 2-4 weeks to assess for rise in haemoglobin (Correct Answer)
- C. After 3 months when haemoglobin normalisation is expected
- D. After 6 months to assess for repletion of iron stores
- E. After 1 month, but only if symptoms persist
Explanation: ***After 2-4 weeks to assess for rise in haemoglobin*** - In the management of **iron deficiency anaemia**, a follow-up **full blood count (FBC)** is typically performed within **2-4 weeks** to confirm an adequate response, defined as a rise in **haemoglobin (Hb)** of approximately **20 g/L**. - This early check is crucial to verify **treatment compliance**, confirm adequate **gastrointestinal absorption**, and ensure the initial diagnosis was correct. *After 1 week to assess for reticulocytosis* - While **reticulocytosis** peaks around **7-10 days** after starting iron therapy, it is not the standard clinical parameter used to monitor response in primary care. - A **Full Blood Count** at this stage is too early to see a significant, clinical change in the **haemoglobin concentration**. *After 3 months when haemoglobin normalisation is expected* - Waiting **3 months** for the first check is inappropriate because it delays the detection of **treatment failure** or ongoing **occult blood loss**. - Although iron stores may take this long to replenish, the **initial response** must be verified much sooner to ensure the patient is on the right track. *After 6 months to assess for repletion of iron stores* - **Iron stores** (measured by **ferritin**) are typically assessed **3-6 months** after the Hb has normalized, not as the primary timing for the first FBC follow-up. - Monitoring at this late stage would miss the opportunity to address **non-compliance** or **malabsorption** issues early in the treatment course. *After 1 month, but only if symptoms persist* - Follow-up testing is mandatory for **all patients** treated for iron deficiency to ensure the **haemoglobin** reaches the target range, regardless of symptom resolution. - Many patients may feel better before their **iron stores** are adequate, making clinical symptoms an unreliable guide for treatment monitoring.
Question 53: A 38-year-old woman with no significant past medical history presents with bilateral hand and wrist pain for 5 months. Examination reveals synovitis of the metacarpophalangeal joints bilaterally and both wrists. Blood tests show: CRP 34 mg/L, ESR 42 mm/hr, rheumatoid factor negative, anti-CCP antibodies negative. Hand X-rays show soft tissue swelling only with no erosions. What is the most appropriate classification of her condition?
- A. Seronegative rheumatoid arthritis requiring disease-modifying therapy (Correct Answer)
- B. Undifferentiated inflammatory arthritis requiring monitoring and symptomatic management
- C. Psoriatic arthritis requiring assessment for psoriasis
- D. Early rheumatoid arthritis not meeting ACR/EULAR criteria, continue observation
- E. Probable viral arthritis likely to resolve spontaneously
Explanation: ***Seronegative rheumatoid arthritis requiring disease-modifying therapy*** - The patient meets the **ACR/EULAR 2010 classification criteria** for RA (score of 7 points: 10 joints = 5, duration >6 weeks = 1, and elevated CRP/ESR = 1). - Approximately **20-30% of RA cases** are seronegative for RF and anti-CCP; prompt treatment with **DMARDs** like methotrexate is essential to prevent erosions. *Undifferentiated inflammatory arthritis requiring monitoring and symptomatic management* - This diagnosis is reserved for patients who do not meet the full **classification criteria** for a specific inflammatory disease. - Since this patient scores over 6 points on the **RA criteria**, she is formalised as having RA rather than an undifferentiated condition. *Psoriatic arthritis requiring assessment for psoriasis* - While **psoriatic arthritis** can present as a polyarthritis, the symmetric involvement of **MCP joints** and wrists is more classic for rheumatoid arthritis. - There is no mention of **dactylitis**, nail changes, or relevant family history to tilt the diagnosis toward the **CASPAR criteria** for PsA. *Early rheumatoid arthritis not meeting ACR/EULAR criteria, continue observation* - This patient already meets the **ACR/EULAR criteria** (score ≥6), so observation alone would delay necessary **DMARD therapy**. - Delaying treatment in early RA increases the risk of irreversible **joint destruction** and functional impairment. *Probable viral arthritis likely to resolve spontaneously* - **Viral arthritis** (e.g., Parvovirus B19) typically resolves within **6 weeks**, whereas this patient has persistent symptoms for 5 months. - The presence of significantly elevated **CRP and ESR** over a long duration is highly suggestive of a chronic inflammatory process rather than a transient viral infection.
Question 54: A 64-year-old woman presents to the emergency department with severe pain and swelling of her right first metatarsophalangeal joint. She has a history of chronic kidney disease stage 3b (eGFR 42 mL/min/1.73m²) and hypertension treated with ramipril and bendroflumethiazide. Joint aspiration reveals negatively birefringent crystals. Her serum urate is 0.52 mmol/L. What is the most appropriate immediate management?
- A. Commence allopurinol 100mg daily with NSAIDs for acute inflammation
- B. Commence colchicine 500 micrograms four times daily until symptoms resolve
- C. Commence prednisolone 30mg daily for 5-7 days with proton pump inhibitor cover (Correct Answer)
- D. Commence febuxostat 80mg daily with colchicine prophylaxis
- E. Commence naproxen 500mg twice daily for 7-10 days with proton pump inhibitor
Explanation: ***Commence prednisolone 30mg daily for 5-7 days with proton pump inhibitor cover*** - Oral **corticosteroids** are the first-line treatment for acute gout when both **NSAIDs** and **colchicine** are contraindicated or poorly tolerated. - This patient has **CKD stage 3b**, making steroids the safest choice to avoid **renal toxicity** or colchicine accumulation. *Commence allopurinol 100mg daily with NSAIDs for acute inflammation* - **Urate-lowering therapy (ULT)** like allopurinol should not be initiated during an **acute attack** as rapid changes in urate levels can exacerbate symptoms. - **NSAIDs** are contraindicated in patients with significant **chronic kidney disease** due to the risk of acute-on-chronic renal failure. *Commence colchicine 500 micrograms four times daily until symptoms resolve* - A dose of 500mcg four times daily is considered **excessive** and exceeds modern safety recommendations for acute gout management. - In **renal impairment**, colchicine must be dose-reduced (typically to BD) to prevent **toxicity** affecting the gastrointestinal and neuromuscular systems. *Commence febuxostat 80mg daily with colchicine prophylaxis* - Similar to allopurinol, **febuxostat** is a ULT and must be delayed until 2-4 weeks after the **acute inflammation** has fully resolved. - Starting ULT during a flare can **prolong the attack** by causing further mobilization of urate crystals from tissue stores. *Commence naproxen 500mg twice daily for 7-10 days with proton pump inhibitor* - **NSAIDs** are generally avoided in patients with an **eGFR <60** and are strictly contraindicated when the eGFR is below 30-45. - Naproxen can cause **prostaglandin inhibition**, leading to afferent arteriolar vasoconstriction and a further decline in **renal function**.
Question 55: A 51-year-old woman with early rheumatoid arthritis has been on methotrexate 20mg weekly for 8 months with good disease control (DAS28 score 2.4). She now presents with progressive painless swelling of her left elbow over 3 weeks, with no history of trauma. The joint is non-tender with a large effusion but no warmth or erythema. Her inflammatory markers are normal. What pathological process best explains this presentation?
- A. Septic arthritis with low-grade infection requiring urgent aspiration and antibiotics
- B. Acute flare of rheumatoid arthritis indicating treatment failure
- C. Olecranon bursitis secondary to repetitive trauma
- D. Rheumatoid nodulosis with extra-articular disease manifestation
- E. Synovial hypertrophy and effusion despite systemic disease control, representing structural rather than inflammatory disease (Correct Answer)
Explanation: ***Synovial hypertrophy and effusion despite systemic disease control, representing structural rather than inflammatory disease***- The patient's **DAS28 score of 2.4** indicates **clinical remission** or low disease activity, and **normal inflammatory markers** (ESR/CRP) suggest a lack of systemic inflammation.- In **rheumatoid arthritis**, even with good systemic control, a single joint can develop **persistent synovial hypertrophy** and **effusion** due to chronic structural changes and past damage, which may not resolve despite a quiet inflammatory state.*Septic arthritis with low-grade infection requiring urgent aspiration and antibiotics*- While **immunosuppression** (methotrexate) increases infection risk, the absence of **pain, warmth, erythema**, and **normal inflammatory markers** makes septic arthritis highly unlikely.- Septic arthritis typically presents with a **hot, swollen, painful joint**, often with **systemic symptoms** and elevated inflammatory markers, even in low-grade cases.*Acute flare of rheumatoid arthritis indicating treatment failure*- An **acute rheumatoid arthritis flare** would typically involve a **worsening of systemic symptoms**, an increase in the **DAS28 score**, elevated **inflammatory markers**, and often involve multiple joints, not an isolated, painless swelling.- The patient's **good disease control** (DAS28 2.4) and **normal inflammatory markers** directly contradict an acute inflammatory flare.*Olecranon bursitis secondary to repetitive trauma*- **Olecranon bursitis** presents as swelling **posterior** to the elbow, directly over the olecranon process, and is often painful with direct pressure.- This patient describes a **large effusion** of the joint itself, implying intra-articular pathology, rather than a superficial bursal swelling, and denies **trauma**.*Rheumatoid nodulosis with extra-articular disease manifestation*- **Rheumatoid nodulosis** involves the development of **firm, non-tender subcutaneous nodules**, usually over pressure points (e.g., elbows, fingers), which are solid lesions.- The presentation of a **painless, progressive swelling** with a **large effusion** describes a fluid-filled joint rather than a solid nodule.
Question 56: A 47-year-old man presents with a 3-month history of progressive fatigue and exertional dyspnoea. He has a history of Crohn's disease managed with azathioprine. Blood tests reveal: Hb 94 g/L, MCV 108 fL, WCC 3.2 × 10⁹/L, platelets 145 × 10⁹/L, reticulocyte count 45 × 10⁹/L. Blood film shows hypersegmented neutrophils. What is the most likely underlying mechanism for his anaemia?
- A. Chronic inflammation causing impaired iron utilisation and reduced erythropoietin response
- B. Azathioprine-induced bone marrow suppression affecting all cell lineages
- C. Folate deficiency secondary to impaired absorption in active Crohn's disease
- D. Terminal ileal disease causing vitamin B12 malabsorption (Correct Answer)
- E. Haemolysis secondary to azathioprine toxicity with inadequate bone marrow compensation
Explanation: ***Terminal ileal disease causing vitamin B12 malabsorption*** - This patient demonstrates **megaloblastic anaemia** characterized by a high **MCV (108 fL)** and the distinctive presence of **hypersegmented neutrophils** on the blood film. - **Crohn's disease** frequently affects the **terminal ileum**, which is the primary site for the absorption of the **Vitamin B12-intrinsic factor complex**, leading directly to this deficiency. *Chronic inflammation causing impaired iron utilisation and reduced erythropoietin response* - This describes **anaemia of chronic disease**, which typically presents as a **normocytic** or sometimes mildly microcytic anaemia, not macrocytic. - This mechanism would not explain the presence of **hypersegmented neutrophils**, which are a specific morphological hallmark of impaired DNA synthesis. *Azathioprine-induced bone marrow suppression affecting all cell lineages* - While **Azathioprine** can cause **pancytopenia** (low WBC, RBC, and platelets) and sometimes macrocytosis, it does not typically cause **hypersegmented neutrophils**. - The specific finding of **hypersegmented neutrophils** strongly points towards a **megaloblastic** process, which is primarily a nutritional deficiency, rather than direct cytotoxic bone marrow suppression. *Folate deficiency secondary to impaired absorption in active Crohn's disease* - **Folate** is primarily absorbed in the **jejunum**, and while deficiency can occur in Crohn's, it is less commonly associated with Crohn's than B12 deficiency due to terminal ileal involvement. - Both B12 and folate deficiency cause megaloblastic anaemia, but **terminal ileal disease** in Crohn's is classically linked to **B12 malabsorption**. *Haemolysis secondary to azathioprine toxicity with inadequate bone marrow compensation* - **Haemolysis** typically results in an **elevated reticulocyte count** as the bone marrow tries to compensate for increased red cell destruction. - This patient has a **low reticulocyte count (45 × 10⁹/L)** and **hypersegmented neutrophils**, which are inconsistent with a primary haemolytic process.
Question 57: A 34-year-old woman with newly diagnosed seropositive rheumatoid arthritis is started on methotrexate. She asks about the monitoring requirements for this medication. Which of the following represents the correct initial monitoring schedule for methotrexate therapy?
- A. Full blood count and liver function tests weekly for 6 weeks, then monthly for 3 months, then every 3 months
- B. Full blood count and liver function tests fortnightly for 6 weeks, then monthly for 3 months, then every 3 months (Correct Answer)
- C. Full blood count and renal function tests weekly for 4 weeks, then monthly thereafter
- D. Full blood count, liver function tests and renal function tests monthly for 6 months, then every 3 months
- E. Full blood count and liver function tests monthly throughout treatment
Explanation: ***Full blood count and liver function tests fortnightly for 6 weeks, then monthly for 3 months, then every 3 months*** - According to **BSR and NICE guidelines**, initial monitoring for methotrexate involves **Full Blood Count (FBC)** and **Liver Function Tests (LFTs)** every 2 weeks (**fortnightly**) for the first 6 weeks. - This rigorous schedule is crucial for early detection of potentially serious side effects such as **bone marrow suppression** (e.g., leukopenia, thrombocytopenia) and **hepatotoxicity** (elevated transaminases). *Full blood count and liver function tests weekly for 6 weeks, then monthly for 3 months, then every 3 months* - **Weekly monitoring** is generally considered more frequent than necessary for standard initial methotrexate therapy in most patients, which can lead to increased patient burden without significantly enhanced safety. - Current guidelines, such as those from **NICE or BSR**, typically recommend a **fortnightly** monitoring schedule for the initial 6-week period rather than weekly. *Full blood count and renal function tests weekly for 4 weeks, then monthly thereafter* - This option critically **omits liver function tests (LFTs)**, which are an essential component of methotrexate monitoring due to the drug's well-known potential for causing **hepatotoxicity**. - While **renal function tests (RFTs)** are important as methotrexate is renally cleared, they are typically monitored as part of baseline assessment and then less frequently than FBC/LFTs unless specific risk factors exist. *Full blood count, liver function tests and renal function tests monthly for 6 months, then every 3 months* - **Monthly monitoring** from the very beginning of methotrexate therapy is insufficient for the initial, high-risk period when adverse effects are most likely to manifest. - Established guidelines require more frequent testing, specifically **fortnightly**, during the first 6 weeks to ensure patient safety during dose initiation and escalation. *Full blood count and liver function tests monthly throughout treatment* - This schedule fails to incorporate the critical **fortnightly monitoring** phase mandated during the initial 6 weeks of methotrexate therapy, which is essential to identify acute toxicities. - While monitoring intervals can be extended once a patient is stable on the medication, a fixed monthly schedule throughout treatment does not align with the standard safety protocols for initiation.
Question 58: A 66-year-old man is investigated for macrocytic anaemia. Blood tests show: Hb 89 g/L, MCV 118 fL, WCC 4.2 × 10⁹/L, platelets 156 × 10⁹/L, reticulocytes 18 × 10⁹/L, serum B12 95 ng/L (normal 200-900), serum folate 18 μg/L (normal 4-20), bilirubin 42 μmol/L (unconjugated), LDH 890 U/L. Blood film shows macrocytes, polychromasia, and spherocytes. What is the most likely diagnosis?
- A. Pernicious anaemia with ineffective erythropoiesis
- B. Autoimmune haemolytic anaemia with reticulocytosis causing macrocytosis (Correct Answer)
- C. Myelodysplastic syndrome with associated haemolysis
- D. Combined B12 deficiency and hereditary spherocytosis
- E. Hypersplenism secondary to portal hypertension
Explanation: ***Autoimmune haemolytic anaemia with reticulocytosis causing macrocytosis*** - The presence of **spherocytes**, **unconjugated hyperbilirubinaemia**, and markedly elevated **LDH** are classic indicators of **extravascular haemolysis**. - Since **reticulocytes** are larger than mature red blood cells (high MCV), a robust regenerative response to haemolysis often manifests as **macrocytosis**. *Pernicious anaemia with ineffective erythropoiesis* - While B12 deficiency causes high LDH and bilirubin due to **intramedullary haemolysis**, it is typically associated with **hypersegmented neutrophils**, not **spherocytes**. - The low B12 here might be deceptive or secondary, as the **blood film morphology** (spherocytes) strongly points toward an immune-mediated destructive process. *Myelodysplastic syndrome with associated haemolysis* - **Myelodysplastic syndrome (MDS)** usually presents with **pancytopenia** and dysplastic features rather than isolated haemolytic markers and spherocytes. - While MDS can cause a high MCV, it does not explain the acute **unconjugated hyperbilirubinaemia** and high LDH seen in this patient's profile. *Combined B12 deficiency and hereditary spherocytosis* - **Hereditary spherocytosis** usually presents much earlier in life with a family history and **splenomegaly**, rather than a new-onset macrocytic anaemia in a 66-year-old. - A low B12 level in the presence of spherocytes is more likely a concurrent autoimmune finding (Evans syndrome or associated AIHA) rather than a genetic membrane defect. *Hypersplenism secondary to portal hypertension* - **Hypersplenism** typically leads to **pancytopenia** due to increased sequestration, not a targeted destruction that produces **spherocytes**. - This patient's biochemical markers (very high LDH and bilirubin) are more characteristic of **active haemolysis** than simple splenic sequestration.
Question 59: A 44-year-old woman with psoriatic arthritis affecting her hands and feet has had inadequate response to methotrexate and leflunomide. She develops new-onset blurred vision and eye pain. Ophthalmology diagnoses acute anterior uveitis. What is the most appropriate next step in managing her arthritis?
- A. Add sulfasalazine to her current DMARD therapy
- B. Switch to a TNF inhibitor, preferably a monoclonal antibody such as adalimumab (Correct Answer)
- C. Add hydroxychloroquine with close ophthalmology monitoring
- D. Start apremilast as first-line biologic for psoriatic arthritis
- E. Switch to IL-17 inhibitor such as secukinumab
Explanation: ***Switch to a TNF inhibitor, preferably a monoclonal antibody such as adalimumab***- In patients with **psoriatic arthritis** failing conventional **DMARDs** who develop **acute anterior uveitis**, monoclonal TNF antibodies like **adalimumab** or **infliximab** are the preferred treatment.- These agents are significantly more effective than etanercept at treating and preventing recurrences of **extra-articular manifestations** like uveitis.*Add sulfasalazine to her current DMARD therapy*- **Sulfasalazine** has only modest efficacy in peripheral joint disease and is generally insufficient for patients who have already failed multiple **conventional DMARDs**.- It provides limited protection against **uveitis flare-ups** compared to biologics in the setting of refractory disease.*Add hydroxychloroquine with close ophthalmology monitoring*- **Hydroxychloroquine** is generally avoided or used with caution in psoriatic patients as it can potentially cause a **psoriasis flare** or exacerbate skin symptoms.- It does not have a therapeutic role in the management of **acute anterior uveitis**, which requires more potent systemic or topical immunosuppression.*Start apremilast as first-line biologic for psoriatic arthritis*- **Apremilast** is a **PDE4 inhibitor**, not a biologic, and typically demonstrates lower efficacy in joint disease compared to **TNF inhibitors**.- It has no established role or clinical evidence for the management or prevention of **uveitis**.*Switch to IL-17 inhibitor such as secukinumab*- While **IL-17 inhibitors** are highly effective for skin and joint symptoms, they have been associated with a lack of efficacy or potential worsening of **uveitis** episodes.- **TNF inhibitors** remain the gold standard when **uveitis** is a prominent clinical feature of the spondyloarthropathy.
Question 60: A 52-year-old woman diagnosed with immune thrombocytopenia (ITP) 18 months ago has been managed with intermittent corticosteroids. Her platelet count has gradually declined to 25 × 10⁹/L despite prednisolone 40mg daily for 3 weeks. She has easy bruising but no active bleeding. She has had her spleen previously removed following trauma 15 years ago. What is the most appropriate next treatment option?
- A. Thrombopoietin receptor agonist such as eltrombopag or romiplostim (Correct Answer)
- B. Rituximab infusion therapy
- C. Intravenous immunoglobulin therapy
- D. Azathioprine as steroid-sparing agent
- E. Mycophenolate mofetil
Explanation: ***Thrombopoietin receptor agonist such as eltrombopag or romiplostim*** - This patient has **chronic ITP** (>12 months) that is **refractory to corticosteroids** and has already undergone a **splenectomy**, making **TPO-RAs** the preferred next-line treatment. - **Eltrombopag** and **romiplostim** stimulate the **bone marrow** to increase platelet production, with high response rates (~70-80%) in patients who have failed other therapies. *Rituximab infusion therapy* - **Rituximab** (anti-CD20) is a second-line option, but it has **lower sustained response rates** (approximately 40-60%) compared to **TPO-RAs**. - While it targets B-cell mediated destruction, the duration of response is often shorter than that provided by **thrombopoietin receptor agonists**. *Intravenous immunoglobulin therapy* - **IVIg** is primarily used for **rapid elevation** of platelet counts in emergency settings with **active bleeding** or prior to surgery. - Its effects are **temporary and short-lived**, typically lasting only a few weeks, which makes it unsuitable for the **long-term management** of chronic refractory ITP. *Azathioprine as steroid-sparing agent* - **Azathioprine** is a slow-acting immunosuppressant that can take **several months** to achieve a clinical effect. - It has a lower efficacy profile and a higher risk of **side effects** like bone marrow suppression compared to the targeted action of **TPO-RAs**. *Mycophenolate mofetil* - **Mycophenolate mofetil** (MMM) is an alternative second-line immunosuppressant that is sometimes used in chronic ITP management. - However, current guidelines generally favor **TPO-RAs** in post-splenectomy patients due to their superior **platelet-stimulating potency** and established efficacy data.
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