Rheumatoid arthritis: pharmacologic management MCQs With Answer

Rheumatoid arthritis: pharmacologic management MCQs With Answer

This set of multiple-choice questions is designed for M.Pharm students studying Pharmacotherapeutics I (MPP 102T) to deepen understanding of drug therapy in rheumatoid arthritis (RA). Questions focus on mechanisms of action, pharmacokinetics, recommended dosing regimens, safety monitoring, adverse effects, drug interactions, and therapeutic strategies including conventional synthetic DMARDs, biologics and targeted synthetic DMARDs. Clinical and laboratory monitoring, screening prior to biologic use, pregnancy considerations, and toxicity management are emphasized. Use these MCQs to test knowledge for exams and practical prescribing considerations, and to reinforce the rationale behind evidence-based, treat-to-target pharmacologic management of RA.

Q1. Which mechanism best explains low-dose methotrexate’s anti-inflammatory effect in rheumatoid arthritis?

• Inhibition of dihydrofolate reductase (DHFR) leading to decreased thymidylate synthesis
• Inhibition of AICAR transformylase causing accumulation of adenosine
• Direct inhibition of TNF-alpha production by synovial macrophages
• Blockade of IL-6 receptor signaling

Correct Answer: Inhibition of AICAR transformylase causing accumulation of adenosine

Q2. Which baseline screening is essential before initiating anti-TNF biologic therapy in a patient with RA?

• Serum uric acid and creatine kinase
• Tuberculosis screening (IGRA or PPD) and chest radiograph
• Serum vitamin D level and parathyroid hormone
• Brain MRI to rule out demyelinating disease

Correct Answer: Tuberculosis screening (IGRA or PPD) and chest radiograph

Q3. Which adverse effect is most specifically associated with hydroxychloroquine and requires ophthalmologic monitoring?

• Interstitial pneumonitis
• Ocular retinopathy
• Hepatotoxicity
• Agranulocytosis

Correct Answer: Ocular retinopathy

Q4. What is the recommended folic acid strategy when a patient is started on weekly methotrexate for RA?

• No folic acid supplementation is indicated
• Daily folic acid (1–5 mg/day) except on the MTX day or continuous daily dosing to reduce toxicity
• High-dose folinic acid (leucovorin) daily to neutralize MTX efficacy
• Folic acid 20 mg weekly together with methotrexate

Correct Answer: Daily folic acid (1–5 mg/day) except on the MTX day or continuous daily dosing to reduce toxicity

Q5. Which DMARD requires cholestyramine washout if rapid elimination is needed due to pregnancy planning or toxicity?

• Sulfasalazine
• Hydroxychloroquine
• Leflunomide
• Methotrexate

Correct Answer: Leflunomide

Q6. Which biologic agent depletes CD20-positive B cells and is indicated for seropositive RA refractory to TNF inhibitors?

• Abatacept
• Rituximab
• Tocilizumab
• Etanercept

Correct Answer: Rituximab

Q7. Which oral targeted synthetic DMARD inhibits Janus kinases (JAK) and is associated with increased risk of herpes zoster and thromboembolism?

• Tofacitinib
• Azathioprine
• Mycophenolate mofetil
• Cyclosporine

Correct Answer: Tofacitinib

Q8. Which laboratory parameter requires close monitoring during leflunomide therapy?

• Urine albumin-to-creatinine ratio
• Liver function tests (ALT/AST)
• Fasting glucose
• Thyroid-stimulating hormone (TSH)

Correct Answer: Liver function tests (ALT/AST)

Q9. Which DMARD is generally considered safe to continue during pregnancy with appropriate folate supplementation?

• Methotrexate
• Leflunomide
• Sulfasalazine
• Tofacitinib

Correct Answer: Sulfasalazine

Q10. Which statement best describes the onset of clinical effect when initiating conventional synthetic DMARD therapy in RA?

• Methotrexate and sulfasalazine typically produce maximal effects within 24–48 hours
• Most csDMARDs require weeks to months; methotrexate often shows benefit by 4–8 weeks and full effect by 3–6 months
• Biologic DMARDs and csDMARDs have identical onset times
• Hydroxychloroquine produces immediate analgesia within 1–3 days

Correct Answer: Most csDMARDs require weeks to months; methotrexate often shows benefit by 4–8 weeks and full effect by 3–6 months

Q11. Which of the following best characterizes abatacept’s mechanism of action?

• TNF-alpha receptor antagonism
• CTLA-4–Ig fusion protein that blocks CD28-mediated T-cell co-stimulation
• B-cell receptor tyrosine kinase inhibition
• IL-1 receptor blockade

Correct Answer: CTLA-4–Ig fusion protein that blocks CD28-mediated T-cell co-stimulation

Q12. Which is the most appropriate monitoring for a patient receiving long-term methotrexate therapy?

• Monthly chest X-ray and serum amylase
• Regular CBC, liver enzymes and renal function testing (eg, every 1–3 months after stabilization)
• Only baseline labs are required; no further monitoring
• Daily blood glucose monitoring

Correct Answer: Regular CBC, liver enzymes and renal function testing (eg, every 1–3 months after stabilization)

Q13. Which adverse event is a class-related concern for TNF inhibitors requiring vigilance?

• Acute pancreatitis
• Reactivation of latent tuberculosis
• Severe hyperkalemia
• Nephrotic syndrome

Correct Answer: Reactivation of latent tuberculosis

Q14. Which agent is an IL-6 receptor antagonist used in moderate-to-severe RA and can cause elevated lipid levels and neutropenia?

• Infliximab
• Tocilizumab
• Adalimumab
• Hydroxychloroquine

Correct Answer: Tocilizumab

Q15. When combining methotrexate with a biologic DMARD, what is a demonstrated clinical benefit?

• Increased immunogenicity of the biologic leading to loss of efficacy
• Reduced formation of anti-drug antibodies and improved clinical response for many biologics
• Complete elimination of infection risk
• Necessity to double the biologic dose to achieve effect

Correct Answer: Reduced formation of anti-drug antibodies and improved clinical response for many biologics

Q16. Which drug is most associated with pulmonary fibrosis as a rare but serious toxicity in RA patients?

• Hydroxychloroquine
• Methotrexate
• Ibuprofen
• Sulfasalazine

Correct Answer: Methotrexate

Q17. Which of the following is an appropriate pre-vaccination recommendation for a patient starting on biologic therapy?

• Administer live vaccines after biologic therapy is started
• Give indicated live vaccines at least 4 weeks before starting biologic therapy and inactivated vaccines ideally before or during therapy
• No vaccinations are recommended for RA patients
• Only administer intranasal live-attenuated influenza vaccine during biologic therapy

Correct Answer: Give indicated live vaccines at least 4 weeks before starting biologic therapy and inactivated vaccines ideally before or during therapy

Q18. Which combination is considered first-line initial pharmacologic strategy for most patients with newly diagnosed moderate-to-severe RA?

• Monotherapy with NSAID alone
• Early initiation of methotrexate (with folic acid) often combined with short-term glucocorticoids and treat-to-target adjustments
• Immediate use of two biologic DMARDs together
• Long-term opioid therapy as primary disease control

Correct Answer: Early initiation of methotrexate (with folic acid) often combined with short-term glucocorticoids and treat-to-target adjustments

Q19. Which drug interaction requires caution because it may increase methotrexate toxicity by reducing its renal clearance?

• Allopurinol
• Trimethoprim-sulfamethoxazole (TMP-SMX)
• Proton pump inhibitors (some agents) and certain NSAIDs can increase MTX levels; TMP-SMX also increases risk
• Vitamin C supplementation

Correct Answer: Proton pump inhibitors (some agents) and certain NSAIDs can increase MTX levels; TMP-SMX also increases risk

Q20. Which laboratory abnormality is characteristically monitored and may worsen after starting a JAK inhibitor such as tofacitinib?

• Severe hypokalemia
• Elevations in lipid parameters (LDL/HDL) and potential decreases in neutrophil count
• Marked hypercalcemia
• Persistent hyperbilirubinemia without enzyme elevation

Correct Answer: Elevations in lipid parameters (LDL/HDL) and potential decreases in neutrophil count

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