Clinical case 1

Anne, a 25-year old woman, has just been diagnosed as having RA, based on approximately 8 weeks of symmetrical
arthritis in several MCP, PIP and MTP joints bilaterally and morning stiffness of 90 minutes. Her symptoms started 3
months ago (with joint pain and stiffness). She has received no therapy for her symptoms, except occasional NSAIDs.
She is IgM rheumatoid factor negative.

1. What type of assessments would you do before start of therapy? Select the one best option
a. None
False. It is important to have baseline assessment before start of therapy, to establish a baseline disease status, from
which the disease course during therapy can be compared
b. Patient reported outcomes (e.g questionnaires)
False. A sufficient baseline examination includes patient reported outcomes, but more is needed.
c. Clinical examination
False. A sufficient baseline examination includes clinical examination, but more is needed.
d. Biochemical examination
False. A sufficient baseline examination includes biochemical examinations, but more is needed.
e. 2+3
False. A sufficient baseline examination includes this, but more is needed.
f. 2+4
False. A sufficient baseline examination includes this, but more is needed.
g. 3+4
False. A sufficient baseline examination includes this, but more is needed.
h. 2+3+4
True. A sufficient baseline examination includes patient reported outcomes, and clinical and biochemical examinations.

2. Which types of patient reported outcomes would you ask the patient to do, in order to assess her disease
activity and function? Select the one best option
a. Health Assessment Questionnaire
False. This should be done, but also a patient's global assessment.
b. SF-36
False. SF36 is used for assessment of Quality of Life
c. Patient's global assessment
False. This should be done, but also the Health Assessment Questionnaire.
d. None
False. Health Assessment Questionnaire and patient's global assessment should be filled in, in order to assess the
patient's disease activity and function, while SF36 is used for assessment of Quality of Life.
e. 1+2

False. Health Assessment Questionnaire and patient's global assessment should be filled in, in order to assess the
patient's disease activity and function, while SF36 is used for assessment of Quality of Life.
f. 1+3
True. Health Assessment Questionnaire and patient's global assessment should be filled in, in order to assess the
patient's disease activity and function.
g. 2+3
False. Health Assessment Questionnaire and patient's global assessment should be filled in, in order to assess the
patient's disease activity and function, while SF36 is used for assessment of Quality of Life.
h. All
False. Health Assessment Questionnaire and patient's global assessment should be filled in, in order to assess the
patient's disease activity and function, while SF36 is used for assessment of Quality of Life.

3. What types of clinical assessments would you perform? Select the one best option
a. Examination of the joints (swollen and tender joint count)
False. This should be done, but also a physician's global assessment.
b. Physician's global assessment
False. This should be done, but also an examination of the joints.
c. Examination of spinal mobility
False. Generally not. Examination of spinal mobility is not part of the standard examination program before treatment
initiation in RA.
d. None
False. Physician's global assessment and an examination of the joints should be performed before treatment initiation,
while examination of spinal mobility is not part of the standard examination program before treatment initiation in RA.
e. 1 and 2
True. Physician's global assessment and an examination of the joints should be performed before treatment initiation.
f. 1 and 3
False. Physician's global assessment and an examination of the joints should be performed before treatment initiation,
while examination of spinal mobility is not part of the standard examination program before treatment initiation in RA.
g. 2 and 3
False. Physician's global assessment and an examination of the joints should be performed before treatment initiation,
while examination of spinal mobility is not part of the standard examination program before treatment initiation in RA.
h. 1 and 2 and 3
False. Physician's global assessment and an examination of the joints should be performed before treatment initiation,
while examination of spinal mobility is not part of the standard examination program before treatment initiation in RA.
The patient has 6 swollen and 7 tender joints, a serum-CRP of 15 mg/l and patient global health (VAS) of 48 mm,
corresponding to a DAS28-CRP of 4.8.
4. How would you characterize the patient's disease activity? Select the one best option
a. Remission
False. a DAS28 of 4.8 corresponds to a moderate disease activity (range: DAS28 > 3.2 and 5.1).

b. Low disease activity

False. a DAS28 of 4.8 corresponds to a moderate disease activity (range: DAS28 > 3.2 and 5.1).
c. Moderate disease activity
True. A DAS28 of 4.8 corresponds to a moderate disease activity (range: DAS28 > 3.2 and 5.1).
d. High disease activity
False. a DAS28 of 4.8 corresponds to a moderate disease activity (range: DAS28 > 3.2 and 5.1).
As you may remember the patient had only received on-demand NSAID therapy until now. The patient has not had
conventional radiography (or any other imaging) of her joints.
5. What would you do? Select the one best option from the list:
a. Order radiographs of hands, wrists and forefeet, await the result and start therapy in case of radiographic erosions
False. Radiographs of hands, wrists and forefeet are important at baseline in order to assess future erosive progression,
but when the patients has RA adequate therapy should be started as soon as possible. Thus, treatment initiation is not
dependent on presence or absence of radiographic erosions and should not await the result of radiography.
b. Order radiographs of hands, wrists and forefeet and start therapy immediately.
True. Radiographs of hands, wrists and forefeet are important as baseline to assess future progression, but when the
patients has RA adequate therapy should be started as soon as possible, Treatment initiation is not dependent on
presence or absence of radiographic erosions, and should not await the result of radiography.
c. Order radiographs of hands and knees and start therapy immediately.
False. Baseline radiographic assessment should include assessment of hands, wrists and forefeet. It is correct that
treatment should be started immediately and not await the result of radiography.
d. Start therapy but not order any radiographs.
False. Radiographs of hands, wrists and forefeet are important at baseline in order to be able to assess future
progression. It is correct that treatment should be started immediately and not await the result of radiography.
You decided to start methotrexate therapy. The conventional radiography result now becomes available
6. On which pathologies will you get information from the conventional radiograph? Select the two best options
from the list:
a. Synovitis
False. radiographs do not visualize this feature.
b. Bone erosion
True.
c. Tenosynovitis
False. radiographs do not visualize this feature.
d. Joint inflammation
False. radiographs do not visualize this feature.
e. Joint space narrowing
True.
Radiographs of hands, wrists and forefeet were normal. Six months later the patient has improved. The patient now has
2 swollen and 1 tender joints, a serum-CRP of 8 mg/l and patient global health of 12 mm, corresponding to a DAS28 of
2.9. You are considering imaging investigations that would help you establish the risk of progressive erosive disease.

7. Which investigations would give you additional information on the risk of progressive erosive disease?
Select the one best option from the list
a. Repeated conventional radiography of hands, wrists and forefeet
False. Development of bone erosions on radiographs during the 6 months of MTX therapy is a poor prognostic sign and
would increase the risk of further erosive progression. However, this is not the only correct option.
b. MRI of unilateral wrist and MCP-joints
False. MRI synovitis and bone marrow odema have predictive value regarding future erosive progression, so MRI of
unilateral wrist and MCP-joints would provide prognostic information. However, this is not the only correct option.
c. Ultrasonography of hands and wrists
False. Ultrasonography does allow visualization of synovitis and other signs of disease activity in RA; however, the
predictive value of US findings for future erosive progression in early RA is controversial. If on the one hand
time-integrated values of US-power Doppler correlate well with the amount of joint damage progression, a single time
assessment has not been consistently associated with radiographic outcomes.
d. None
False. Both MRI and repeated radiography could provide prognostic information
e. 1+2
True. Both development of bone erosions on radiographs during the 6 months of MTX therapy and MRI synovitis and
bone marrow odema are poor prognostic signs and would increase the risk of further erosive progression.
f. 1+3
False. Both development of bone erosions on radiographs during the 6 months of MTX therapy and MRI synovitis and
bone marrow odema are poor prognostic signs and would increase the risk of further erosive progression. Even though
ultrasonography does allow visualization of synovitis and other signs of disease activity in RA; however, the predictive
value of US findings for future erosive progression in early RA is controversial. If on the one hand time-integrated values
of US-power doppler correlate well with the amount of joint damage progression, a single time assessment has not been
consistently associated with radiographic outcomes.
g. 2+3
False. Both development of bone erosions on radiographs during the 6 months of MTX therapy and MRI synovitis and
bone marrow odema are poor prognostic signs and would increase the risk of further erosive progression. Even though
ultrasonography does allow visualization of synovitis and other signs of disease activity in RA; however, the predictive
value of US findings for future erosive progression in early RA is controversial. If on the one hand time-integrated values
of US-power doppler correlate well with the amount of joint damage progression, a single time assessment has not been
consistently associated with radiographic outcomes.
h. All
False. Both development of bone erosions on radiographs during the 6 months of MTX therapy and MRI synovitis and
bone marrow odema are poor prognostic signs and would increase the risk of further erosive progression. Even though
ultrasonography does allow visualization of synovitis and other signs of disease activity in RA; however, the predictive
value of US findings for future erosive progression in early RA is controversial. If on the one hand time-integrated values
of US-power doppler correlate well with the amount of joint damage progression, a single time assessment has not been
consistently associated with radiographic outcomes.
You see the same patient on a follow-up visit. She is now taking methotrexate 20mg/week. Her tender joint count is
zero, her swollen joint count is 2, her global assessment is 10mm, her CRP is 10 mg/l and your global assessment is
15mm. Her DAS28 score is 2.37.
8. Is this patient in clinical remission? Select the one best option from the list

a. Yes, according to the DAS28 cut-off

True. The DAS28 cut-off for clinical remission is 2.6 and her current DAS28 is 2.37.
b. Yes, according to the SDAI cut-off
False. Her SDAI value is 5.5 (0 TJC + 2 SJC + 1cm patient global assessment + 1mg/dl CRP + 1.5cm doctor global
assessment). An SDAI below or equal to 3.3 represents clinical remission.
c. Yes, according to the CDAI cut-off
False. Her SDAI value is 4.5 (0 TJC + 2 SJC + 1cm patient global assessment + 1.5cm doctor global assessment). A
CDAI below or equal to 2.8 represents clinical remission.
d. Yes, according to the Boolean definition of the ACR/EULAR remission criteria
False. According to the ACR/EULAR definition of remission the patient must satisfy all of the following: TJC1,
SJC1, patient global assessment 1cm and CRP1mg/dl. The patient does not satisfy the SJC and CRP
criteria.
e. No, the patient is not in remission according to any criteria
False. The patient is in remission according to the DAS28.
f. 1+2
False. The patient is only in remission according to the DAS28, but not SDAI, CDAI or ACR/EULAR criteria.
g. 1+3
False. The patient is only in remission according to the DAS28, but not SDAI, CDAI or ACR/EULAR criteria.
h. 1+4
False. The patient is only in remission according to the DAS28, but not SDAI, CDAI or ACR/EULAR criteria.
i. 1+2+3+4
False. The patient is only in remission according to the DAS28, but not SDAI, CDAI or ACR/EULAR criteria.
Three years after the initial diagnosis, the patient is started on anti-TNF owed to persistent high disease activity
refractory to DMARD combination therapy. The DAS28 at start of treatment is 5.8. Her DAS28 after 3 months of
treatment is 3.8.
9. What is the EULAR response in this patient? Select the one best option from the list
a. The patient did not respond to therapy.
False. DAS28 improvement was 2 units; an improvement >1.2 units allows the classification of a patient as responder.
b. Good response.
False. Despite being a responder (improvement >1.2 units), the patient still has moderate disease activity (DAS28>3.2
and 5.1). In order to be a good responder a post-treatment DAS283.2 would be required.
c. Moderate response.
True. There is a DAS28 improvement >1.2 units and the post-treatment assessment reveals moderate disease activity
(DAS28>3.2 and 5.1), therefore the response is moderate. In order to be a good responder a post-treatment
DAS283.2 would be required.
Clinical case 2
Tom, a 32-year old accountant, is seeking your help for a second opinion. He has been diagnosed with AS 5 years ago.
He has used and is still using NSAIDs on a regular basis. He has read about a new treatment, an anti-TNF treatment,
but his rheumatologist says that he is not a good candidate for this treatment. He wants to hear your opinion.

1. What would you do? Select the best option

a. Agree with your colleague as this patient is too young for anti-TNF treatment
False. there is no age limit to start anti-TNF treatment
b. Agree with your colleague as this patient's disease duration is too short
False. there is no limit on disease duration with respect to start of anti-TNF treatment
c. Take a full history and clinical examination
True. Of course! First you need to get more information to judge the activity and severity of the disease
d. Ask for radiographs of the pelvis
False. this is only helpful after a full history and clinical examination if you doubt the diagnosis or suspect hip
involvement
He suffers from morning stiffness and awakens during the second half of the night. His pain is moderate and he is able
to perform his work without sick leave. He has more difficulty in bending forward to pick a pen from the ground
compared to one year ago. Overall there is not much change in his situation over the past 2 years.
2. What more information do you want from the history in order to choose the right treatment? Select the best
option
a. Does he have painful and/or swollen joints?
False. this is important to judge if he has possible involvement of peripheral joints
b. Does he suffer from uveitis?
False. this is important to judge if he has (active) extra-articular manifestations; also important to ask for are complaints
of inflammatory bowel disease and psoriasis
c. Does one of his relatives have AS?
False. for the start of treatment this is irrelevant; only relevant in making diagnosis
d. Nothing
False. this is important to judge if he has possible involvement of peripheral joints. this is important to judge if he has
(active) extra-articular manifestations; also important to ask for are complaints of inflammatory bowel disease and
psoriasis
e. 1 and 2
True. this is important to judge if he has possible involvement of peripheral joints. this is important to judge if he has
(active) extra-articular manifestations; also important to ask for are complaints of inflammatory bowel disease and
psoriasis.
f. 1 and 3
False. this is important to judge if he has possible involvement of peripheral joints. for the start of treatment this is
irrelevant; only relevant in making diagnosis.
g. 1 and 2 and 3
False. this is important to judge if he has possible involvement of peripheral joints. this is important to judge if he has
(active) extra-articular manifestations; also important to ask for are complaints of inflammatory bowel disease and
psoriasis. for the start of treatment this is irrelevant; only relevant in making diagnosis.
h. 2 and 3
False. this is important to judge if he has (active) extra-articular manifestations; also important to ask for are complaints
of inflammatory bowel disease and psoriasis. for the start of treatment this is irrelevant; only relevant in making

diagnosis.

3. What clinical examination(s) will you perform?

a. Examination of the joints
False. this is important to judge if he arthritis
b. Examination of hip movement
False. this is important to judge if he has hip involvement, which is a prognostically unfavourable sign
c. Examination of spinal mobility
False. this is important to judge how much the function of the spine is influenced by the disease
d. Nothing
False.
e. 1 and 2
False. this is important to judge if he arthritis. this is important to judge if he has hip involvement, which is a
prognostically unfavourable sign.
f. 1 and 3
False. this is important to judge if he arthritis. this is important to judge how much the function of the spine is influenced
by the disease.
g. 1 and 2 and 3
True. this is important to judge if he arthritis. this is important to judge if he has hip involvement, which is a prognostically
unfavourable sign. this is important to judge how much the function of the spine is influenced by the disease.
h. 2 and 3
False. this is important to judge if he has hip involvement, which is a prognostically unfavourable sign. this is important
to judge how much the function of the spine is influenced by the disease.
His hands are stiff in the morning. He never suffered from uveitis or complaints related to IBD or psoriasis. At physical
examination his spinal mobility is limited in all planes but there is a normal mobility of both hips. A few hand joints are
swollen.
4. Do you have sufficient information? Select the best option
a. Yes, he has active disease and needs anti-TNF treatment
False. You have just some idea but this is not quantified at all and not complete
b. Yes, his disease is not very active and he does not need anti-TNF treatment
False. This is very premature conclusion which might change with more information
c. No, I need additional information from history and clinical examination
False. You need to quantify the information from history and clinical examination
d. No, I need additional information from lab and/or imaging
False. Lab and imaging can support the information on activity and severity of the disease
e. No, I need additional information from history and clinical examination, and from lab and/or imaging
True. You need all this information to be fully informed

5. How do you want to quantify the information from his history? Select the 2 best options from the list:
a. DAS
False. This score is not validated for AS but for RA
b. BASDAI
True. This instrument gives an overall level of disease activity and incorporates information on pain, fatigue, and
morning stiffness
c. VAS patient global disease activity
False. This gives limited information if compared to BASDAI and is highly correlated with BASDAI
d. BASFI
True. Quantifies the level of functioning specifically in AS
e. HAQ
False. HAQ is not widely applied in AS; not wrong but BASFI is better
f. VAS morning stiffness
False. This is part of the BASDAI
g. VAS pain
False. Various aspects of pain already included in BASDAI

6. How do you want to quantify the information from his physical examination? Select the 3 best options from
the list:
a. Number of 28 swollen joints
False. Swollen joint count is important to judge the amount of arthritis but the 28 joint count is too limited for the
assessment of AS
b. Number of 44 swollen joints
True. This is the selected joint count by ASAS and includes joints frequently involved in AS, although DIP are not
included
c. Number of 28 tender joints
False. The number of tender joints is not included in the ASAS core set and is less useful as the number of swollen
joints
d. Ritchie articular index
False. The number of tender joints is not included in the ASAS core set and is less useful as the number of swollen
joints
e. Finger to floor distance
False. The finger to floor distance is not a good measure to assess spinal mobility as it is also influenced by other
factors, e.g. length of the hamstrings
f. Lateral lumbar flexion
True. The lateral lumbar flexion is a sensitive measure of spinal mobility. It is as informative as the entire BASMI.
Limitations in lateral lumbar flexion are a good indication that spinal mobility is compromised.
g. Modified Schober

True. The modified Schober is a specific test for involvement of the spine

7. What additional information do you want to obtain from the lab? Select the best option from the list:
a. ESR or CRP
True. Acute phase reactants are elevated in about 40-50% of the patients. Normal level of acute phase reactants does
not exclude active disease, but elevated acute phase reactant indicates active disease.
b. HLA-B27
False. HLA-B27 does not give any information on activity of the disease. Moreover, positivity for HLA-B27 does not
influence the start of anti-TNF treatment.
c. Creatinine
False. Creatinine does not give information on activity of the disease.
d. Haemoglobin
False. Hemoglobin gives only limited information on activity of the disease and this is already mostly captured by the
acute phase reactant
e. IgA
False. IgA has been described in older literature but it turned out not to be very helpful.
You obtained the following results: BASDAI 4.8, BASFI 3.8, ESR 8, 2 swollen joints (MCPs), Lateral lumbar flexion 18
cm (normal >20), modified Schober 4.5 cm (normal >5). You conclude that the disease is moderately active (BASDAI>4)
and has so far little impact on function of the spine and overall level of functioning. However, the patient has also two
joints with arthritis.
8. What is your decision? Select the best option
a. He has active disease and needs anti-TNF treatment
False. He has indeed some disease activity but it is not obvious that this is sufficient to start anti-TNF treatment
b. His disease is not very active and he does not need anti-TNF treatment
False. Your information is not complete and the patient could still have more inflammation than is obvious from the
present data. Patients with AS are often used to their pain and limitations and do not complain much.
c. I need additional information from imaging
True. Imaging could give the extra information needed to decide if treatment is indicated.

9. What imaging do you order? Select the best 2 options from the list:
a. Lateral radiographs of the entire spine
False. Lateral radiographs give the best view of syndesmophytes, severity of the disease. However, the thoracic spine is
difficult to interpret because of over-projection. Therefore, this segment of the spine is usually not taken unless the
indication is to look for vertebral fractures.
b. Lateral and AP radiographs of the entire spine
False. The AP adds only very little information to the lateral film.
c. Lateral radiographs of the cervical and lumbar spine
True. This is the best cost-effective choice: highest yield of information with the lowest radiation exposure.
These films are sufficient to apply the mSASSS score.

d. Lateral and AP radiographs of the cervical and lumbar spine

False. The AP adds only very little information to the lateral film.
e. MRI of the SI joints and spine
True. This is the preferred option to be fully informed about inflammation.
f. MRI of the spine
False. If there are limitations to the possibility of making an MRI, MRI of the spine only could be an alternative.
g. MRI of the SI joints
False. MRI of the SI joints only is too limited to judge the extension of inflammation. This is more useful in the process of
making a diagnosis.
The lateral radiographs of the cervical and lumbar spine show three syndesmophytes. The MRI of the spine and SI joints
shows inflammation almost throughout the entire spine but not in the SI joints. Together with the earlier findings
[BASDAI 4.8, BASFI 3.8, ESR 8, 2 swollen joints (MCPs), Lateral lumbar flexion 18 cm (normal >20), modified Schober
4.5 cm (normal >5)] you have to conclude about the next step.
10. What is your next step?
a. He has active disease and needs anti-TNF treatment
True. You have a full assessment of disease severity and activity: He has already syndesmophytes indicating that he
has a severe form of the disease. Moreover, the MRI indicates that there is widespread inflammation in the spine.
Together with the complaints from the patient starting anti-TNF treatment is justified.
b. His disease is not very active and he does not need anti-TNF treatment
False. Although the clinical signs are not very impressive the additional imaging information shows that there is active
disease.
c. I need additional information on activity and severity of the disease
False. Your information on the activity and severity of the disease is rather complete. Still you have to check for possible
contraindications for the start of the anti-TNF treatment, but you do this only after you have taken the decision that you
will start.