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1. Which of the following is not a common feature of rheumatoid arthritis (RA):

A. Chest pain B. Symmetric pain in the small peripheral joints C. Fatigue D. Morning stiffness

2. Which of the following laboratory tests would typically not be included to assist in the diagnosis of suspected RA:

A. Anticyclic citrullinated peptide (anti-CCP) antibody titer B. Erythrocyte sedimentation rate (ESR) C. Rheumatoid factor (RF) D. Creatine kinase (CK)

3. Which of the following is used as the anchor drug to which all other therapies are added, during RA treatment:

A. Methotrexate B. Rituximab C. Sulfasalazine D. Prednisone

4. Which type of adverse effect is the most common in patients receiving tumor necrosis factor (TNF)-alpha inhibitors?

A. Infections with typical and atypical organisms B. Rash C. Diarrhea D. Hypotension

5. Which of the following describes the most important feature of the current RA treatment paradigm:

A. Use of biologics B. Early, aggressive therapy with a disease modifying antirheumatic drug (DMARD) C. Watchful waiting D. Combination therapy

6. Which of the following best describes chronotherapy for those with RA:

A. Optimizing therapy to time zone and temperature B. Optimizing therapy to circadian rhythms C. Iterative increase in DMARDs to achieve remission D. Tapering, especially glucocorticoids (GCs), after remission is achieved

7. What is the most common biologic class used as a treatment for RA?

A. Selective costimulation modulators B. Interleukin (IL)-6 inhibitors C. IL-1 antagonists D. TNF inhibitors

8. Which of the following is NOT a goal of therapy for RA:

A. Control of pain and swelling B. Achieve remission C. Reverse bony erosions D. Prevent functional disability

9. Which of the following is NOT a poor prognostic factor of RA:

A. High titer of RF B. Extra-articular manifestations C. Morning stiffness for longer than 30 minutes D. High titer of anti-CCP antibody

10. Which of the following is a TNF inhibitor:

A. Anakinra B. Adalimumab C. Abatacept D. Azathioprine

11. RA is difficult to diagnose early because of all the following, EXCEPT:

A. It takes 2 years before bony erosions are detectable by X-ray B. RF is not always present C. RA is a heterogeneous disease D. There is no definitive test for RA

12. Which of the following is TRUE regarding the progression of RA:

A. RA always gets worse over time B. RA is now considered a curable disease C. RA is a waxing and waning chronic disease D. RA inevitably leads to joint destruction and disability

13. Pharmacists should review which of the following with RA patients:

A. Patient preferences for mode and frequency of administration B. Side effects and precautions C. Importance of adherence D. All of the above

14. What would be the most appropriate response to the following case:A woman, 49 years of age, who was diagnosed with RA 2 years ago took methotrexate for 6 months following her diagnosis, but discontinued treatment because of the fear of side effects. She is currently being managed with prednisone 15 mg PO daily but still has active inflammation in her hands and feet. Her family doctor has asked you for your opinion on the management of her RA.

A. Add a bisphosphonate and calcium to protect against GC-induced bone loss B. Increase the prednisone to 25 mg PO daily C. Counsel patient about the risks and benefits of DMARDs for the treatment of RA and suggest to re-initiate methotrexate or another DMARD (sulfasalazine or leflunomide) D. Recommend starting tocilizumab as soon as possible

15. In Medication Therapy Management (MTM), which one of the following is NOT one of the 5 core elements:

A. Personal medication record B. Fee for dispensing C. Medication action plan D. Documentation and follow-up

16. A man, 60 years of age, with RA visited your pharmacy for a MTM appointment. After discussing his other current medications, you asked how he was doing with his RA therapy. The patient explained that since his diagnosis, 3 years earlier, he had a very good response to methotrexate until this past year when he started experiencing severe pain, inflammation, and limited physical functioning. He visited his rheumatologist who ran extensive tests and ultimately prescribed a biologic (adalimumab) to be used in combination with methotrexate. The patient is concerned about the new medication. What do you do?

A. Give the patient a standard handout describing the potential side effects of biologics B. Acknowledge the patient's concerns and counsel on the benefits of tight control of inflammation and the importance of adherence C. Explain that the standard procedure is to initiate combination therapy with the addition of a second synthetic DMARD not a biologic and suggest the patient make a follow-up appointment to question the rheumatologist's strategy D. Refer the patient to the ACR website for concerns about his RA management strategy

17. A woman, aged 64 years, was diagnosed with RA 6 years ago, which has been managed by her general practitioner (GP). Her RA was initially treated with methotrexate and sulfasalazine, which brought the disease under control. She currently receives maintenance methotrexate/sulfasalazine. Periodically, she has flares of her disease. Recently she has had several flares and this has resulted in several spells of GC therapy, with adjunctive nonsteroidal anti-inflammatory drug (NSAID) and proton pump inhibitor (PPI), as well as increased doses of her maintenance DMARDs. You are concerned about the effects of long-term high-dose GC therapy. What is the best course of action?

A. Contact the prescribing GP to discuss the patient's RA management and concerns regarding GC therapy—suggest referral to a rheumatologist B. Do nothing and book patient for a 3-month follow-up C. Counsel patient to stop GC therapy immediately to avoid side effects D. Counsel patient to increase methotrexate to once daily until flare subsides

18. A local GP has contacted you regarding one of your regular patients with severe refractory RA that recently initiated tocilizumab while continuing methotrexate under the supervision of their rheumatologist. The GP is unfamiliar with this therapy and concerned about particular risks that he should be aware of in terms of managing his patient's general health. What is the best course of action?

A. Refer the physician to the American College of Rheumatology (ACR) Web site to learn about the potential side effects of biologics B. Counsel the physician that the rheumatologist is responsible for surveillance and follow-up C. Explain that tocilizumab increases the risk for infection, GI perforations, & neutropenia, as well as both elevated liver enzymes & cholesterol. Suggest that a CBC with differential, a liver function test, & blood lipid profiles D. Explain to the GP that biologics are generally safe

19. One of your regular patients begins filling prescriptions for prednisone and naproxen at your pharmacy. When you talk to her about these prescriptions, she indicates that she was diagnosed with RA 6 months ago and her family doctor is managing her. She says she has noticed a little improvement and she's happy with her therapy. What is the best course of action?

A. Counsel the patient to stop GC therapy immediately to avoid potential serious side effects B. Counsel the patient about the risks and benefits of GC therapy, suggest she make a follow-up appointment with her GP and schedule her for a 3-month follow-up with you C. Contact the prescribing physician and refer to clinical guidelines, stressing that RA is best managed with early, aggressive therapy with a DMARD D. Both answers B and C are correct