Prometric Exam Questions for Rheumatology Specialists 2026: 20 MCQs with Answers on Rheumatoid Arthritis, Lupus, Spondyloarthritis, Gout, Vasculitis, Osteoporosis and Biologic Safety

The specialist rheumatology paper (RHU5501 at DHA, and the equivalent SCFHS, QCHP and NHRA papers) is 100 to 150 single-best-answer questions in up to three hours with a pass mark of about 60%. Candidates with an MD, DM, MRCP with rheumatology experience or an Arab Board sit it after the authority confirms the specialist title. The paper is clinical: it wants the diagnosis from a pattern, the first-line drug, the monitoring that drug needs, and the emergency that must not be missed. This set covers the recurring themes. The licensing route is in the rheumatologist guide.

Inflammatory arthritis

Question 1

A 42-year-old woman has six weeks of symmetrical pain and swelling of the metacarpophalangeal and proximal interphalangeal joints with 90 minutes of morning stiffness. Anti-CCP is strongly positive and CRP is raised. The most appropriate first-line disease-modifying treatment is:

1. Long-term oral prednisolone alone
2. Methotrexate, with folic acid, bridging low-dose glucocorticoid if needed, and a treat-to-target review within 3 months
3. A TNF inhibitor as monotherapy
4. NSAIDs alone

Answer: B. Methotrexate is the anchor drug for rheumatoid arthritis; biologics are added when the target is not reached after conventional synthetic DMARDs.

Question 2

Before and during methotrexate therapy, the monitoring required includes:

1. No blood tests after the first month
2. Baseline full blood count, liver and renal function, hepatitis B and C serology and chest radiograph, then blood counts and liver function every 2 to 4 weeks initially and every 8 to 12 weeks once stable, with alcohol restriction and reliable contraception
3. Annual eye examination only
4. Monthly urate levels

Answer: B. Methotrexate is teratogenic and must be stopped at least three months before conception; co-prescribed trimethoprim is a dangerous interaction.

Question 3

Before starting a TNF inhibitor in a patient with rheumatoid arthritis, the essential screening is:

1. Thyroid function
2. Latent tuberculosis (interferon-gamma release assay or tuberculin test plus chest radiograph), hepatitis B and C serology, and HIV where indicated, with treatment of latent TB before the biologic
3. Urate level
4. Bone density

Answer: B. Reactivation of TB and hepatitis B are the major infective risks; TB screening is heavily tested in Gulf papers because of high-prevalence source countries.

Question 4

A 28-year-old man has three years of inflammatory low back pain with morning stiffness that improves with exercise, alternating buttock pain and a recent episode of acute anterior uveitis. He is HLA-B27 positive. The first-line pharmacological treatment is:

1. Methotrexate
2. Continuous or on-demand NSAIDs at full dose with an exercise programme, escalating to a TNF or IL-17 inhibitor if disease activity remains high after two NSAIDs
3. Oral glucocorticoids
4. Sulfasalazine for axial disease

Answer: B. Conventional DMARDs do not work for axial disease; sulfasalazine helps peripheral arthritis only.

Question 5

A patient with psoriasis develops dactylitis, enthesitis at the Achilles tendon, nail pitting and an asymmetrical oligoarthritis. Which feature most distinguishes psoriatic arthritis from rheumatoid arthritis?

1. Symmetrical small-joint involvement
2. Distal interphalangeal joint involvement, dactylitis, enthesitis, nail changes and a negative rheumatoid factor
3. Rheumatoid nodules
4. Positive anti-CCP

Answer: B. Radiographs may show the pencil-in-cup deformity and juxta-articular new bone formation.

Connective tissue disease

Question 6

A 25-year-old woman has a malar rash, oral ulcers, arthritis, lymphopenia and a positive ANA. Which antibody is most specific for systemic lupus erythematosus and correlates with disease activity, especially nephritis?

1. Anti-Ro
2. Anti-double-stranded DNA, alongside low complement levels
3. Rheumatoid factor
4. Anti-histone

Answer: B. Anti-Smith is also specific but does not track activity. Anti-histone suggests drug-induced lupus.

Question 7

Every patient with lupus should receive which baseline medication unless contraindicated?

1. Cyclophosphamide
2. Hydroxychloroquine, with a baseline retinal examination and annual screening after five years (earlier with risk factors), dosed at no more than 5 mg/kg actual body weight
3. High-dose prednisolone indefinitely
4. Methotrexate

Answer: B. Hydroxychloroquine reduces flares, thrombosis and mortality and is safe in pregnancy.

Question 8

A woman with lupus has had two late miscarriages and a deep vein thrombosis. Her lupus anticoagulant and anticardiolipin antibodies are persistently positive 12 weeks apart. In her next pregnancy she should receive:

1. Warfarin throughout pregnancy
2. Low-dose aspirin plus prophylactic or therapeutic low-molecular-weight heparin, depending on prior thrombosis, with specialist obstetric care
3. No treatment
4. A direct oral anticoagulant

Answer: B. Warfarin is teratogenic in the first trimester; direct oral anticoagulants are not recommended in antiphospholipid syndrome, especially with triple positivity.

Question 9

A 50-year-old woman has Raynaud's phenomenon, skin thickening of the fingers extending to the forearms, and new breathlessness. Her blood pressure is 190/110 mmHg with rising creatinine. The most appropriate treatment of the renal problem is:

1. High-dose glucocorticoids
2. An ACE inhibitor started promptly for scleroderma renal crisis, with careful avoidance of high-dose glucocorticoids, which are a risk factor
3. A calcium channel blocker alone
4. Dialysis as first treatment

Answer: B. Anti-RNA polymerase III antibodies predict renal crisis; anti-Scl-70 predicts interstitial lung disease.

Question 10

A patient with dry eyes, dry mouth, parotid swelling and anti-Ro and anti-La antibodies is at increased long-term risk of:

1. Osteosarcoma
2. B-cell non-Hodgkin lymphoma, particularly with persistent parotid enlargement, cryoglobulinaemia and low complement
3. Gout
4. Psoriasis

Answer: B. Sjögren's disease carries a 10- to 40-fold lymphoma risk; a mother with anti-Ro also needs fetal heart monitoring for congenital heart block.

Crystal arthritis and metabolic bone disease

Question 11

A 55-year-old man with chronic kidney disease (eGFR 35) has a third attack of gout this year and tophi on the elbows. Urate is 560 micromol/L. The best urate-lowering approach is:

1. Start allopurinol at 300 mg daily during the acute attack
2. Treat the acute attack, then start allopurinol at a low dose (50 to 100 mg daily) titrated upward to a urate target below 360 micromol/L (below 300 with tophi), with prophylactic low-dose colchicine or an alternative for the first 3 to 6 months
3. Avoid urate-lowering therapy because of renal disease
4. Febuxostat at maximum dose immediately

Answer: B. Allopurinol hypersensitivity is more likely with high starting doses and renal impairment; HLA-B*5801 screening is recommended in high-risk populations. Current guidance supports starting urate-lowering therapy during the attack in some patients, but low-dose initiation and titration is the tested principle.

Question 12

An elderly woman has an acute hot swollen knee. Aspirate shows positively birefringent rhomboid crystals. Radiograph shows chondrocalcinosis. The diagnosis is:

1. Gout
2. Acute calcium pyrophosphate crystal arthritis (pseudogout); hyperparathyroidism, haemochromatosis and hypomagnesaemia should be considered in younger patients
3. Septic arthritis
4. Reactive arthritis

Answer: B. Urate crystals are needle-shaped and negatively birefringent.

Question 13

A 68-year-old postmenopausal woman has a vertebral fragility fracture and a T-score of −2.8 at the hip. After confirming adequate calcium and vitamin D, the first-line treatment is usually:

1. Calcium alone
2. An oral bisphosphonate such as alendronate, or intravenous zoledronic acid if oral therapy is not tolerated, with dental review and a treatment-duration review at five years
3. Teriparatide for everyone
4. No treatment, because one fracture is expected

Answer: B. Vitamin D deficiency is extremely common in Gulf populations and should be corrected before bisphosphonates. Anabolic therapy is considered for very high fracture risk.

Vasculitis and emergencies

Question 14

A 72-year-old woman has two weeks of new temporal headache, jaw claudication and a transient episode of visual loss. ESR is 95 mm/h. The immediate action is:

1. Arrange a temporal artery biopsy and await the result before treatment
2. Start high-dose glucocorticoids immediately (intravenous methylprednisolone with visual symptoms, otherwise prednisolone 40 to 60 mg), then confirm with ultrasound or biopsy within days
3. Aspirin alone
4. Refer to ophthalmology routinely

Answer: B. Giant cell arteritis threatens permanent blindness; biopsy remains positive for days to weeks after steroids start. Tocilizumab is a steroid-sparing option.

Question 15

A 60-year-old man has sinusitis, haemoptysis, a rising creatinine with haematuria and red cell casts, and a positive PR3-ANCA. The induction treatment is:

1. Oral prednisolone alone
2. High-dose glucocorticoids plus rituximab or cyclophosphamide, with plasma exchange considered in severe renal disease or alveolar haemorrhage
3. Methotrexate alone
4. Antibiotics only

Answer: B. Granulomatosis with polyangiitis is organ-threatening; delayed induction costs renal function.

Question 16

A 35-year-old man has recurrent painful oral and genital ulcers, erythema nodosum, a positive pathergy test and an episode of posterior uveitis. The most likely diagnosis is:

1. Reactive arthritis
2. Behçet's disease, which is relatively common along the old Silk Road including Turkey, Iran and parts of the Middle East, and in which eye disease and vascular thrombosis are the main threats
3. Crohn's disease
4. Herpes simplex

Answer: B. Colchicine is used for mucocutaneous disease; azathioprine, TNF inhibitors or interferon for eye involvement.

Question 17

A 19-year-old Arab man has recurrent self-limiting episodes since childhood of fever, severe abdominal pain and pleuritic chest pain lasting one to three days, with an erysipelas-like rash on the leg. Between attacks he is well. The treatment that prevents attacks and amyloidosis is:

1. Long-term antibiotics
2. Daily colchicine for life, with colchicine-resistant cases treated with an IL-1 inhibitor
3. Appendicectomy
4. Glucocorticoids during attacks

Answer: B. Familial Mediterranean fever (MEFV mutations) is common in Arab, Turkish, Armenian and Sephardic Jewish populations; AA amyloidosis is the feared complication.

Question 18

A patient on a biologic for rheumatoid arthritis presents with a single hot swollen knee, fever and inability to weight-bear. The first step is:

1. Intra-articular glucocorticoid injection
2. Urgent joint aspiration for Gram stain, culture and crystals before antibiotics, blood cultures, then empirical intravenous antibiotics covering Staphylococcus aureus, and holding the biologic
3. Increase the biologic dose
4. Oral NSAIDs and review in a week

Answer: B. Septic arthritis destroys cartilage within days; steroids into an infected joint are a classic examination error.

Pregnancy and drug safety

Question 19

A woman with rheumatoid arthritis well controlled on methotrexate and a TNF inhibitor wishes to conceive. The appropriate advice is:

1. Continue both drugs
2. Stop methotrexate at least three months before conception and switch to pregnancy-compatible DMARDs such as hydroxychloroquine, sulfasalazine or azathioprine; certolizumab or other TNF inhibitors may be continued per current guidance with timing adjusted in the third trimester
3. Stop all treatment
4. Switch to leflunomide

Answer: B. Leflunomide and mycophenolate are also teratogenic; leflunomide needs a cholestyramine washout.

Question 20

Which patient is most at risk of hydroxychloroquine retinopathy and needs earlier and more frequent screening?

1. A 30-year-old on 200 mg daily for one year
2. A patient on more than 5 mg/kg per day for over five years, with renal impairment or concurrent tamoxifen
3. A patient with lupus but normal renal function
4. Any patient over 40

Answer: B. Optical coherence tomography and visual fields are the screening tools; dose, duration and renal function drive risk.

How to practise

• Learn drugs with their monitoring: methotrexate, leflunomide, hydroxychloroquine, biologics, colchicine, allopurinol.
• Know the emergencies: giant cell arteritis, septic arthritis, scleroderma renal crisis, ANCA vasculitis with renal or lung involvement, macrophage activation syndrome.
• Expect Gulf-prevalent conditions: familial Mediterranean fever, Behçet's, vitamin D deficiency, sickle cell bone disease, TB screening before biologics.
• Practise under time in the Rheumatology bank with the error-log method.

Related sets: internal medicine, dermatology and orthopaedic surgery. The exam structure for all specialties is in specialist practice questions online.

Frequently asked questions

How many questions are in the Prometric rheumatology specialist exam?

Typically 100 to 150 single-best-answer MCQs in up to three hours, with a pass mark of about 60%, varying by authority.

Which rheumatology topics come up most?

Rheumatoid arthritis treatment and monitoring, lupus and antiphospholipid syndrome, spondyloarthritis, gout, giant cell arteritis and biologic safety including TB screening.

Does the exam cover familial Mediterranean fever and Behçet's disease?

Yes. Both are common in the region and appear regularly on Gulf papers.

Which guidelines does the exam follow?

Current ACR and EULAR recommendations; where they differ, the shared principles are tested.

Are these real exam questions?

No. They are original practice questions written to the published blueprint. Real exam content is confidential.