100+ Free ABIM Rheumatology Practice Questions

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Question 1

Score: 0/0

According to the 2010 ACR/EULAR rheumatoid arthritis classification criteria, what is the minimum total score required for a definite classification of RA?

≥4

≥6

≥8

≥10

to track

2026 Statistics

Key Facts: ABIM Rheumatology Exam

~220

Exam Questions

ABIM 2026

~10 hours

Exam Day Length

ABIM 2026

~$2,990

Application + Exam Fee

ABIM 2026

~85-92%

First-Attempt Pass Rate

ABIM Assessment Results

2 years

Rheumatology Fellowship Required

ACGME

5-yr LKA

MOC Option

ABIM MOC

The ABIM Rheumatology subspecialty exam certifies internists as consultative rheumatologists. It contains approximately 220 single-best-answer multiple-choice questions administered across four ~2-hour modules on a single ~10-hour test day at Pearson VUE centers. The application + exam fee is approximately $2,990. Eligibility requires active ABIM Internal Medicine certification plus satisfactory completion of a 2-year ACGME-accredited Rheumatology fellowship. The 2026 blueprint emphasizes evidence-based management anchored to ACR/EULAR guidelines — rheumatoid arthritis (ACR/EULAR 2010 classification ≥6, MTX + folate first-line, TNFi/IL-6/IL-17/T-cell co-stim/anti-CD20 biologics, JAKi class-wide BBW after ORAL Surveillance for patients ≥50 with ≥1 CV risk factor), SLE and lupus nephritis (ACR/EULAR 2019 classification, ISN/RPS classes, induction MMF or cyclophosphamide + belimumab BLISS-LN 2020 or voclosporin AURORA 2021, anifrolumab TULIP-1/TULIP-2 2021, HCQ ≤5 mg/kg actual body weight with AAO screening), APS (persistently positive LA/aCL/anti-β2GPI ≥12 weeks apart; triple-positive highest risk; DOACs contraindicated per TRAPS 2018; pregnancy ASA + LMWH), scleroderma (DETECT for PAH screening, captopril for renal crisis, nintedanib SENSCIS for SSc-ILD, tocilizumab focuSSced), myositis (anti-MDA5 rapidly progressive ILD, anti-HMGCR statin-associated, IBM steroid-refractory), vasculitis (tocilizumab GiACTA 2017 for GCA, rituximab RAVE for AAV, avacopan ADVOCATE 2021, mepolizumab for EGPA, HBV-associated PAN, HCV cryoglobulinemia with DAAs + rituximab), gout (ACR 2020 ULT target <6 or <5 mg/dL for tophi, HLA-B*5801 screening), axial SpA and PsA (IL-17 caution with IBD, bimekizumab 2023-2024 approvals), JIA and MAS (anakinra/emapalumab), and comprehensive medication monitoring including TB/HBV screening before biologics and PJP prophylaxis with high-dose steroids. Once certified, diplomates maintain certification via the Longitudinal Knowledge Assessment (LKA) or the 10-year recertification exam.

Sample ABIM Rheumatology Practice Questions

Try these sample questions to test your ABIM Rheumatology exam readiness. Each question includes a detailed explanation. Start the interactive quiz above for the full 100+ question experience with AI tutoring.

1According to the 2010 ACR/EULAR rheumatoid arthritis classification criteria, what is the minimum total score required for a definite classification of RA?

A.≥4

B.≥6

C.≥8

D.≥10

Explanation: The 2010 ACR/EULAR classification criteria for RA require a score of ≥6 out of 10, combining joint involvement (0-5), serology RF/anti-CCP (0-3), acute-phase reactants CRP/ESR (0-1), and symptom duration ≥6 weeks (0-1). The criteria apply to patients with at least one joint with definite clinical synovitis not better explained by another disease. A score ≥6 supports a classification of definite RA and permits early DMARD initiation.

2For a newly diagnosed patient with moderate-to-severe rheumatoid arthritis, what is the recommended first-line csDMARD according to ACR 2021 guidelines?

A.Hydroxychloroquine monotherapy

B.Methotrexate with folic acid supplementation

C.Leflunomide loading dose

D.Sulfasalazine alone

Explanation: Methotrexate is the anchor first-line DMARD for moderate-to-severe RA per ACR 2021. Target dose is 15-25 mg weekly (oral or subcutaneous), with folic acid 1 mg/day (or folinic acid) to reduce stomatitis, GI, and cytopenia side effects. Baseline and periodic LFTs, CBC, creatinine, and hepatitis screening are required. HCQ monotherapy is reserved for mild disease, leflunomide is an alternative, and SSZ is typically used in combination.

3Following the 2022 FDA boxed warning update on JAK inhibitors based on the ORAL Surveillance trial, which population should generally avoid tofacitinib as first-choice therapy in RA?

A.Patients under 40 with no cardiovascular risk factors

B.Patients 50 years or older with at least one cardiovascular risk factor

C.Patients with seronegative RA regardless of age

D.Patients on concurrent methotrexate under age 50

Explanation: The ORAL Surveillance trial compared tofacitinib to TNF inhibitors in RA patients ≥50 with ≥1 CV risk factor and demonstrated higher rates of major adverse cardiovascular events, venous thromboembolism, malignancy (excluding NMSC), and all-cause mortality. The FDA class-wide boxed warning now applies to tofacitinib, baricitinib, and upadacitinib. In patients ≥50 with ≥1 CV risk factor, JAKi should generally be reserved until after failure of TNF inhibitors.

4Which composite measure of RA disease activity is most commonly recommended for use in routine clinical treat-to-target practice because it does not require laboratory data?

A.DAS28-CRP

B.CDAI

C.SDAI

D.HAQ-DI

Explanation: The Clinical Disease Activity Index (CDAI) sums the tender joint count (28), swollen joint count (28), patient global, and provider global visual analog scales. It requires no laboratory data, making it especially convenient for point-of-care treat-to-target decision-making. SDAI adds CRP. DAS28 uses ESR or CRP. HAQ-DI is a functional disability instrument rather than a disease activity measure.

5A 58-year-old with long-standing seropositive RA develops progressive dyspnea and bibasilar crackles. HRCT demonstrates a basal predominant reticulation and honeycombing pattern consistent with UIP. Which therapy has evidence for slowing decline of FVC in RA-ILD with progressive pulmonary fibrosis phenotype?

A.Nintedanib

B.Cyclophosphamide oral daily

C.TNF inhibitor therapy

D.Hydroxychloroquine

Explanation: Nintedanib (an intracellular tyrosine kinase inhibitor) slowed FVC decline in the INBUILD trial across several progressive fibrosing ILDs, including RA-ILD with a UIP-like pattern. It is FDA-approved for progressive fibrosing ILD and SSc-ILD. TNF inhibitors are not preferred for RA-ILD and can be associated with worsening of pre-existing ILD in some patients. Pirfenidone is another option with evolving RA-ILD data (TRAIL1).

6A patient with seropositive RA develops splenomegaly and chronic neutropenia (ANC <2000) with recurrent bacterial infections. Which diagnosis best fits this triad?

A.Felty syndrome

B.Still disease

C.Large granular lymphocyte leukemia alone

D.Common variable immunodeficiency

Explanation: Felty syndrome is the classic triad of seropositive RA, splenomegaly, and neutropenia. It occurs in <1% of RA patients, typically with long-standing erosive disease. Treatment targets the underlying RA with methotrexate; rituximab and G-CSF can be used for severe neutropenia. LGL leukemia can coexist or mimic Felty via clonal T-LGL expansion; bone marrow and flow cytometry help distinguish them.

7Which biologic DMARD mechanism best describes tocilizumab and sarilumab in rheumatoid arthritis?

A.TNF-alpha blockade

B.IL-6 receptor antagonism

C.T-cell co-stimulation blockade via CTLA-4-Ig

D.B-cell depletion via anti-CD20

Explanation: Tocilizumab and sarilumab block the IL-6 receptor. IL-6 drives acute-phase reactant production, synovial inflammation, and systemic features. Both agents can suppress CRP even in ongoing inflammation, which complicates using CRP as a safety signal (watch for bowel perforation, LFT elevations, neutropenia, lipid changes). Abatacept is the CTLA-4-Ig co-stimulation blocker; rituximab depletes B cells via anti-CD20.

8Before initiating a TNF inhibitor, which baseline screening test is most important to exclude latent infection that could reactivate?

A.Interferon-gamma release assay (IGRA) or TST for latent TB

B.Strongyloides serology in all patients

C.Toxoplasma IgG

D.Babesia PCR

Explanation: TNF inhibitors markedly increase the risk of tuberculosis reactivation. All patients should be screened with an IGRA (or tuberculin skin test) plus chest imaging before initiation. Hepatitis B serology (HBsAg, anti-HBc, anti-HBs) is also essential to assess for reactivation risk. Strongyloides and other tropical screens may be warranted based on exposure history but are not routine for all patients.

9According to the 2019 EULAR/ACR SLE classification criteria, what is the entry criterion required before any additive domain scoring applies?

A.Positive dsDNA antibody

B.ANA titer ≥1:80 on HEp-2 cells or equivalent

C.Lupus band test positivity

D.Low C3 and C4 complement

Explanation: The 2019 EULAR/ACR SLE classification criteria require an ANA titer of at least 1:80 on HEp-2 cells (or equivalent positive test) as an obligate entry criterion. Patients meeting the ANA threshold then accumulate weighted points across clinical (constitutional, hematologic, neuropsychiatric, mucocutaneous, serosal, musculoskeletal, renal) and immunologic (antiphospholipid, complement, SLE-specific antibodies) domains. A cumulative score ≥10 classifies SLE.

10Which ISN/RPS lupus nephritis class is characterized by focal (<50% of glomeruli) endocapillary or extracapillary glomerular involvement?

A.Class I

B.Class II

C.Class III

D.Class V

Explanation: The ISN/RPS 2003 (revised 2018) classification defines class III lupus nephritis as focal proliferative disease involving <50% of glomeruli. Class IV is diffuse (≥50%), class V is pure membranous, class I is minimal mesangial, class II is mesangial proliferative, and class VI is advanced sclerosis (>90% globally sclerotic glomeruli). Classes III and IV carry the greatest risk for progression and require potent immunosuppression.

About the ABIM Rheumatology Exam

The ABIM Rheumatology subspecialty exam certifies internists as consultative rheumatologists. The exam covers rheumatoid arthritis (ACR/EULAR 2010 classification and treat-to-target), SLE and lupus nephritis (ACR/EULAR 2019 classification; voclosporin AURORA 2021 and belimumab BLISS-LN 2020; anifrolumab TULIP), APS (Sydney criteria, avoiding DOACs in triple-positive per TRAPS), Sjögren disease (ACR/EULAR 2016, MALT lymphoma risk), systemic sclerosis (SENSCIS nintedanib, focuSSced tocilizumab, scleroderma renal crisis), myositis (MDA5, HMGCR, Jo-1, IBM), vasculitis (GiACTA, RAVE, ADVOCATE avacopan), crystal arthritis (ACR 2020 gout), axial SpA/PsA (IL-17, IL-23, JAKi post-ORAL Surveillance BBW), JIA and MAS, and medication monitoring.

Questions

220 scored questions

Time Limit

~10-hour exam day (four ~2-hour modules)

Passing Score

Criterion-referenced scaled score (pass/fail)

Exam Fee

~$2,990 application + exam fee (American Board of Internal Medicine (ABIM))

ABIM Rheumatology Exam Content Outline

18%

Rheumatoid Arthritis

ACR/EULAR 2010 classification (≥6), MTX + folate first-line, TNFi/IL-6/T-cell co-stim/anti-CD20, JAKi post-ORAL Surveillance BBW (CV, VTE, malignancy especially in patients ≥50 with ≥1 CV RF), treat-to-target with CDAI/SDAI/DAS28, anti-CCP, extra-articular (RA-ILD UIP, Felty, vasculitis, scleritis)

15%

Systemic Lupus Erythematosus

ACR/EULAR 2019 (ANA ≥1:80 entry + additive domains), ISN/RPS lupus nephritis I-VI, class III/IV induction MMF or IV cyclophosphamide + belimumab (BLISS-LN 2020) or voclosporin (AURORA 2021), anifrolumab (TULIP-1/TULIP-2 2021), HCQ ≤5 mg/kg actual weight with AAO eye screening, dsDNA/C3/C4 trend, neuropsychiatric SLE, neonatal lupus

Antiphospholipid Syndrome

Sydney criteria — LA, aCL, anti-β2GPI ≥12 weeks apart; triple-positive highest risk; primary vs secondary; warfarin INR 2-3 for VTE; avoid DOACs in triple-positive (TRAPS 2018); pregnancy ASA + LMWH; catastrophic APS; CNS ischemic NPSLE

Sjögren Disease & IgG4-Related

ACR/EULAR 2016 criteria with weighted points (focus score ≥1, anti-SSA, Schirmer ≤5 mm, ocular staining, USF flow), MALT parotid lymphoma risk, IgG4-RD (type 1 AIP, sclerosing cholangitis, Mikulicz, retroperitoneal fibrosis; storiform fibrosis + IgG4+ plasma cells; rituximab)

10%

Systemic Sclerosis

Limited vs diffuse, anti-centromere (PAH), Scl-70 (ILD), RNA pol III (renal crisis/malignancy); renal crisis ACEi captopril; PAH screening DETECT/ISHLT + RHC mPAP >20 per ESC/ERS 2022; SSc-ILD nintedanib (SENSCIS), tocilizumab (focuSSced), MMF (SLS-II); Raynaud CCB, iloprost, bosentan (RAPIDS); HSCT (ASTIS/SCOT)

Idiopathic Inflammatory Myopathies

Dermatomyositis Gottron/heliotrope, anti-Jo-1 antisynthetase, anti-MDA5 rapidly progressive ILD, anti-HMGCR statin-associated necrotizing, anti-SRP necrotizing, anti-Mi2; DM malignancy (ovary/breast/lung/GI/NHL, anti-TIF1γ/NXP2); inclusion body myositis (finger flexors + quadriceps, rimmed vacuoles, steroid-refractory)

15%

Vasculitis

Large vessel GCA (prednisone 40-60 + tocilizumab GiACTA + aspirin; pulse IV methylpred for vision loss; PMR 15 mg), Takayasu; medium PAN (HBV) and Buerger (smoking); ANCA+ GPA/MPA/EGPA (rituximab RAVE, mepolizumab EGPA MIRRA, avacopan ADVOCATE 2021); IgA vasculitis; cryoglobulinemia (HCV — DAAs + rituximab); Behçet (colchicine, apremilast, TNFi); VEXAS UBA1; relapsing polychondritis

JIA, Adult Still & MAS

Systemic JIA canakinumab/tocilizumab/anakinra, polyarticular MTX + biologics, adult-onset Still IL-1/IL-6 blockade, MAS (persistent fever, very high ferritin, coagulopathy, cytopenias) — corticosteroids + anakinra/emapalumab + cyclosporine, autoinflammatory syndromes (FMF colchicine, CAPS anti-IL-1)

Axial SpA & Psoriatic Arthritis

ASAS criteria axial SpA, CASPAR PsA, NSAIDs continuous first-line, TNFi + IL-17 (secukinumab/ixekizumab/bimekizumab 2023-2024), IL-23 (risankizumab/guselkumab) for PsA, JAKi upadacitinib for AS/nr-axSpA/PsA; HLA-B27; IL-17 caution in IBD; reactive arthritis

Crystal Arthritis

Gout — ACR 2020 ULT indications (≥2 flares/year, tophi, erosions, CKD ≥stage 3), allopurinol start ≤100 mg/day (50 in CKD) target <6 (<5 tophi), HLA-B*5801 in Han Chinese/Thai/Korean, pegloticase (check G6PD), colchicine prophylaxis; flare NSAID/colchicine/steroid/IL-1 blocker; CPPD chondrocalcinosis

Osteoarthritis

ACR 2019 — oral/topical NSAIDs strongly recommended, acetaminophen adjunct, duloxetine, intra-articular steroid short-term; strongly against glucosamine/chondroitin and IA hyaluronic acid for knee

Infection-Related Arthritis & Fibromyalgia/Medication Monitoring

Septic joint (S. aureus empiric vanc + ceftriaxone + drainage), gonococcal arthritis-tenosynovitis-dermatitis, Lyme arthritis (doxycycline 28 days), parvovirus; fibromyalgia (ACR 2016 WPI + SSS); medication monitoring (HCQ AAO eye, MTX LFTs, TB/HBV before biologics, PJP prophylaxis at prednisone ≥20 mg, live vaccines contraindicated on biologics, glucocorticoid-induced osteoporosis prophylaxis)

How to Pass the ABIM Rheumatology Exam

What You Need to Know

Passing score: Criterion-referenced scaled score (pass/fail)
Exam length: 220 questions
Time limit: ~10-hour exam day (four ~2-hour modules)
Exam fee: ~$2,990 application + exam fee

Keys to Passing

Complete 500+ practice questions
Score 80%+ consistently before scheduling
Focus on highest-weighted sections
Use our AI tutor for tough concepts

ABIM Rheumatology Study Tips from Top Performers

1Know the JAK inhibitor boxed warning cold: after the ORAL Surveillance trial, tofacitinib, baricitinib, and upadacitinib carry a class-wide FDA boxed warning for major adverse cardiovascular events, venous thromboembolism, malignancy, and all-cause mortality in RA patients ≥50 years with at least one cardiovascular risk factor. In this population, reserve JAKi until after failure of a TNF inhibitor. In axial SpA and PsA the same warning applies but regulatory labels and clinical risk-benefit differ slightly by indication

2Master lupus nephritis induction for class III/IV proliferative disease: the 2024 ACR guideline supports triple therapy with either mycophenolate mofetil 2-3 g/day or IV cyclophosphamide (EUROLUPUS low-dose or NIH high-dose), plus belimumab (BLISS-LN 2020) or voclosporin (AURORA-1 2021), plus low-dose glucocorticoids to minimize cumulative steroid exposure. Hydroxychloroquine should continue in all patients with SLE. Response assessment targets proteinuria reduction >50% at 6 months and complete renal response at 12 months

3Memorize autoantibody patterns for systemic sclerosis: anti-centromere → limited cutaneous, high PAH risk, protected from renal crisis; anti-Scl-70 (topoisomerase I) → diffuse cutaneous, high ILD risk; anti-RNA polymerase III → diffuse cutaneous, very high scleroderma renal crisis risk (up to 25-30%) and increased malignancy within 3 years. ACEi (captopril) is first-line for renal crisis even as creatinine rises. Nintedanib is FDA-approved for SSc-ILD based on SENSCIS; tocilizumab is FDA-approved for SSc-ILD specifically in early diffuse disease with elevated CRP (focuSSced)

4Lock in ANCA-associated vasculitis induction: RAVE (2010) established rituximab 375 mg/m² weekly × 4 as non-inferior to cyclophosphamide for severe AAV and superior in relapsing disease. Avacopan (ADVOCATE 2021), an oral C5aR antagonist, is FDA-approved as an adjunct that enables substantial glucocorticoid reduction. PEXIVAS (2020) allowed more rapid steroid taper and largely restricted plasma exchange to alveolar hemorrhage with hypoxemia or aggressive RPGN with rising creatinine. For EGPA use mepolizumab (MIRRA) for relapsing or refractory disease

5Know gout ULT initiation rules (ACR 2020): strongly recommend ULT for ≥2 flares/year, tophi, radiographic damage, or CKD ≥stage 3. Allopurinol is first-line; start ≤100 mg/day (50 mg in CKD stage 4) and titrate to serum urate <6 mg/dL (<5 mg/dL for tophi). Screen HLA-B*5801 in Han Chinese, Thai, and Korean patients before allopurinol (especially with CKD) to prevent SJS/TEN. Provide anti-inflammatory prophylaxis (colchicine, low-dose NSAID, or prednisone) for 3-6 months during ULT initiation. Pegloticase is reserved for refractory tophaceous gout and requires G6PD screening

Frequently Asked Questions

Who can take the ABIM Rheumatology exam?

Candidates must hold active ABIM Internal Medicine certification and have satisfactorily completed an ACGME-accredited 2-year Rheumatology fellowship. The fellowship program director must attest to clinical competence. A valid, unrestricted US medical license and ABIM professional standing are also required.

How is the ABIM Rheumatology exam structured?

The Rheumatology exam contains approximately 220 single-best-answer multiple-choice questions administered across four ~2-hour modules on a single ~10-hour test day at Pearson VUE centers. Questions are case-based and emphasize application of current ACR and EULAR guidelines — ACR/EULAR 2010 RA, ACR/EULAR 2019 SLE, ACR/EULAR 2016 Sjögren, ACR 2020 gout, ACR 2021 RA treat-to-target, plus pivotal trials — rather than rote recall.

What is the passing score for the ABIM Rheumatology exam?

ABIM uses a criterion-referenced scaled passing score established through standard-setting methodology. The score is reported as pass/fail and the cut point is not publicly disclosed as a percentage. Historical first-time pass rates are approximately 85-92% for candidates who complete an ACGME-accredited Rheumatology fellowship.

How much does the ABIM Rheumatology exam cost?

The application fee plus exam fee is approximately $2,990 for initial certification. Costs are subject to change — always confirm on the ABIM website. Total preparation cost including ACR board review, MKSAP Rheumatology, Kelley's Textbook of Rheumatology, and a dedicated question bank typically ranges from $3,500 to $5,500.

What topics are emphasized on the ABIM Rheumatology exam?

The blueprint emphasizes Rheumatoid Arthritis (~18%), Systemic Lupus Erythematosus and lupus nephritis (~15%), Vasculitis (~15%), Systemic Sclerosis (~10%), Axial Spondyloarthritis and Psoriatic Arthritis (~8%), Sjögren and IgG4-related disease (~7%), Idiopathic Inflammatory Myopathies (~7%), Antiphospholipid Syndrome (~6%), Crystal Arthritis (~5%), JIA/Adult Still/MAS (~4%), Osteoarthritis (~3%), and Infection-related arthritis, fibromyalgia, and medication monitoring (~2%). High-yield content includes the JAKi boxed warning (ORAL Surveillance), GiACTA tocilizumab for GCA, RAVE rituximab for AAV, ADVOCATE avacopan, BLISS-LN belimumab and AURORA voclosporin for lupus nephritis, TULIP anifrolumab, SENSCIS nintedanib and focuSSced tocilizumab, and avoiding DOACs in triple-positive APS (TRAPS).

How do I maintain ABIM Rheumatology certification?

ABIM diplomates maintain Rheumatology certification through the Longitudinal Knowledge Assessment (LKA) — an open-book, quarterly question set delivered over a 5-year cycle — or through the traditional 10-year recertification exam. Diplomates must also meet MOC activity requirements, hold an active unrestricted medical license, and maintain ABIM professional standing.

How long should I study for the ABIM Rheumatology exam?

Most candidates study 250-400 hours over 6-12 months in parallel with their 2-year rheumatology fellowship. Preparation typically combines ACR Rheumatology Board Review, MKSAP Rheumatology, Kelley's Textbook, pivotal trial summaries (especially ORAL Surveillance, RAVE, GiACTA, ADVOCATE, BLISS-LN, AURORA, TULIP, SENSCIS, focuSSced, ASTIS/SCOT), ACR and EULAR guidelines, and a dedicated question bank. Clinical volume on inpatient consult, infusion suite, and outpatient continuity clinic is the strongest predictor of exam success.

Is rheumatology different from orthopedic surgery or physical medicine?

Yes. Rheumatology is a medical (non-surgical) subspecialty of Internal Medicine focused on systemic autoimmune, autoinflammatory, and musculoskeletal diseases — rheumatoid arthritis, SLE, scleroderma, vasculitis, myositis, and crystal arthropathies. Orthopedic surgery is a surgical specialty focused on mechanical/structural musculoskeletal care. Physical medicine and rehabilitation (PM&R) focuses on functional restoration. ABIM Rheumatology certifies a medical subspecialty distinct from these related fields.