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Clin Med III: MSK > Arthritis Part 1 > Flashcards

Arthritis Part 1 Flashcards

1
Q

MC form of joint disease
Mainly a disease of aging

A

Osteoarthritis

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2
Q

90% of pts will have radiographic evidence of arthritis in wt bearing joints by what age?

A

40

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3
Q

RF for osteoarthritis

A
  1. age
  2. obesity
  3. genetics
  4. anatomical factors
  5. joint injury
  6. contact sport
  7. jobs requiring bending or carrying
  8. gender
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4
Q

T/F: OA of the hands and knees are MC in men

A

F - women

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5
Q

pathophys/causes of OA

A
  1. degeneration of cartilage and hypertrophy of bone in articular margins (osteophytes)
  2. altered mechanics within joint (trauma, gait abnmlities)
  3. inflammation
  4. loss of estrogen
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6
Q

s/s of OA

A
  1. insidious onset
  2. pain on motion, worse by activity or wt bearing and relieved by rest
  3. reduced ROM; Crepitus over the knee
  4. No systemic manifestations
  5. Mild Joint effusion and other articular signs of inflammation
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7
Q

Bony enlargements of the DIP and PIP are occasionally prominent in OA, what are the terms for these enlargements?

A
  1. DIP - Heberden nodes
  2. PIP - Bouchard nodes
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8
Q

w/u for OA? Findings?

A
  1. ESP NOT elevated
  2. SF analysis - noninflammatory
  3. XR - narrowing of joint space, osteophyte formation and lipping of marginal bone, and thickened, subchondral bone; bone cysts possible
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9
Q

mgmt for OA

A
  1. assistive devices, joint protection
  2. exercising, losing wt
  3. acetaminophen, NSAIDs (voltaren/pennsaid, meloxicam)
  4. intra-articular steroids
  5. hyaluronic acid
  6. surgery
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10
Q

MC serious SE of NSAID toxicity

A

GI toxicity, such as gastric ulceration, perforation and GI bleeding

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11
Q

RF for NSAID toxicity

A

long-term use, higher NSAID dose, concomitant corticosteroids or anticoagulants, RA, hx of PUD, alcoholism or age > 70

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12
Q

what medication can reduce risk of serious GI effects from NSAIDs when treating OA?

A

PPIs (omeprazole)
should be used in high-risk pts

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13
Q

ALL NSAIDs can cause ____ toxicity?
RF?

A
  • renal
  • age > 60, h/o CKD, HF, ascites, and diuretic use
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14
Q

inc viscosity of synovial fluid = lubricate, cushion and reduce pain in joint
A last resort before surgery and provides symptomatic relief
inc in effectiveness over the course of 4 wks, reaching a peak at 8 wks

which tx for OA?

A

hyaluronic acid

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15
Q

when is surgery indicated for OA?

A

severe OA that restricts walking or causes pain at rest

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16
Q

metabolic disease associated with abnormal amounts of urates
Characterized by a recurring arthritis, usually monoarticular

A

gout

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17
Q

90% of primary gout are what pt demographic?

A

men >30 y/o

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18
Q
  • a characteristic nodular deposit of monosodium urate crystals with an associated FB reaction
  • found in cartilage, subcutaneous and periarticular tissues, tendon, bone, kidneys
  • seen in chronic or recurrent gout
A

tophus

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19
Q
  • sudden onset and frequently nocturnal
  • Precipitated by alc, changes in meds that affect urate metabolism, fasting for procedures
  • Joint is swollen and exquisitely tender and the overlying skin tense, warm, and dusky red
A

gout

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20
Q

what is podagra?

A

manifestation of gout, in which uric acid crystallizes and settles in one or more joints. - MC MTP joint of big toe

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21
Q

Chronic tophi may be found in what locations?

A

the external ears, feet, olecranon and prepatellar bursae, and hands

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22
Q

w/u for gout

A
  1. serum uric acid
  2. CBC - inc WBC
  3. Joint fluid analysis - sodium urate crystals
  4. XR
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23
Q

joint fluid analysis shows needle-like and negatively birefringent with light microscopy

dx?

A

gout - sodium urate crystals

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24
Q

late XR finding of gout?

A

punched-out erosions with an overhanging rim of cortical bone (“rat bite”)

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25
Q

mgmt for asx Hyperuricemia

A
  • Should not be treated, unless arthritis, renal calculi or tophi become apparent
  • avoid high purine foods?
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26
Q

mgmt of acute gout attack

A
  1. NSAIDs - naproxen
  2. colchicine
  3. CS (best if NSAIDs are CI) - methylprednisone/prednisone; TAC injection if monoarticular
  4. +/- urate-lowering tx
  5. change diet - avoid excessive alc, purine foods, drink a lot of water
  6. avoid hyperuremic meds
27
Q

possible MOA of colchicine?
SE?

A
  • Interfere with inflammasome complex present in neutrophils and monocytes preventing activation of IL-1
  • GI upset, gout flare, DIC, neuromuscular dz
28
Q

hyperurcemic meds?

A
  1. thiazide
  2. loops
  3. niacin
29
Q

indications for Urate-lowering Therapy when treating gout?

A
  • Freq acute arthritis (>=2 per yr), tophaceous deposits, or CKD (stage 2 or worse)
  • Min goal of serum uric acid < 6
30
Q

Lower plasma uric acid level by blocking the final enzymatic steps in the production of uric acid

what med?

gout

A

Xanthine oxidase inhibitors

Allopurinol 1st line

31
Q

SE of Allopurinol (Zyloprim)

A
  1. gout flare
  2. rash - can progress to toxic epidermal necrolysis assoc w/ vasculitis and hepatitis (rare)
32
Q

Caution when using Uloric (febuxostat) in patients with what chronic condition?

A

CV disease - higher rate of CV death compared to allopurinol

33
Q

Lower serum uric acid levels by blocking the tubular reabsorption of filtered urate, thereby increasing uric acid excretion by the kidney

A

Probenecid

34
Q

SE of Probenecid

A
  • Hem&onc: Anemia, aplastic anemia, hemolytic anemia (in G6PD deficiency), leukopenia
  • Hepatic: necrosis
  • Hypersensitivity
35
Q

DDI probenecid

A

Acetaminophen

36
Q

Resorption of extensive tophi requires maintaining a serum uric acid level below ?

A

6 mg/dL

37
Q

mgmt for large tophi

A

surgery

38
Q

what is pseudogout?

A

Calcium pyrophosphate deposition (CPPD) in fibrocartilage and hyaline cartilage can cause an acute crystal-induced arthritis

39
Q

MC > 60 yrs old
acute, recurrent arthritis involving large joints, MC knees and wrists
Joint analysis shows positive birefringent rhomboid-shaped crystals
XR shows chondrocalcinosis

dx?

A

pseudogout

40
Q

mgmt for pseudogout

A
  1. NSAIDs; colchicine
  2. CS - methylprednisone
  3. CS injections
41
Q

a chronic systemic inflammatory disease whose major manifestation is synovitis of multiple joints

A

RA

42
Q

RA MC in what pt demographic?

A
  • female
  • 40-50s (female); 60-80s (male)
43
Q

pathologic findings in joints of RA

A

chronic synovitis with formation of a pannus, which erodes cartilage, bone, ligaments and tendons

44
Q
  • Symmetrical swelling of multiple joints with tenderness and pain
  • Stiffness for a long period of time prominent in AM; may recur after daytime inactivity
  • nodules over bony prominences
  • PIP joints of fingers, MCP joints, wrists, knees, ankles, and MTP joints MC
  • Synovial cysts and rupture of tendons possible
  • deformities possible

dx?

A

RA

45
Q

other RA manifestations besides MSK?

A
  • HEENT: Dryness of eyes, mouth and other mucous membranes is found, esp in advanced disease
  • Interstitial lung disease: cough and progressive dyspnea
  • Pericarditis and pleural disease
  • Felty syndrome – occurrence of splenomegaly and neutropenia, usually in the setting of severe, destructive arthritis
  • Small vessel vasculitis: tiny hemorrhagic infarcts in the nail folds or finger pulps
46
Q

w/u for RA

A
  1. Anti-CCP ab - most specific
  2. rheumatoid factor
  3. ESP & CRP
  4. CBC
  5. joint fluid analysis
  6. XR changes
47
Q

mgmt for RA

A
  1. DMARDs + NSAIDs
    - add TNFi if DMARD not enough
  2. CS; TAC injections
48
Q

Max amount of CS injections that can be done?

RA

A

4x a year

49
Q

1st line DMARD?

A

MTX

50
Q

SE of MTX

A
  1. teratogenic - preg test beforehand + contraceptives during
  2. gastric irritation, stomatitis
  3. panctyopenia
  4. hepatotoxicity w/ fibrosis and cirrhosis
51
Q

is it ok to drink alc while on MTX?

A

no!

52
Q

supplement MTX with?

A

folic acid 1 mg PO daily

53
Q

SE of Hydroxychloroquine

A

cardiomyopathy

54
Q

2nd line DMARD?

A

sulfasalazine

55
Q

SE and CI of sulfasalzine

A
  1. Neutropenia and thrombocytopenia; hemolysis if G6PD def
  2. CI: ASA allergy

Check G6PD level beforehand; monitor w/ CBC q2-4 wks x 3 mo, then q 3 mo

56
Q

what medication is freq added for RA patients who have not responded adequately to MTX?

A

TNF inhibitors

57
Q

a soluble recombinant TNF receptor

A

Etanercept (Enbrel)

58
Q

a chimeric monoclonal antibody

A

Infliximab (Remicade)

59
Q

a human monoclonal antibody that binds to TNF

A

Adalimumab (Humira)

60
Q

a human anti-TNF monoclonal antibody

A

Golimumab (Simponi)

61
Q

a PEGylated monoclonal antibody TNF inhibitor

A

Certolizumab pegol (Cimzia)

62
Q

which TNF inhibitor is IV infusions?

A

Infliximab (Remicade)

63
Q

which TNF inhibitor requires more injections?

A

Etanercept (Enbrel) - dose 50 mg SQ qweek

64
Q

which TNF inhibitor requires the least administation?

A

Golimumab (Simponi) - 50 mg subQ monthly

Clin Med III: MSK (14 decks)

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