Corrections Flashcards
At what age can a diagnosis of OA be made without any investigations?
≥45 y/o
Mechanism of NSAIDs?
Block COX1 and COX2 enzymes
COX1 - generates prostaglandins involved in the protection of GI mucosa
COX2 - generates prostaglandins that mediate inflammation and pain
How can NSAIDs cause HTN?
Block prostaglandin production –> prostaglandin is a vasodilator
What is the most common gene associated with rheumatoid arthritis?
HLA-DR4
What 2 Abs may be seen in RA?
1) RF
2) Anti-CCP
How does rheumatoid factor cause inflammation in RA?
Targets Fc portion of IgG
Causes immune system activation against the patient’s own IgG –> autoimmune reaction
What type of immunoglobulin is RF normally?
IgM
What 3 pulmonary manifestations can be seen in RA?
1) Pulmonary fibrosis
2) Caplan syndrome
3) Bronchiolitis obliterans
What is caplan syndrome?
Pulmonary nodules in patients with RA exposed to coal, silica, or asbestos dust.
Cataracts in RA is a side effect of what drug treatment?
Steroids
What 2 scoring systems can be used in RA?
1) Health assessment questionnaire (HAQ)
2) Disease activity score 28 joints (DAS-28)
What 2 things are used to measure success of RA treatment?
1) DAS-28
2) CRP
Which is the mildest DMARD used in RA?
Hydroxychloroquine
What are the 2 safest DMARDs in pregnancy?
1) Hydroxychloroquine
2) Sulfalazine (extra folic acid required)
Which 2 DMARDs are teratogenic?
1) Methotrexate
2) Leflunomide
Which DMARD causes pyridine suppression?
Leflunomide
Which DMARD causes peripheral neuropathy?
Leflunomide
3 key side effects of sulfalazine?
1) orange urine
2) bone marrow suppression
3) reversible male infertility
3 key side effects of hydroxychloroquine?
1) retinal toxicity
2) blue-grey skin discolouration
3) hair lightening
Which RA drugs can cause reactivation of tuberculosis?
Anti-TNF drugs
What is the initial mx for RA?
DMARD monotherapy (usually methotrexate)
+
short-term bridging corticosteroid
Describe swellings in OA vs RA
OA - bony
RA - boggy
What is used to manage a flare of RA?
IM methylprednisolone
How long must the symptoms be present for for a PMR diagnosis to be made?
2 weeks
When is PMR pain and stiffness worse? (2)
1) in morning
2) after rest/inactivity
What are some associated features seen in PMR?
- giant cell arteritis
- systemic symptoms e.g. weight loss, fatigue
- carpal tunnel syndrome
- peripheral oedema
What antibodies are seen in SLE?
Anti-nuclear antibodies (ANAs)
Mx of PMR?
Steroids (start 15mg prednisolone daily)
Treatment typically lasts 1-2 years
What should be consdiered to prescribe alongside long-term steroids?
1) PPIs
2) Osteoporosis protection e.g. vit D, calcium, bisphosphonates
What 3 medications can be used in the mx of fibromyalgia?
1) pregabalin
2) duloxetine
3) amitriptyline
What T score is normal on a DEXA scan?
> -1
What T score defines osteopenia?
-1 to -2.5
What T score defines osteoporosis?
<-2.5
What T score defines severe osteoporosis?
<2.5 + fracture
What investigation measures bone mineral density?
DEXA scan
How does a DEXA scan work?
Measures how much radiation is absorbed by bone - indicates density.
What medications can lead to osteoporosis?
- PPIs
- Steroids
- Anti-oestrogens
- SSRIs
Impact of tamoxifen on osteoporosis?
Tamoxifen is a SERM:
- Blocks oestrogen in breast tissue
- Stimulates oestrogen in uterus & bone –> helps prevent osteoporosis BUT increases risk of endometrial cancer
What is a SERM used to treat osteoporosis?
Raloxifene
What 2 tools can be used to calculate the 10-year risk of a major osteoporotic fracture and a hip fracture?
1) FRAX tool
2) QFracture (preferred)
What QFracture score indicates the need for a DEXA scan?
> 10%
Medical mx of osteoporosis?
1) Calcium
2) Vitamin D
3) Bisphosphonates
Give some side effects of bisphosphonates
1) Osteonecrosis of jaw
2) Osteonecrosis of external auditory canal
3) Reflux & oesophageal erosion
4) Atypical fractures
What is a notable risk of raloxifene?
VTE risk
NICE advise that all women aged ≥65 years and all men aged ≤75 years should be assessed for osteoporosis.
When would younger patients be assessed?
In the presence of risk factors such as:
1) previous fragility fracture
2) current use or frequent recent use of steroids
3) history of falls
4) family history of hip fracture
5) other causes of 2ary osteoporosis:
- hypogonadism e.g. low testosterone in men and premature menopause in women
- endocrine e.g. diabetes, Cushing’s, hyperthyroidism
- malabsorption e.g. IBD, coeliac
- RA
6) low BMI
7) smoking
8) alcoholism
What is the first step in risk assessment in osteoporosis?
Exclude 2ary causes !! e.g. hypogonadism, diabetes, Cushing’s, RA, IBD, coeliac
Bone protection in steroid use:
If it likely that the patient will have to take steroids for at least 3 months then you should start bone protection straight away.
What is 1st line for bone protection?
Oral alendronate (also ensure calcium + vitamin D replete)
What should all patients prescribed NSAIDs for osteoarthritis be co-prescribed?
PPIs (regardless of their age or GI symptom history)
How do NSAIDs affect the stomach?
NSAIDs inhibit prostaglandin synthesis, compromising the protective mucosal barrier of the stomach and increasing the risk of ulceration and GI bleeding.
Mechanism of PPIs?
Inhibit the hydrogen-potassium ATPase pump in gastric parietal cells –> reduce gastric acid secretion.
1st line in osteoarthritis?
Topical NSAIDs e.g. diclofenac
What does the management of patients following a fragility fracture depend on?
Age
Mx of patients ≥75 y/o that have had a fragility fracture?
These patients are PRESUMED to have osteoporosis.
Start immediately on 1st line therapy (oral bisphosphonate e.g. alendronate) without the need for a DEXA scan.
Mx of patients <75 y/o that have had a fragility fracture?
Arrange a DEXA scan
What is the most effective treatment for osteoarthritis patients who experience significant pain?
Joint replacement (arthroplasty)
What is the nerve most likely to be injured during knee arthroplasty?
Common peroneal nerve (problems dorsiflexing foot)
What is broken down into uric acid in gout?
Purine
What is a key class of medication that increases risk of gout?
Thiazide diuretics e.g. indapamide
These increase direct urate reabsorption in the proximal renal tubules.
Measuring Uric acid levels can be used in the diagnosis of gout.
What should the levels be measured?
At least 2 weeks AFTER first presentation of gout
What does aspirated joint fluid show in gout? (3)
MSU crystals:
1) Needle shaped
2) Negatively birefringent of polarised light
3) No bacterial growth
What are the crystals made of in pseudogout?
Calcium pyrophosphate
Medical management of ACUTE gout flares (1st, 2nd & 3rd line)?
1st –> NSAIDs (with PPI cover)
2nd –> Colchicine (in patients who cannot use NSAIDs e.g. renal disease)
3rd –> Oral steroids
Prophylaxis of gout?
1st line –> Allopurinol
2nd line –> Febuxostat
What are 2 common side effects of colchicine?
Abdo symptoms & diarrhoea
Very dangerous in OD
What is the mechanism of allopurinol & febuxostate?
Xanthine oxidase inhibitors –> lower uric acid level
Who is offered urate-lowering therapy (e.g. allopurinol)?
Offered to ALL patients after their FIRST attack of gout.
1) Prophylaxis is not started until weeks after the first acute attack has resolved.
2) Once allopurinol or febuxostat is initiated, it is continued during an acute attack.
Who is gonococcal septic arthritis most common in?
Sexually active individuals.
In a young patient presenting with a single acutely swollen joint, consider gonococcal septic arthritis until proven otherwise.
What is reactive arthritis usually triggered by?
Urethritis or gastroenteritis
What criteria is used for the diagnosis of septic arthritis?
Kocher criteria
What is the Kocher critiera?
1) Fever >38.5
2) Non weight bearing
3) Raised ESR
4) Raised CRP
What needs to be ruled out after diagnosing septic arthritis?
Systemic bacteraemia
What is typical 1st line Abx given in septic arthritis (or until sensitivities are known)?
Flucloxacillin
- vancomycin if MRSA suspected
- clindamycin in penicillin allergy
Which Abx is typically used for the treatment of Neisseria gonorrhoea in septic arthritis?
Ceftriaxone
if osteomyelitis is suspected, what investigation should be done?
MRI
What should be added when starting allopurinol in gout prophylaxis?
Consider colchicine cover when starting allopurinol (may need to be continued for 6m).
NSAIDs if colchicine cannot be tolerated.
Typical appearance of joint aspiration fluid in RA?
Yellow (as RA is an inflammatory condition)
What predominates in cytology of aspirated fluid in RA?
High WBC count, predominantly polymorphonuclear neutrophil (PMNs).
What condition is most commonly associated with scleritis?
RA
What does XR of the sacroiliac joints typically demonstrate in ankylosing spondylitis?
Subchondral erosions & subchondral sclerosis of the sacroiliac joint
What is used to manage acute flares of RA?
IM methylprednisolone
What area of the lungs can fibrosis be seen in in ankylosing spondylitis?
Apical region
1st line Abx in early suspected Lyme disease?
I.e. tick bite + erythema migrans
Doxycycline (amoxicillin if pregnant)
1st line Abx in disseminated Lyme disease?
Ceftriaxone
What is the most useful investigation in confirming a diagnosis of ankylosing spondylitis?
Pelvic XR –> sacroilitis
What might you see on a CXR in a patient with ankylosing spondylitis?
Apical fibrosis
What is adhesive capsulitis?
AKA frozen shoulder.
A common cause of shoulder pain.
What condition does adhesive capsulitis have an association with?
Diabetes mellitus
Features of adhesive capsulitis?
- EXTERNAL rotation is affected more than internal rotation or abduction
- both active and passive movement is affected
- bilateral in up to 20% of patients
How long does an episode of adhesive capsulitis typically last?
6m to 2y
1st line mx of ankylosing spondylitis?
Oral NSAIDs & physio
What is the most common reason total hip replacements need to be revised?
Aseptic loosening.
Over time, wear and tear can lead to the prosthesis becoming loose within the bone, causing pain and reduced function. This typically occurs many years after the initial surgery.
CK value in rhabdo vs exercise induced CK elevation?
Rhabdo -> markedly and acutely elevated usually to at least 5 times the upper limit of normal
Exercise induced –> 2-4x upper limit
CK level in polymyalgia rheumatica?
Normal
Asbestosis causes pulmonary fibrosis predominantly affects what area of lungs?
Lower zones
CK level in PMR?
Normal
1st line mx for ankylosing spondylitis?
NSAIDs & physio
1st line bisphosphonate in osteoporisis?
alendronate
1st line mx of moderate/severe psoriatic arthritis?
Methotrexate
What may be considered if a rib fracture is not controlled by normal analgesia?
Intercostal nerve block
What is discitis?
Discitis is an infection in the intervertebral disc space.
what is the most common organism causing discitis?
S. aureus
What is the most common mechanism of ankle sprain?
Inversion –> stretching of lateral ligament
What is a highly sensitive but poorly specific sign for scaphoid fracture?
Anatomical snuffbox tenderness
Typical mechanism of injury in scaphoid fracture?
FOOSH
What 2 movements causes worsened pain in lateral epicondylitis (‘tennis elbow’)?
1) wrist extension against resistance with elbow extended
2) supination of forearm with elbow extended
After the first VTE, patients with antiphospholipid syndrome should be on what medication?
Lifelong warfarin
What investigations should be performed in all patients with suspected rheumatoid arthritis?
1) Xrays of hands & feet
2) Anti-CCP & RF antibodies
What ligament is most commonly injured in inversion ankle sprains?
Anterior talofibular ligament (ATFL)
This is located on the lateral side of the ankle
1st imaging investigation in vertebral osteoporotic fractures of the spine?
Xray of the spine –> may show wedging of the vertebra
What score is used to assess if a patient is deemed high risk for osteoporosis?
FRAX or QFracture sscore
If a patient is deemed high-risk based on a QFracture or FRAX score they should have a DEXA scan.
What is the threshold for defining osteoporosis on a DEXA scan?
T score of ≤ 2.5 SD
Purpose of a DEXA scan?
Assess bone mineral density
Mx of postmenopausal women, and men age ≥50, who are treated with oral glucocorticoids?
1) If starting ≥7.5 mg/day prednisolone or equivalent for the next 3 months, start bone protective treatment at the same time
2) Start oral bisphosphonates (don’t wait for DEXA)
Mx of a postmenopausal woman, or a man age ≥50 has a symptomatic osteoporotic vertebral fracture?
General osteoporosis management
Start treatment straight away - oral bisphosphonates are used first-line e.g. alendronate or risedronate
For osteoporosis in young men, what should you check?
testosterone
Low testosterone levels are associated with higher bone turnover therefore osteoporosis.
If a patient suffers significant upper GI side effects from the use of alendronate, what should this be changed to?
Risedronate or etidronate
