Exam 1 -- Rheumatology #1 Flashcards
How much of the primary care workload is rheumatology?
20-30%
What is another term for rheumatology?
Collagen vascular diseases
Does a ligament connect bone to bone or muscle to bone?
LBB (Ligament connects bone to bone)
Does a tendon connect bone to bone or muscle to bone?
TMB (Tendon connects muscle to bone)
How does the enthesis (end of a bone) differ from the shaft of the bone?
The enthesis is more porous and is vascularized; the shaft is denser and avascular
Articular cartilage is a specific type of what cartilage?
Hyaline
Is articular cartilage vascular or avascular?
Avascular
Articular cartilage is made of what type of collagen?
Type 2
Where can type 2 collagen be found?
Articular cartilage and the vitreous humor of the eye
Extracellular fluid is made of what components?
Collagens, elastins, glycoproteins, proteoglycans, and cells
Collagens make up how much of the synovial fluid?
90%
What role do glycoproteins have in joints?
Tissue remodeling (they are also known as fibronectin)
True or false: cytokines stimulate fibronectin
False; they inhibit fibronectin, decreasing tissue rebuilding
What purpose do proteoglycans have in the extracellular fluid?
They are GAG chains that bind the fluid together and retain nutrients
What is the name for nutrient rich fluid that is secreted by cells in the ECM?
Hyaluronan
Matrix Metalloproteinases (MMPs) 2 and 9 degrade CT. What specific portions of the ECM do they degrade?
Collagen, proteoglycans, and fibronectin
True or false: MMPs are upregulated during inflamation
True.
What is a common drug used to decrease MMP activity?
Doxycycline
Are bursitis, carpal tunnel syndrome, and tenosynovitis rheumatologic in nature?
No, but they are dealt with by rheumatologists often
What can cause bursitis?
Repetitive motion, pressure, RA, gout, trauma
True or false: bursitis normally presents bilaterally and symmetrically
False; it presents unilaterally and asymmetrically
In what way (relating to activity and rest) does bursitis differ from reheumatoid arthritis?
Bursitis is exacerbated by activity and improved by rest; RA is the opposite.
True or false: bursitis is more common than RA and lupus
True.
What is a good way to treat buritis?
PRICE (Protect, Rest with a little activity, Ice, Compress, Elevate); NSAIDs (higher doses); massage; corticosteroid (only if not bacterial in nature); possibly antibiotics; surgery in extreme cases
True or false: carpal tunnel syndrome is the most common entrapment neuopathy
True.
What causes carpal tunnel syndrome?
Prolonged pressure and/or use, arthritis, pregnancy
How would you treat carpal tunnel syndrome?
Splint at night, corticosteroid injection, surgery
What is tenosynovitis?
Inflammation of the synovium around a tendon (not inflammation of the tendon itself
What is another name for tenosynovitis?
Trigger finger
What causes tenosynovitis?
Repetitive use, RA, injury, genetics
How would you treat tenosynovitis?
Split, corticosteroid injection, surgery
True or false: tenosynovitis is more common in diabetics
True.
What treatment strategies can be employed for not only bursitis, carpal tunnel syndrome, and tenosynovitis, but also for RA?
Rest and light exercise, physical therapy, smoking cessation, alcohol reduction, weight loss, Omega-3, fish oil supplements, medications
What role do omega-3 and fish oil supplements play in treating RA or other conditions that involve the joints?
They inhibit MMPs
Treatment of conditions involving the joints can consist of different classes of drugs. Which classes are meant to relieve the pain?
NSAIDs, corticosteroids, analgesics
Treatment of conditions involving the joints can consist of different classes of drugs. What class is meant to treat the actual condition, not just relieve the pain?
DMARDs (including biologics and tetracyclines)
What enzyme do corticosteroids target?
Phospholipase A2 (releases arachidonic acid from the cell membrane–AA is the precursor molecule for thromboxanes, protacyclins, and prostaglandins
The COX-1 pathway leads to what kind of prostaglandins?
Cytoprotective–protection of gastric mucosa; also aid in platelet aggregation
What are some side effects that can arise from COX-1 inhibition?
GI upset, GI bleeding, nausea
The COX-2 pathway leads to what kind of prostaglandins?
Inflammatory–recruitment of inflammatory cells, sensitization of skin pain receptors.
The COX-2 pathway is active in the kidneys. What is its result in the kidney?
Regulation of BP
The COX-2 pathway results in prostacyclins. What is the role of prostacyclins?
They cause vasodilation and keep thromboxanes in check. Hence, inhibition of COX-2 results in vasoconstriction (an increase in BP) and an increase in clot formation due to the thromboxanes.
What are the 4 benefits of NSAIDs?
Anti-pyresis (fever-reducing); anti-platelet (clot reduction); analgesic (pain-reducing); anti-inflammatory (in higher doses)
True or false: NSAIDs can damage the liver
True.
Which NSAIDs are very COX-1 selective? Which are COX-2 selective?
Aspirin and piroxicam are very COX-1 selective; celecoxib and meloxicam are COX-2 selective
Patients with what type of allergy should not be given celecoxib?
Sulfa
Which NSAIDs are used as topical agents to reduce macular swelling after cataract surgery (and prophylactically, too)?
Ketorolac, diclofenac
What are some side effects that can arise from corticosteroid use?
Osteoporosis, diabetes, HTN, weight gain, infections, Cushing’s syndrome (not disease), cataracts, glaucoma
Corticosteroid use is contraindicated in what common condition?
Pregnancy
What is the upper limit of how long a corticosteroid should be used?
About 3 months
How long do DMARDs take for their full effect?
6 weeks to 6 months
What type of infection can be reactivated with DMARD use?
Usually TB
Methotrexate causes a decrease in what cellular substance?
Folic acid, decreasing the ability of the cell to contribute to the inflammatory response. This leads to apoptosis.
True or false: methotrexate is safe to take during pregnancy
False.
What are some of the side effects of methotrexate use?
Nausea, liver damage, pulmonary toxicity, mouth ulcers, alopecia, infections
Which DMARDs act as folic acid inhibitors?
Methotrexate and sulfasalazine
How long do patients take to respond to sulfasalazine treatment?
3-6 months
True or false: sulfasalazine is safe to take during pregnancy
True.
What are some of the side effects of sulfasalazine use?
Nausea, rash, reversible infertility in males
How does hydroxychloroquine work?
It impairs the cytokine response
How long do patients take to respond to hydroxychloroquine treatment?
3-6 months
What is a normal dose of hydroxychloroquine for RA?
200-400mg (usually 200mg) bid
Hydroxycloroquine binds to melanin, making it especially toxic for what part of the eye?
The macula
What are some of the side effects of hydroxychloroquine use?
Irreversible retinopathy (bull’s eye retinopathy) 1 in 2000; GI upset, nightmares, psychosis
True or false: hydroxychloroquine is safe to take during pregnancy
True.
True or false: azathioprine and leflunomide (DMARDs) are safe to take during pregnancy
False.
Which DMARD might be used if previous DMARDs haven’t been working?
Cyclophosphamide
How does cyclophosphamide work?
Suppresses B and T cell function by 30-40%
How long can cyclophosphamide be used for?
3-6 months
What are some of the side effects of cyclophosphamide use?
Herpes zoster, alopecia, nausea/vomiting, infertility in males and females
True or false: cyclophosphamide is safe to take during pregnancy
False.
How does cyclosporine work?
It inhibits IL-1 and IL-2 and T cells
What ophthalmic solution contains cyclosporine?
Restasis (for dry eye)
What are some of the side effects of cyclosporine use?
HTN, kidney problems (in 50%), infection
True or false: cyclosporine is safe to take during pregnancy
False.
Which DMARDs are tetracyclines?
Minocycline and doxycycline
True or false: doxycycline has both antibiotic and anti-inflammatory effects
True.
How does doxycycline work?
It inhibits MMPs, TNF, T cells, and cytokines
What are some of the side effects of doxycycline use?
Skin rash, GI upset, sensitivity to sun, dizziness, decreases effectiveness of birth control, increases potency of blood thinners, causes teeth and bone deformity in children (CI pregnancy and breast feeding)
Use of doxycycline is contraindicated in what populations?
Pregnant, breast-feeding, or kids (causes bone and teeth deformity)
True or false: all biologic drugs for RA are injections
True.
If a biologic drug is used to treat RA, it is usually given with what other DMARD?
Methotrexate
What are the side effects of biologic drugs?
Infection risk, TB activation, increased risk of malignancy, demyelination
Use of biologic drugs for a patient with RA is contraindicated if the patient has what other condition?
MS
The biologic drugs have what type of suffix?
“-mab”
True or false: all biologic drugs for RA are safe to use in pregnancy
False; none of them are safe to use during pregnancy
Which biologic drug for RA is approved for children?
Tocilizumab
True or false: using two biologic drugs is completely safe for treatment of RA
False; it decreases the immune response too much
