Exam 2: Rheumatology/Autoimmune Disorders [15] Flashcards
1
Q
Is rheumatoid arthritis more common in men or women or equally common?
A
RA is more common in women (3:1)
Peak age of onset is age 20-40 but can occur at any age (peak age for diagnosis is 40s-50s)
Family history of RA or other autoimmune disorders not uncommon
2
Q
What is the goal of treatment for RA?
A
RA goal of treatment is to:
- Reduce pain, stiffness, and swelling while preserving mobility and joint function
- Prevention of further joint damage
3
Q
What are some common symptoms of RA?
A
Can be gradual over weeks to months Fatigue Low-grade fever Generalized body aches Generalized joint pain
Joint pain can be in the: Fingers/hands Wrists Elbows Shoulders Ankles Feet Toes
4
Q
Is RA symmetrical or mainly on one side of the body?
A
RA is symmetrical and involves more joints than OA
5
Q
With this arthritis, the patient has pain, warm/red/swollen/tender joints in the wrist, MCP, and PIP joints, and stiffness that occurs for at least an hour or longer in the mornings and/or after inactivity.
A
RA
6
Q
What are other possible systemic manifestations (other diseases) from RA?
A
RA can cause:
Raynaud's Systemic Lupus Dry eyes and mouth (secondary to Sjogren's syndrome) Interstitial lung disease Pleuritis or pericarditis Vasculitis Grave's disease Pernicious anemia Uveitis
7
Q
Which types of arthritis is associated with “sausage joints?”
A
RA
Psoriatic
8
Q
In this type of arthritis, an x-ray will reveal erosions, joint space narrowing, and subluxations (or dislocation).
A
RA
9
Q
What are the major labs and their findings for RA?
A
Anti-CCP: positive (this is the most specific test for RA)
Rheumatoid Factor: most likely positive but can indicate other autoimmune issues
CRP: elevated with inflammation
ESR: elevated with inflammation
CBC: mild microcytic or normocytic anemia
Anti-cyclic citrullinated peptide antibodies (anti-CCP)
ANA: may be elevated but can be d/t other autoimmune disorder
10
Q
How long must RA symptoms be present in order to diagnose?
A
6 weeks or longer
11
Q
What is the treatment for RA?
A
NSAIDs (relieves inflammation/pain but does not change the progression of disease)
Steroids (oral and/or joint injections) - may be used in place of NSAIDs and to bridge therapy
(**NOTE: First-line treatment is methotrexate)
Disease-modifying Antirheumatic Drugs (DMARDs): (Methotrexate), sulfasalazine, hydroxychloroquine (Plaquenil)
Tumor Necrosis Factor (TNF) drugs (biologics) if DMARDs not helpful:
Etanercept (Enbrel) - SC
Adalimumab (Humira) - SC
Infliximab (Remicade) - IV
12
Q
What do we have to monitor when a patient is taking hydroxychloroquine (Plaquenil)?
A
Vision
A baseline eye exam should be completed prior to starting the medication and then every 6 months to prevent blindness.
13
Q
What medication is the “gold standard” and first-line treatment for RA?
A
Methotrexate
14
Q
Should patients on biologic meds receive vaccines?
A
Yes, but not live vaccines
15
Q
What is dactylitis?
A
Dactylitis = sausage fingers
16
Q
Can RA and OA occur at the same time?
A
Yes
17
Q
Other than the eyes, what do we need to monitor and how often in RA patients taking meds especially methotrexate?
A
Main concerns: hepatoxicity and bone marrow suppression
Labs to monitor: liver, kidneys
Labs every 4-8 weeks then every 12 weeks if no adverse affects after a year
Most patients need to be seen 3 to 6 times per year
18
Q
Is OA inflammatory?
A
No; OA affects individual joints without systemic effects (cartilage and bone issue usually from wear and tear)
19
Q
What is the most common form of arthritis in adults?
A
OA
20
Q
What is Osteoarthritis (OA) or Degenerative Joint Disease (DJD) and what areas are affected?
A
OA or DJD occurs when the cartilage covering the articular surface of joints becomes damaged from overuse and from age.
Most commonly occurs in hips, knees, hands, spine, and feet
21
Q
What are the risk factors for OA?
A
Risk factors for OA:
Older age Overuse of joints Positive family history Female Obesity Joint trauma
22
Q
What are signs and symptoms of OA?
A
Early morning joint stiffness lasting < 60 minutes
Pain exacerbated by activity of the joint; relieved at rest
Tenderness of involved joints on palpation
Decreased range of motion
Joint instability
Bony enlargement
Crepitus (audible)
Joint space narrowing
23
Q
Is OA symmetrical or asymmetrical?
A
Typically asymmetrical
24
Q
Which joints of the hands does OA affect?
A
The PIPs and DIPs are affected with OA
The MCPs are not affected by OA
25
Heberden's nodes are found where?
DIP joints (distal) - (you can eat herb dip)
26
Bouchard's nodes are found where?
PIP joints
27
What are the goals of treatment of OA?
Disability prevention
Pain reduction
Continued mobility
28
What are non-pharmacological treatments for OA?
Exercise: ROM and strengthening (weightbearing)
Isometric exercises to strengthen quadriceps (knee OA)
Weight loss if appropriate
Cold/heat packs
Ultrasound?
Physical therapy
Stop smoking
29
What is first-line treatment for OA?
Acetaminophen up to 3 g/day
| Can start with PRN and then scheduled if need be
30
What else can be used to treat OA if acetaminophen if there are liver problems or it does not provide relief
NSAIDs (oral)
| If older than age 75 use topical NSAIDs instead of oral
31
What other pharmacologic can be used to treat OA if NSAIDs or acetaminophen not effective on their own?
```
Intra-articular steroid joint injections (if inflammation present)
Hyaluronate injection (viscous solution helps relieve knee pain)
```
32
What is the most invasive treatment for OA?
Surgery
33
Any autoimmune disease increases risk with or without meds for _______.
Lymphoma (non-tender, fixed, firm lymph nodes)
34
For RA treatment, why is triple therapy with methotrexate, sulfasalazine, and hydroxychloroquine tried before treatment with methotrexate and Enbrel?
The triple therapy uses much older and cheaper drugs and works for many patients. The biologics such as Enbrel can cost $30k to $40k per year.
35
Which joints are involved in psoriatic arthritis that are not involved in RA?
Psoriatic arthritis can affect the MCPs, PIPs, and DIPs
RA does not affect the DIPs
36
What findings are commonly seen in psoriatic arthritis?
Pitting nails
Psoriasis
Dactylitis
37
In this type of arthritis, the joint dissolves on itself (mutilans)
Psoriatic
38
What are the treatment options for psoriatic arthritis?
NSAIDs, steroid injections - comfort
Methotrexate (MTX): helps with skin and joints
Anti-TNF biologics
Less appealing:
Hydroxychloroquine (usually for RA, SLE): can flare psoriasis
Prednisone: helps but the taper is associated with psoriasis flare
39
In this type of arthritis, the patient is at least 50 years old and usually over the age of 70. It has an acute onset of weeks and occurs in two or more "axial" joints (neck, shoulders, pelvic girdle). The patient can have morning stiffness of an hour or more.
Polymyalgia Rheumatica (PMR)
40
Which type of arthritis is associated with giant cell arteritis?
Polymyalgia Rheumatica (PMR)
41
A patient with polymyalgia rheumatica (PMR) has complaints of vision changes, jaw pain, or scalp tenderness. What will you do?
Send to the ED
Medical emergency
Need high dose of IV steroids to prevent blindness
42
Which medication does polymyalgia rheumatica (PMR) respond to best?
Prednisone (15-20 mg/day)
43
In a patient with polymyalgia rheumatica (PMR), what is the timeframe to taper the prednisone and why?
After 4-8 weeks on 15-20 mg/daily,
begin tapering doses by 5 mg/week,
continue on the lowest dose for the remainder of time
Taper over 1-2 years depending on patient response
First year: monitor every 4-8 weeks
Second year: monitor every 8-12 weeks
44
In a patient with polymyalgia rheumatica (PMR), if the patient fails 2 attempts to taper the prednisone, which medication can we add on while attempting to taper the prednisone?
Methotrexate
45
In which 3 types of arthritis will you see inflammation?
RA
Psoriatic
Ankylosing spondylitis (Not on exam)
46
What is the most important thing patients with lupus can do to protect themselves?
Stay out of the sun (causes outbreak of rashes)
Use sunscreen
Wear long-sleeved shirts and wide-brimmed hats
47
This autoimmune disease is more common in women (9:1) and is characterized by remissions and exacerbations
Systemic Lupus Erythematosus (SLE)
48
Systemic Lupus Erythematosus (SLE) is more common in these ethnicities
African American
| Hispanic
49
Which type of lupus is most disfiguring with permanent lesions?
In discoid lupus (chronic lupus), lesions do not go away and can cause scarring on the scalp (with patches of hair loss), on the face, pinnae, behind the ears, and neck.
50
What are 5 triggers for SLE?
```
Recent sun exposure (#1)
Emotional stress
Infection
Certain drugs
Stress of surgery
```
51
The _____ is the main organ affected by SLE
The _kidney_ is the main organ affected by SLE
Other systems SLE can affect:
Nervous system
Cardiovascular (pericarditis)
Pleura and lungs
52
Which drug is the main treatment for SLE?
Hydroxychloroquine (Plaquenil): FDA approved
```
Other meds:
NSAIDs
Steroids topical but not on face
Steroids oral
Immunosuppressants: Methotrexate, Cellcept, Azathioprine, Cytoxan
```
53
If a patient has double-stranded DNA it means they have some type of which system involvement?
Renal
54
When monitoring SLE activity, it is important to watch for involvement of other body systems. What autoantibodies should be monitored routinely?
dsDNA (double strand DNA) can indicate flare with renal involvement
C3 and C4 will be low
55
What is the typical presenting age of those with SLE?
Female reproductive years (20-40)
56
The sun can cause flares in which 2 disorders?
SLE
| Psoriatic arthritis
57
CPR and ESR may be elevated in RA and SLE. Why is this and is it diagnostic?
CPR and ESR are inflammatory markers but they are not diagnostic and not specific to either disorder.
58
For the diagnosis of SLE, do you need a positive or negative ANA?
ANA must be positive for SLE diagnosis
59
Name 2 reasons you would want to stop TNF inhibitors in a patient with SLE and why.
Strep infection
Before surgery
TNF inhibitors lower the immune response
60
In a patient with OA, would you do a joint aspiration?
No, OA is not inflammatory
61
Joint pain and stiffness is usually symmetrical in theses 3 conditions
Joint pain and stiffness is usually symmetrical in theses 3 conditions:
RA
SLE
Ankylosing spondylitis (not on exam)
62
Joint pain and stiffness is usually asymmetrical in these 2 conditions
Joint pain and stiffness is usually asymmetrical in these 2 conditions:
OA
Psoriatic arthritis
63
Intermittent stiffness and gelling are seen in ______
OA
| Bates Guide to Physical Exam p. 632 in red
64
This type of arthritis can have an acute onset mimicking gout and/or RA
Psoriatic arthritis
65
Is psoriatic arthritis more common in men or women?
Psoriatic arthritis equally affects men and women at any age
66
A 55-year-old patient reports new onset bilateral shoulder pain with morning stiffness lasting about an hour. Which diagnostic tests would you do?
A. Antinuclear antibodies (ANA)
B. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)
C. Serum calcitonin
D. Rheumatoid factor (RF)
A 55-year-old patient reports new onset bilateral shoulder pain with morning stiffness lasting about an hour. Which diagnostic tests would you do?
Answer: B
ESR, CRP, and protein electrophoresis are completed initially when polymyalgia rheumatica is suspected (PMR). Thinking rheumatoid because c/o bilateral pain and morning stiffness lasting an hour
ANA testing is not specific for this disorder
Serum calcitonin is not indicated
67
A patient is diagnosed with polymyalgia rheumatica (PMR) with giant cell arteritis. What dose of prednisone would you prescribe?
A. 15 mg
B. 20 mg
C. 40 mg
D. 60 mg
Answer: D
Although usual starting dose to treat PMR is 15-20 mg daily, a higher dose of 60 mg daily is used when there is evidence of concomitant giant cell arteritis.
68
A patient is diagnosed rheumatoid arthritis (RA) after a review of systems, confirmatory lab tests, and synovial fluid analysis. What will the NP order initially to treat the patient?
A. Disease-modifying anti-rheumatic (DMARDs) drugs
B. Long-term glucocorticoids
C. Non-pharmacological treatments
D. NSAIDs
Answer: A
DMARDs should be started as soon as the diagnosis of RA is established to achieve a progression in the disease.
(Methotrexate = gold standard treatment for RA)
Long-term use of steroids not recommended
NSAIDs are not first-line treatment but they may be used as adjunctive therapy as long as there are no renal or cardiac issues
69
Which are symptoms of RA that distinguish it from OA? Select all that apply:
```
A. Extra-articular inflammatory signs
B. History of injury to affected joints
C. Morning stiffness of at least 1 hour
D. Symmetric tender, swollen joints
E. Unilateral joint involvement
```
Answers: A, C, D
RA includes:
Extra-articular symptoms
Morning stiffness lasting at least 1 hour
Symmetric, bilateral joint involvement
OA:
Often a history of previous injury
Usually asymmetric and may be unilateral
70
Which lab tests may help distinguish lupus from other systemic rheumatologic disorders?
A. Antinuclear antibody (ANA)
B. C-reactive protein (CRP)
C. Rheumatoid factor (RF)
D. Serum complement levels (C3, C4)
Answer: D
Low complement levels (3, C4) signifies active SLE, especially lupus nephritis
The other tests are non-specific for inflammation and rheumatologic disorders
71
A patient with lupus has frequent symptoms and has been taking prednisone for each episode. The NP plans to start hydroxychloroquine and the patient asks why the medication is necessary. What will the NP say?
A. It is effective in reducing disease flares and for tapering steroids
B. It is given in conjunction with steroids to improve outcomes
C. It lowers blood pressure and decreases risk for renal disease
D. It prevents the need for bisphosphonate therapy
Answer: A
Hydroxychloroquine is effective in managing musculoskeletal, cutaneous, and serosal manifestations of lupus and allows tapering of steroids and reduces disease flares.
Cyclophosphamide is given with prednisone to improve renal outcomes.
Hydroxychloroquine is not given for affects on BP and kidneys
Calcium and Vitamin D are given to prevent the need for bisphosphonates
72
Which of the following has a high sensitivity and specificity for RA?
A. Rheumatoid factor
B. Antinuclear antibody (ANA)
C. Anti-cyclic citrullinated peptides (anti-CCP)
D. Erythrocyte sedimentation rate (ESR)
Answer: C (anti-CCP)
Answer: C
Anti-CCP has 75% sensitivity and 96% specificity for RA
Rheumatoid factor not specific to RA and may be present in other autoimmune diseases, hep c, and in healthy older adults
ANA may be present in RA but not specific for RA and can be elevated in lupus
CRP and ESR are non-specific markers of inflammation but may be used during treatment of RA to follow disease activity and medication response
73
Which of the following should be considered in the treatment of mild osteoarthritis?
A. Oral opioids
B. Weight loss and physical activity
C. Intra-articular steroid injection
D. Joint replacement
Answer: B
Mild OA can be treated with exercise, PT, weight loss, acetaminophen, NSAIDs
Moderate OA can be treated with glucosamine and chondroitin but d/c if not helpful after 3 months
The rest are considered in severe OA
74
Which of the following medications should be used as first-line therapy treatment for mild OA pain in a patient with chronic kidney disease?
A. NSAIDs
B. Intra-articular corticosteroids injections
C. Oral opioids
D. Acetaminophen
Answer: D
Acetaminophen is first-line therapy for mild OA
NSAIDs are probably equivalent to acetaminophen but should be avoided in people with peptic ulcer disease and chronic kidney disease
75
Patients with psoriatic arthritis are at increased risk of which of the following:
A: Cardiomyopathy
B. DVT
C. Uveitis
D. Osteoporosis
Answer: C
Systemic involvement is limited to eye inflammation (uveitis or conjunctivitis) which occurs in approximately 30% of patients.
76
Which of the following is an early clue for psoriatic arthritis in the absence of skin rash?
A. Alopecia
B. Nail pitting
C. Oral ulcerations
D. Easy bruising
Answer: B
Nail pitting can present before the rash and is often the first clue
77
Psoriatic arthritis has been genetically linked to:
A. HLA class 1 alleles
B. BRCA 1 and 2 mutations
C. Predisposition to group A strep infection
D. Rheumatoid arthritis
Answer: A
Psoriatic arthritis has been linked to HLA class 1 alleles
78
What are the 7 diagnostic criteria for RA?
The patient has RA if at least 4 of the following are present and for at least 6 weeks:
1. Morning stiffness > 1 hours
2. Symmetrical
3. Nodules
4. Rheumatoid factor > than expected for age
5. Arthritis of the hand joints (at least 1 of the affected joints must be wrist, MCP, or PIP)
6. X-ray changes that include erosions or unequivocal bony decalcification
7. Arthritis of 3 or more joints symmetrically (PIPs, MCP, wrist, elbow, knee, ankle, MTP)
79
What are some of the signs and symptoms noted with lupus?
Symmetrical arthritis
Fever, malaise, anorexia, weight loss
Malar rash to face, alopecia
Conjunctivitis, photophobia, blurred vision
Oral ulcers
Restrictive lung conditions, pleurisy, pleural effusion, PNA
Pericarditis, arrhythmias, endocarditis, Libman-Sacks
Belly pain
Protein urea (kidney involvement - glomerulonephritis)
Psychosis, cognitive impairment, seizures, neuropathies
Leukopenia and thrombocytopenia
+ ANA
+ Anti-Smith test
80
Name 3 medications that can cause drug-induced lupus:
1. Procainamide
2. Hydralazine
3. Isoniazid
81
Which 3 features of RA overlap with lupus?
Arthritis
Pleural inflammation
Leukopenia
82
How can we differentiate RA from lupus?
Lupus: Photosensitivity, + ANA
RA: Inflammatory, symmetrical, tender joints
Erosions on X-ray
83
Pain in the first CMC is frequently found with this type of arthritis:
First CMC = base of thumb is indicative of OA
84
This type of arthritis affects about 25% of those with Crohn's disease:
(Not on exam)
Peripheral arthritis
85
What condition occurs approximately 7 years after giant cell arteritis?
Aortic dissection commonly occurs approximately 7 years after have giant cell arteritis
Symptoms: tearing substernal chest pain radiating to the back, anxiety, diaphoresis, tachycardia, hypotension
CT would be best test to order for symptoms
86
Radiographs with psoriatic arthritis show what?
Pencil-in-cup deformity
87
Can you get an STD in the knee and if so, which one?
Yes; gonorrhea
| Check sexual history in young arthritis patients
88
What type of medication is CellCept and which condition is it sometimes prescribed for?
CellCept is an immunosuppressant drug originally used in transplant patients to lower chances of rejection. It is also used in treating lupus especially if the kidneys are involved.
89
What color should synovial fluid be?
What color is synovial fluid in RA?
Synovial fluid should be clear
In RA, it is yellow and cloudy
90
Which 2 autoimmune disorders are treated with hydroxychloroquine?
RA - hydroxychloroquine can be added in methotrexate alone not effective
SLE
91
In which autoimmune disorder is the main treatment prednisone?
And if prednisone not effective, which medication can be added?
Polymyalgia Rheumatica (PMR)
If patient fails 2 tapering attempts with prednisone, Methotrexate is prescribed.
92
In which autoimmune disorders is Methotrexate first-line treatment?
RA
| Psoriatic arthritis
93
In polymyalgia rheumatica (PMR) what level would the ESR be?
In PMR, ESR > 40 mm/h
94
What is a late complication of giant cell arteritis and approximately when does it occur after GCA diagnosis?
Dissecting thoracic aortic aneurysm is a late complication of GCA and generally occurs 6-7 years after the initial diagnosis. It is often mistaken for an MI.
95
What differential diagnoses should be included for RA workup?
Human parvovirus
Hep B and C
HIV
96
Can group A streptococcus (GAS) cause arthritis?
Yes, a post-streptococcal reactive arthritis can occur in children (with higher incidence in those who are HLA-B27 positive) that involves both small, large joints, and the spine. Eventually the arthritis resolves without joint damage.
