General Flashcards
Rx non-renal SLE
Mild/moderate
Hydroxychloroquine +/- pred
Moderate
Azathioprine or MTX
- Azathioprine in childbearing age/pregnancy. Otherwise MTX is probably a bit better.
Severe
Mycophenolate (more for renal SLE) - very potent
Rituximab
Cyclophophsmiade
Anti-dsDNA in SLE
very specific, can correlate with disease activity, high result suggests renal disease
Anti-SM positive in SLE
Very specific
Main differences between SpA and DISH
SpA
- Younger people before age 45
- History of psoriasis, IBD, uveitis, dactylitis
- FHx
- Inflammatory back pain or stiffness
- Postural abnormalities
- Response to NSAIDs
- Xray:
DISH
- Asymptomatic
- Found on xray - continuous bulky calcificat of the anterior longitudinal ligaments
- Cervical and thoracic spine
What is Livedo racemosa?
Similar to livedo reticularis
Lace is contained in livedo racemosa but broken in reticularis
What is polyarteritis nodosa?
Raised inflammatory markers
Renal impairment
CT small vessel aneurysms
Livedo racemosa
No available autoantibody screening test
Febuxostat vs allopurinol
Both xanthine oxidase inhibitors
Febuxostat
- Can cause LFT derangement
- Drops uric acid very quickly (more likely to have flares) so important to have people on prophylaxis colchicine 500microg BD (eGFR >60). If renal function is bad, may need pred.
- ?Higher CV events
Uric acid targets for tophi and non-tophi gout
Tophi: <300micromol/L
Non-tophi: <360micromol/L
When to start febuxostat?
Better for renal impairment
Not tolerating uptitration of allopurinol
Allopurinol hypersensitivity syndrome
How to start allopurinol?
Uptitrate allopurinol up to 900mg first - increase 100mg each month if renal function normal until uric acid level is at target
Start prophylaxis (colchicine) at the same time. Continue until you reach target for 6 months.
When to avoid colchicine?
eGFR <30: don’t use colchicine. Use pred instead.
eGFR 30-60: daily dosing instead of BD
When can you start allopurinol after a flare?
Can start during the acute attack
Bad flare and on prednisolone/NSAIDs - wait for flare to turn around and start allopurinol after 3-4 days (100mg if no renal impairment; dose reduce if renal impairment)
Rx acute gout flare
Prednisolone and NSAIDs work equally well
Can hit them harder with prednisolone (up to 50mg for polyarticular gout)
Need to be careful with NSAIDs in kidney impairment
Can you get total resolution of tophi with good serum uric acid control?
Yes
Can take several years
Can also have surgical management but this must be done after good serum uric acid control. If not it will come back quickly.
Dual energy CT for gout
When is it used?
Not that helpful
Can’t rely on it diagnostically
Poor sensitivity, specificity
Can quantify the amount of uric acid in a joint e.g. 20ml
GCA is pretty rare under age …
50
Few case reports around the world!
What’s a specific sign of GCA?
Jaw claudication
Why should we do bilateral temporal artery biopsies for GCA?
Biopsy of the contralateral temporal artery can increase the yield by 15%
What might you see on ultrasound of temporal artery suggesting GCA?
Halo sign
But US is generally not useful cause its not done often
Does steroids influence temporal artery biopsy outcome?
TAB should be performed ASAP after steroid treatment (Within 14 days)
But it can be positive even after weeks of steroids
How big should the temporal artery biopsy be?
2.5cm or more
High suspicion for GCA but negative temporal artery biopsy
What do you do?
Start
PET - large vessel vasculitis but no cranial nerve involvement
Should we screen GCA patients with aortic aneurysm?
No
This is controversial some rheumatologists do
Why do we use aspirin in GCA?
Secondary prevention
Pred increases hypertension, cholesterol, BSLs
Continue until pred is finished (or continue if there are risk factors)
Tozolizumab in GCA
When is it indicated?
Subcut weekly injections
Not PBS covered
But can be used in patients with brittle diabetes and you’re worried about using prednisolone
Describe lefluonamide induced neuropathy
Symmetrical
Hands and feet
Motor and sensory neuropathy
Anti-MDA5 antibody in polymyositis
Rapidly progressively lung disease
What disease?
1) AntiCCP
2) AntiSM
3) AntiScl70
4) AntiDNA
5) RF
6) Anti-centromere
7) Anti-Jo
8) Anti-RNP
9) Ro and La
RA - specific
SLE - specific
Diffuse scleroderma
SLE - particularly worsening disease or renal
RA - not very specific
limited scleroderma (more benign than diffuse)
Anti synthetase syndrome (muscle, lung, joint problem)
Mixed CT disease
Sjogren’s but not very specific
Which feature has the worst prognosis in anti synthetase syndrome?
Dysphagia
How do you differentiate SpA from mechanical back pain?
morning stiffness*** most useful
younger men
Buttock pain
HLAB27 is present in ….% of SpA
90%
But also present in 10% of normal people without SpA
Which investigation is best to support a diagnosis of SpA?
Xray sacroiliac joints
What 3 tests rule out SpA?
Normal sacroiliac xray
Normal MRI
Negative HLAB27
Is colchicine good for acute flare of gout?
No
Better as a prophylaxis
May use colchicine for 24hrs if worried about infection until joint MCS comes back
Use NSAIDs or prednisolone if renal impairment instead
Radiological pattern of ILD in the following
1) RA
2) MCTD
3) SSc
4) Ankylosing spondylitis
5) Sjogren’s
1) UIP >NSIP >OP
2) NSIP/OP >UIP
3) NSIP >UIP
4) Upper lobe fibrosis
5) NSIP >LIP (lymphocytic interstitial pneumonitis - seen exclusively in Sjogren’s)
4As in anklylosing spondylitis
Apical fibrosis
Aorta incompetence
A
Lupus pernio (rash on face) What's the dx?
Sarcoidosis
Livedo reticularis vs livedo racemosa
Livedo reticularis - closed rings - venous problem
Livedo racemosa - open rings - arteritis problem
Retiform purpura - tissue ischaemia, death
Polyarteritis nodosa associated with
HBV
Which rheum drugs are safe in pregnancy?
PASH
Pred
Azathioprine
Sulfasalazine
HCQ
Glucocorticoid-induced OP
What’s the only available therapy?
Bisphosphonates
Blocks osteoclast-mediated bone resorption
Clinical features of PMR
Shoulder, neck, lumbar, hip pain/reduced ROM
Prolonged morning stiffness
Muscle strength normal but testing limited by pain
Associated with depression, fatigue, weight loss
Age of people with PMR
> 50 years old
Investigations in PMR
Elevated CRP, ESR
Negative RF, CCP to exclude sero+ RA
SPEP to exclude myeloma
CK to exclude myositis
Immunology of PMR
IL6 is important
Increased Th17, and reduced Th1 and Treg cells
What assessment tools can you use to assess severity of PMR?
PMR activity score
Can be used to define a flare and to guide treatment
Treatment of isolated PMR
Prednisolone 15mg/day then slow wean after 4 weeks
Respond within 48-72hr
May get relapses during wean
