high yield muscoskeletal

Question 1

ΣΕΛ (16), Νεφρίτιδα ΣΕΛ (4), Εκδηλώσεις

ΚΝΣ(2), Δερματικός ΣΕΛ(1)

Answer 1

Ηπια νόσος (πυρετός, αρθρίτιδα, πλευριτικό
άλγος, περικαρδίτιδα, κεφαλαλγία,
εξάνθημα): ΜΣΑΦ + ανθελονοσιακά
(χλωροκίνη)
Σοβαρή νόσος (αιμολυτική αναιμία,
θρομβοπενική πορφύρα, μαζική πλευριτική
ή περικαρδιακή συμβολή, νεφρίτιδα, οξείες
αγγειιτιδες των άκρων ή του GI, εκδηλώσεις
ΚΝΣ) : Κορτικοστεροειδή και άλλα
ανοσοκατασταλικά (κυκλοφωσφαμίδη),
ηπαρίνη-βαρφαρίνη (INR: 3)
Αζαθειοπρίνη αντί μακράς χορήγησης
κορτικοστεροειδών

1. Avoid sun exposure because it can exacerbate cutaneous rashes
2. NSAIDs—for less severe symptoms
3. Either local or systemic corticosteroids—for acute exacerbations
4. Systemic steroids for severe manifestations
5. Best long-term therapy is antimalarial agents such as hydroxychloroquine—for
   constitutional, cutaneous, and articular manifestations. Hydroxychloroquine is
   continued as a preventative measure even after resolution of symptoms. Annual
   eye examination is needed because of retinal toxicity
6. Cytotoxic agents such as cyclophosphamide—for active glomerulonephritis
7. Monitor the following and treat appropriately:
   a. Renal disease, which produces the most significant morbidity
   b. HTN

Question 2

Ρευματοειδής Αρθρίτιδα(9)

Answer 2

Φαρμακευτική Αγωγή: Αναλγητικά (ΜΣΑΦ),
DMARDs (ανθελονοσιακά, σουλφασαλαζίνη,
μεθοτρεξάτη, κυκλοσπορίνη, λεφλουνομίδη,
γλυκοκορτικοειδή), ανοσοτροποποιητικά:
βιολογικοί παράγοντες (ινφλιξιμάμπη,
ετανερσέπτη, ανταλιμομάμπη)
Φυσιοθεραπεία: Υμενεκτομή,
αρθροπλαστική, αρθρόδεση

1. Goal is to minimize pain and swelling, prevent disease progression, and help
   patient remain as functional as possible.
2. Exercise helps to maintain range of motion and muscle strength.
3. Symptomatic treatment.
   a. NSAIDs are the drugs of choice for pain control.
   b. Corticosteroids (low dose)—use these if NSAIDs do not provide adequate relief.
   Short-term treatment may be appropriate but avoid long-term use.
4. DMARDs
   a. General principles
   • Can reduce morbidity and mortality (by nearly 30%)—by limiting complications,
   slowing progression of disease, and preserving joint function
   • Should be initiated early (at the time of diagnosis)
   • They have a slow onset of action (6 weeks or longer for effect to be seen),
   so begin treating RA while waiting for the disease-modifying therapy to take
   effect. Gradually taper and discontinue NSAIDs and corticosteroids once
   effects are evident
   b. First-line agents
   • Methotrexate—best initial DMARD
   • Initial improvement is seen in 4 to 6 weeks.
   • Side effects include GI upset, oral ulcers (stomatitis), mild alopecia, bone
   marrow suppression (coadminister with folinic acid), hepatocellular injury,
   and idiosyncratic interstitial pneumonitis, which may lead to pulmonary
   fibrosis. It increases liver enzymes in some patients
   • Closely monitor liver and renal function
   • Supplement with folate.
   • Leflunomide is an alternative to methotrexate or can be used as an adjunct to
   therapy with a DMARD.
   • Hydroxychloroquine
   • This is an alternative first-line DMARD, but usually not as effective as methotrexate
   and is typically used in less severe cases
   • It requires eye examinations every 6 months because of the risk of visual loss
   due to retinopathy
   • Sulfasalazine—alternate first-line agent, but less effective than methotrexate
   • Antitumor necrosis factor (anti-TNF) inhibiting agents (etanercept, infliximab,
   etc.)—used if methotrexate does not fully control the disease
   • Requires PPD screening because of risk of reactivation of TB
5. Surgery (in severe cases)
   a. Synovectomy (arthroscopic) decreases joint pain and swelling but does not prevent
   x-ray progression and does not improve joint range of motion
   b. Joint replacement surgery for severe pain unresponsive to conservative measures

Question 3

Ρευματικός Πυρετός(8)

Answer 3

Ασπιρίνη, Κορτικοστεροειδή, αντιβιοτικά
(πενικιλλίνη, ή σουλφαδιαζίνη ή
ερυθρομυκίνη σε αλλεργικούς) για 3-4
εβδομάδες

1. Treat streptococcal pharyngitis with penicillin or erythromycin to prevent rheumatic
   fever.
2. Acute rheumatic fever is treated with NSAIDs. C-reactive protein is used to monitor
   treatment.
3. Treat the valvular pathology of rheumatic heart disease.

Question 4

Οξεία ουρική αρθρίτιδα(8)

Answer 4

ΜΣΑΦ, κορτικοστεροειδή, κολχικίνη (μια
φορά την ημέρα)
1. In all stages, avoid secondary causes of hyperuricemia.
a. Medications that increase uric acid levels (thiazide and loop diuretics).
b. Obesity
c. Reduce alcohol intake.
d. Reduce dietary purine intake. Limit intake of seafood/red meat.
2. Acute gout.
a. Bed rest is important. Early ambulation may precipitate a recurrence.
b. NSAIDs
• Treatment of choice in acute gout (indomethacin is traditionally used, but
other NSAIDs are effective).
c. Colchicine
• An alternative for patients who cannot take NSAIDs or did not respond to
NSAIDs.
• Effective but less favored because 80% of treated patients develop significant
nausea/vomiting, abdominal cramps, and severe diarrhea. Compliance tends
to be low due to these side effects.
• It is contraindicated in renal insufficiency and can cause cytopenia.
d. Corticosteroids
• Oral prednisone (7- to 10-day course) if patient does not respond to or cannot
tolerate NSAIDs and colchicine.
• Intra-articular corticosteroid injections (if only one joint is involved)—dramatic
relief of symptoms.
3. Prophylactic therapy.
a. Wait until patient has had at least two acute gouty attacks (or perhaps three)
before initiating prophylactic therapy. This is because the second attack may
take years to occur (if at all), and so the risk-to-benefit ratio for prophylactic
medication (allopurinol or uricosuric agents) is not favorable after one gouty
attack.
b. When giving prophylaxis, add either colchicine or an NSAID for 3 to 6 months
to prevent an acute attack. The colchicine or NSAID can then be discontinued,
and the patient can remain on the uricosuric agent or allopurinol indefinitely.
c. The choice of whether to use uricosuric drugs or allopurinol depends on how
much uric acid is excreted in the urine in a 24-hour period.
• Uricosuric drugs (probenecid, sulfinpyrazone)—if the 24-hour urine uric acid
is 800 mg/day, this indicates undersecretion of urate. These drugs increase
renal excretion of uric acid; use them only in patients with normal renal
function. They are contraindicated if the patient has a history of renal stones.
• Allopurinol, a xanthine oxidase inhibitor, decreases uric acid synthesis—if
the 24-hour urine uric acid is 800 mg/day, this indicates overproduction.
Never give this for acute gout; it makes it worse. Use once-daily dosing. It is
well tolerated. Watch for rash or Stevens–Johnson syndrome. Unlike NSAIDS
and uricosuric drugs, allopurinol is not contraindicated in kidney dysfunction

Question 5

Ρευματική Πολυμυαλγία (5)

Answer 5

πρεδνιζολόνη
Treatment: corticosteroids
1. Response usually occurs within 1 to 7 days. Corticosteroids are not curative, but
are effective in suppressing inflammation until the disease resolves itself.
2. After 4 to 6 weeks, begin to taper slowly.
3. Most patients (60% to 70%) can stop corticosteroids within 2 years. A few patients
have symptoms for up to 10 years.

Question 6

Κροταφική Αρτηρίτιδα (5)

Answer 6

ΥΨΗΛΕΣ ΔΟΣΕΙΣ ΚΟΡΤΙΚΟΣΤΕΡΟΕΙΔΩΝ
1. Use high-dose steroids (prednisone) early to prevent blindness.
a. Start treatment immediately, even if temporal arteritis is only suspected. Do not
wait for biopsy results. If visual loss is present, admit the patient to the hospital
for IV steroids; otherwise, start oral prednisone.
b. If the diagnosis is confirmed, continue treatment for at least 4 weeks, then
taper gradually, but maintain steroid therapy for up to 2 to 3 years. Relapse is
likely to occur if steroids are stopped prematurely.
2. Follow up on ESR levels to monitor effectiveness of treatment.
3. Visual loss in one eye may be temporary or permanent. Prompt and aggressive
steroid treatment is primarily given to prevent involvement of the other eye, but it
may improve the visual outcome in the affected eye as well.
4. Even if untreated, the disease is usually eventually self-limiting in most patients,
although vision loss may be permanent.

Question 7

ΑΕ κολχικίνης, αλλοπουρινόλης (8)

Answer 7

Κολχικίνη: γαστρεντερικές διαταραχές
(εμετοί, διάρροια, ναυτία), διαταραχές από
το ΚΝΣ (κοπωση, σπάνια κεφαλαλγία)
Αλλοπουρινόλη: εξάνθημα, ουρική
αρθρίτιδα, ναυτία, διάρροια,
ηπατοτοξικότητα