Major Arthritides Flashcards
How should you approach articular disease.
Look for 1 of 3 patterns - monoarticular - symmetric polyarticular - asymmetric polyarticular Look for active vs Passive ROM Distinguish single joint from multiple joint involvement
What are 7 diseases to keep in your differential for Monoarticular Arthritis?
- Osteoarthritis
- Crystals (Gout)
- Trauma
- Infection: septic or viral
- Neoplastic
- Overuse
- Vascular (Necrosis)
What are 9 diseases to keep in differential for Symmetric polyarhritis?
- RA
- SLE (skin findings)
- Psoriatic arthritis
- scleroderma
- polymyalgia rheumatica (older pt with shoulder/hip sx)
- lyme disease
- Pseudogout
- Sarcoid (get CXR)
- Spoldyloarhtropathy (assoc with IBD)
How do you distinguish arthritis from non-articular, soft tissue syndromes?
- Active ROM restriction implies soft tissues
- passice ROM restriction implies joint involvement
What is the most specific finding in RA?
- high ESR?
- positive ANA?
- positive RF?
- Rheumatoid joint erosions?
Rheumatoid joint erosion is the most specific
What are the criteria for RA diagnosis?
> 6 points is unequivocably positive for RA
4 areas considered in diagnosis
1. # of joints: the higher number of small joints the more powerful
2. Serology: + RF, + ACPA
3. Acute phase reactants: + CRP/ESR
4. Duration of symptoms > 6 weeks
After diagnosing R.A. when should DMARDs be started?
Right away
What is the first line non biological dmard?
Methotrexate
Add folic acid
When should patients be referred to rheumatologist?
If symptoms last more than 6 weeks
What is the main cause of mortality in treating R.A.?
Cardiovascular disease
What is first line treatment for ankylosis spondylitis?
NSAIDs
How would you describe the joint findings in psoriatic arthritis?
Oligoarticular associated dactylitis Predominant DIP involvement Nail changes “R.A. like” poly arthritis - lacks RF Axial involvement - spondylitis
How do you treat psoriatic arthritis
- physical therapy - start early
- dmards for slowing down joint- choose the biologic answer if offered
What is reiter’s triad
“can’t see, can’t pee, can’t climb a tree”
nongonococcal utrethritis, conjunctivitis, arthritis
Usually follows GI bugs with hemorrhagic diarrhea
What is the initial management of all spondyloarthropathies?
What DMARDs do you use after this treatment?
1st line - NSAIDS –> SOR C
2nd line - Sulfasalazine –> SOR B
What are the symptoms of OA - which joints does it affect in the hand?
- insidious onset
- aching and burning
- more common in hands and large weight bearing joints
- in hand: DIP and PIP but not wrist and MCP
What treatments for Osteoarthritis are recommended by the AAFP 2014 guidelines?
- recommend self-management programs with strengthenin and low impact aerobic exercise
- Rx: nsaids and tramadol
- don’t recommend injections, glucosamine, chondroitin, acupuncture
When talking about birefringent crystals, what is the buzzword for gout vs pseudogout?
Pseudogout is Positively birefringent
Gout is negatively birefringent
A man comes in with podagra and elevated uric acid, does he have gout?
- maybe
- hyperuricemia alone is insufficient to diagnose gout
- you need to see negatively birefringent crystals
What uric acid level puts you at increased risk for gout?
> 6.8 mg/dL
Which foods increase gout risk?
Foods high in protein
High fructose corn syrup
Which BP meds increase risk for gout?
Essentially all anti-HTN are bad for gout with the exception of CCB and losartan (lower RR in studies)
What are the indications for a uric acid lower agent like allopurinol?
SOR A
- tophi or freuqnt attacks (> 2 per year)
SOR C
- CKD 2
- gout with urolithiasis
- UA overproduction and urinary overexcretion
Management of acute gout
SOR A: start with NSAIDs + PPI or colchicine
SOR C: low dose corticosteroids if colchicine or NSAIDs not tolerated
How long should prophylaxis with UA lowering agents continue in treatment of gout?
First need to achieve target Uric acid levels. once these are achieved, then …
- no tophi: 3 months after achieving target UA levels
- tophi: 6 months after achieving target UA levels
What are some non-rheumatic diseases that cause a false positive rheumatoid factor?
- hep C
- mixed cryoglobulinemia (90%)
- sarcoidosis (5-30%)
- pulmonary fibrosis (20%)
- infections
- aging
What disease is associated with the following biomarker?
Anti-smith
SLE
What disease is associated with the following biomarker?
RF
rheumatoid arthritis
What disease is associated with the following biomarker?
Anti-centromere
Scleroderma
What disease is associated with the following biomarker?
Anti-U1RNP
Mixed connective tissue disease
What disease is associated with the following biomarker?
Anti-Jo1
polymyositis
What disease is associated with the following biomarker?
Anti-SSA and Anti-SSB
Sjogren
What disease is associated with the following biomarker?
C-ANCA and P-ANCA
Wegener
What disease is associated with the following biomarker?
Anti-histone
Rule out drug induced lupus
What is the mechnism of Allopurinol?
When someone is on allopurinol how often should you check uric acid?
MOA: reduces production of UA (inhibits xanthine oxidase)
- obtain maintenance uric acid level Q3 months for 6 months, then once yearly once at goal
What are the clinical symptoms of lyme disease at its different stages
1) erythema migrans (bulls eye) 7-10 days after tick bite
2) early dissemination - migratory arhtralgias, fever, systemic
3) Late dissemination/chronic disease - migratory oligoarthritis, carditis, neurological
