MRCP Rheum Flashcards
1
Q
What is the commonest cause of gout?
A
impaired renal excretion of uric acid
2
Q
What are the main symptoms of PMR
A
early morning stiffness in proximal muscles and aching
constitutional symptoms (FLAWS)
NOT WEAKNESS
3
Q
What is the autoantibody for Still’s disease?
A
autoantibody negative
4
Q
Where does tibial nerve compression occur?
A
medial malleolus
5
Q
Which nerve injury do you see foot drop and eversion deficit?
A
common peroneal nerve
6
Q
Which 3 medications are commonly known to be folate antagonists?
A
Trimethoprim
Methotrexate
Co-trimoxazole
7
Q
What is the treatment for Paget’s?
A
Bisphosphanate
Can give IV zolendronate if GORD
8
Q
HLA for ankylosing spondylitis?
A
HLA B27
NOTE: seronegative
9
Q
What eye symptom do you get in GCA?
A
altitude defect (bottom up or top down)
ischaemic optic neuropathy
10
Q
What age group does PMR occur?
A
60-70
11
Q
Which body parts does PMR affect?
A
shoulder girle, spreading both shoulders
pelvic girdle
12
Q
What condition has small joint polyarthritis?
A
Rheumatoid arthritis
13
Q
What are the main symptoms of sjogrens?
A
dry gritty eyes
dry mouth
14
Q
What condition presents with discoid/malar rash and joint pains?
A
SLE
15
Q
What condition has normal CRP but raised ESR?
A
SLE
ESR used to monitor disease
16
Q
What is felty’s syndrome?
A
rheumatoid arthritis
splenomegaly
neutropenia
17
Q
Why is there hypersplenism in felty syndrome?
A
reticuloendothelial stimulation
18
Q
What drug class is given for ankylosing spondylitis after failure of 2 NSAIDs?
A
anti-TNF agent
19
Q
What drug is given for Wilsons?
A
penicillamine
20
Q
What drug should be given in ankylosing spondylitis with peripheral arthritis?
A
DMARD: sulfasalazine/methotrexate
21
Q
Which antibody is associated with CREST - limited cutaneous scleroderma?
A
anti-centromere
22
Q
Which antibody is associated with diffuse systemic sclerosis (scleroderma)
A
anti- scl70
Anti-Topoisomerase II
23
Q
What is the differential for heaviness in both legs and worse back pain with extending back?
A
spinal stenosis
24
Q
Which vasculitis is most commonly associated with pulmonary renal syndrome
A
microscopic polyangitis
25
Which antibody is associated with microscopic polyangitis?
anti-MPO
PANCA
26
SLE multisystem manifestation mneumonic
Multisystem autoimmune disorder characterised by the presence of an array of the following features (SOAP BRAIN MD)
Serositis
Oral Ulcers
Arthritis
Photosensitivity
Bloods (cytopaenias)
Renal Disease
ANA
Immunological Factors (anti-dsDNA, anti-Sm)
Neurological Factors (psychosis, seizures)
Malar Rash
Discoid Rash
27
What is the earliest sign of RA on XR?
EFFUSION
28
Which type of urate is gout and polarisation?
monosodium urate monohydrate arthropathy
needle shaped
negatively bifringent
29
What is the management of gout?
NSAID (not in CKD)
Colchicine
Prednisolone (not in DM)
30
What condition is associated with looser zones on XR?
osteomalacia
| low vit D- low calcium, low phosphate, high ALP
## Footnote
linear areas of low density
31
What is the management of SLE with simple arthralgia?
hydroxychloroquine
32
What is the management of SLE with arthritis and treatment resistant/severe?
methotrexate
33
What is the management of SLE with internal organ involvement?
prednisolone
34
What is AIN
acute interstitial nephritis
drug hypersensitivity
AKI, fever, arthralgia, eosinophilia
autoimmune
infection
NSAID abx
35
When is minimal change nephropathy seen?
children with nephrotic syndrome
36
What is renal tubular acidosis type 4
NSAID induced
37
Why do you get calcific tendonitis?
Deposits of hydroxyapatite crystal in injured rotator cuff muscles
38
Which AZA is safe in pregnancy
Azathioprine
39
Which haem condition causes avascular necrosis of femoral head
Sickle cell disease
40
What is the first line therapy for gonococcal arthritis?
Ceftriaxone
41
What is the first line treatment for early RA?
METHOTREXATE
Initial Management
First-Line: DMARD Monotherapy
Options: methotrexate, leflunomide and sulfasalazine
Alternative: hydroxychloroquine
Consider DMARDs in combination if monotherapy is ineffective
Steroids
Offer short-course glucocorticoids for managing flares
42
What is reactive arthritis
sexually transmitted disease/gastroenteritis
can't see
cant pee
cant climb trees
| **Mx: NSAID**
43
What does early morning stiffness lasting more than 1 hr suggest?
inflammatory arthritis
44
Fibromyalgia diagnostic criteria
widespread pain for at least 3 months in addition to tenderness of at least 11 out of 18 designated tender point sites.
45
What is lateral epicondylitis?
tennis elbow
46
What is medial epicondylitis?
golfer's elbow
pain on pronation and flexion of wrist
47
Give an example of COX1 inhibitor
Naproxen
piroxicam
| reduces prostaglandin in stomach
48
Which complement is associated with SLE?
C4
note C3 is low in active disease
49
What is z score and T score
Z = 0 (normal BMD for age)
T (>-1 = normal) - compared to normal individual age adjusted
50
What is T score of osteopenia and osteoporosis
Osteopenia:
-1 and -2.5
Osteoporosis:
-2.5 and below
51
What are the features of polyartertis nodosa?
Hep B
Form aneurysms
- rosary sign on renal angio
Constitutional upset
Skin rash
Peripheral neuropathy
Renal impairment
NOTE: associated with hepatitis B
-hypertension
-mononeuritis multiplex,
-sensorimotor polyneuropathy
-p (ANCA) are found in around 20% of patients with 'classic' PAN
-hepatitis B serology positive in 30% of patients
| systemic necrotising vasculitis -> aneurysm forms
## Footnote
Rosary string of bead sign due to microaneurysm
52
How does dermatomyositis present?
symmetrical promixal myopathy
heliotrope purple rash on cheek/eyelid
photosensitive
gottron papule (rough red extensor surface)
CK elevated
| note: polymyositis has no heliotrope rash
53
What eye symptoms does MS present?
Unilateral optic neuritis
54
What is the diagnostic criteria for RA?
J-SAD
Joint involvement (large and small)
Serology (RA factor, anti-CCP)
Acute phase reactant (ESR/CRP)
Duration of symptoms (6 weeks or longer)
55
RA x-ray changes
S: oft tissue swelling
P: eri-articular osteoporosis
A: bsent osteophytes
D: eformity
E: rosions (late feature)
S: ubluxation (late feature)
| SPADES
56
What is enteropathic arthritis?
Athritis associated with IBD (crohn's)
57
What is the first line management for Behcet syndrome?
Colchicine
58
What is Behcet syndrome?
vasculitis affecting mucocutaneous , vascular, GI, eye, CNS
triad of symptoms:
- oral ulcers
- genital ulcers
- anterior uveitis
59
What HLA is associated with behcet syndrome?
HLA B51
| ANA and ANCA negative!
60
What is the classical presentation of Still's
polyarthritis
maculopapular salmon pink rash
intermittent fever
| Mx: NSAID, steroid, methotrexate, tocilizumab
61
What is pseudogout crystal and polarisation?
calcium pyrophosphate dihydrate
Rhomboid crystals
POSITIVELY bifrengence
62
What is pseudogout associated with
metabolic disorders
Haemochromatosis
Hyperparathyroidism
Diabetes
63
What is Sheuermann disease?
Deforming thoracic kyphosis
64
What are the 3 types of cryoglobulinaemia?
(precipitating from temperature diff)
arthralgia, pupura, glomerulonephritis
T1: monoclonal (raynaud/MM/waldenstrom)
T2: mixed (hep C/RA/Sjogrens/lymphoma)
T3: polyclonal (RA/sjogrens)
| Rheumatic factor!
65
Which antibody is associated with SLE?
ds-DNA (specific)
ANA (sensitive)
66
Which antibody is associated with sjogrens?
**anti Ro** and La
67
What is straight leg raise negative?
spinal stenosis
68
Which 3 antibodies are associated with antiphospholipid syndrome?
Anti cardiolipin
lupus anticoagulant
anti beta2 glycoprotein 1
| recurrent miscarriage, livedo rahs, prolonged APTT/INR
69
What side effect is rarely seen with hydroxychloroquine?
retinopathy
hair loss
| bald blind man swimming
70
What side effect is seen with sulfasalazine?
pancytopenia
71
What is a consequence of atlanto-axial subluxation in RA?
Cervical myelopathy => spinal cord compression
72
Which antibodies are non specific?
RF
ANA
73
What is dermatomyositis associated with?
malignancy (paraneoplastic)
74
Which maternal autoantibody causes neonatal lupus?
Anti-Ro (crosses placenta)
75
Which arthritis is associated with keratoderma blenorrhagica?
Reactive arthritis
| brown macule/vesicle/pustule on palms and soles
76
How does arthritis present in gonococcal arthritis?
migratory (not fixed)
tenosynovitis
76
What is the difference between gonococcal arthritis and reactive arthritis?
Both STI
Reactive- oligoarthritis (2-4 joints) no tenosynovitis
Gonococcal- periarthritis dermatitis tenosynovitis
77
What is the blood test like in osteoporosis?
Normal bone profile
Normal PTH
ALP can be elevated following fracture
78
Why are patients with nephrotic syndrome at risk of avascular necrosis?
Loss of protein S and antithrombin 3 in urine
79
What are the two signs for carpel tunnel?
Tinel-tapping median nerve in carpal tunnel
Phalen-inverse prayer
80
Which diuretic cause gout?
thiazide
| indapamide
81
Which antibody is more specific to RA?
anti-CCP
82
What is the difference between spondylosis and spondylolisthesis?
Spondylosis= degenerative, narrow space
Spondylolisthesis=on verterae slips forward or backward over the bone below it (likely due to OA)
83
Which DMARD used in RA is safe in pregnancy?
hydroxychloroquine
84
What is bilateral sacroiliac erosion suggestive of?
Ank Spond (more specific than HLA type)
85
SLE manifestation percentage:
**Joint (>80%)**
Skin (75%)
Lung (60%)
Kidney (30%)
Heart and vessel (25%)
86
Epidemiology of SLE
9 times more common in women
more common in Afro-Caribbeans* and Asian
onset is usually 20-40 years
First degree relatives 3% dwveloping
Associated with HLADR2 and HLADR3 in white people
87
What lung condition is RA associated with?
Bronchiolitis obliterans
| diffuse wheeze
## Footnote
Mx: steroids
88
Which bone is most susceptible to Paget's
Lumbar spine
lytic and sclerosis
89
Which nodes are present in OA?
PIP
- Bouchard
DIP
- Heberden
90
What is the management of chronic fatigue syndrome?
CBT
91
What is arthritis mutilans
psoriatic arthropathy
| telescoping fingers, nail pitting, horizontal ridge
92
What is the XR lumbar appearance of ank spond?
Tramline Bamboo spine
| XR pelvis- fusion of sacroiliac joint
93
Why does Paget's present with deafness
foraminal narrowing causing compression of 8th cranial nerve
94
What eGFR is alendronate contraindicated?
eGFR <35
95
Which medication is used for secondary prevention of fractures in osteoporosis with CKD ?
Denosumab (RANK ligand)
96
How does RA affect joints?
Symmetrical
small joints
97
How does Takayasu present?
upper limb claudication
constitutional upset
weak puse
BP diff both arms
| idiopathic arteritis, women 20-40
98
Which anti TB medication is associated with gout?
Pyrazinamide
99
What should be ruled out in MONOARTHRITIS
SEPTIC JOINT
100
What are the hallmarks of primary raynaud
- 30 year old female
- symmetrical attack
- seronegative antibody
101
What are the hallmarks of secondary raynaud?
- 50+ male
- digital ulcer/gangrene
- asymmetrical attack
- positive autoantibodies
| a/w CREST, SLE
102
# what type of anaemia
What is anaemia of chronic disease
normocytic anaemia
| secondary to chronic inflammatory disease/CKD
103
What is diagnostic of ank spond?
XR of sacroiliac joint
104
What is the first line treatment for ank spond back pain?
NSAID - naproxen
105
Rim of calcification on lateral meniscus?
Pseudogout
chondrocalcinosis - deposition of calcium pyrophosphate along the margins of the cartilage
106
What is the renal complication seen in eGPA?
necrotizing crescent glomerulonephritis
(rapid progressive)
107
What renal complication is seen in SLE
membranous glomerulonephritis
108
Which part of IgG does rheumatoid factor target?
Fc portion of IgG1
109
Which HLA is associated with Felty syndrome?
HLA-DRW4
110
Outline management of Psoriatic arthritis
1. NSAID for sx relief
2. **DMARD - if both skin and arthritis**
- leflunomide
- sulfasalazine - not for skin
- methotrexate - joint and skin
- ciclosporin
3. anti-TNF alfa (refractory to above)
| note- stop sulfasalazine if adding anti TNF
111
What 4 triggers gout
Surgery
Starvation
Diet/Alcohol
Drugs- diuretics
112
What is Pott's disease
SPINAL TB
| Mx: 12 month therapy
113
What are the causes of ATN?
HYPOTENSION
NEPHROTOXINS
PRE-RENAL (HYPOVOLAEMIA)
114
How do you classify between limited and diffuse scleroderma?
Area of skin distribution
- limited to below elbow and knee in limited sclerosis
- trunk in diffuse
- both can affect face
115
Which 2 conditions is ischaemic optic neuropathy associated with?
1. GCA
2. GPA
116
What are the complications of PAN
MI
Stroke
Bowel perforation
**Pulmonary haemorrhage**
117
Management of frozen shoulder
Acute: pain
- steroid injection
Chronic: stiffness
- physio
118
What neurological involvement is APL syndrome associated with?
epilepsy
chorea
migraine
119
APL syndrome management
Secondary thromboprophylaxis:
- previous clot -> warfarin lifelong (INR 2-3)
- recurrent clot-> warfarin lifelong + aspirin (INR 3-4)
Primary Thrmbophrophylaxis:
- aspirin
Pregnant:
aspirin as soon as pregnant->LMWH when fetal HB seen -> until 34 weeks
120
What is meralgia paraesthetica?
entrapped lateral cutaneous nerve of thigh
| triggered by tight clothing
121
Which autoantibody is associated with dermatomyositis?
ANA
Polymyositis: Anti-Jo1
Dermatomyositis: Anti-Mi2
122
Outline management for dermatomyositis
1. steroid
2. azathioprine/ciclosporin/methotrexate
| check TPMT level before azathioprine
123
What are the signs of patellar bursitis
tender
fluctuant oedema
erythema
crepitus of knee
123
What is henoch schonlein purpura
rash on buttock and lower limb
raised IgA- nephropathy
(recent URTI)
124
What is the significance of presence of anti- Jo 1 antibody
POLYmyositis and interstitial lung disease
125
What is the diagnostic test for myositis
muscle biopsy
126
What condition presents with bilateral idiopathic avascular necrosis of scaphoid?
preiser disease
127
What is the medication to reduce further risk of gout attack?
Allopurinol
128
What is the first line investigation for monoarthritis (even in those with known inflammatory arthritis?)
Joint aspiration
Start abx immediately
129
What is the most common organism causing septic arthritis?
Staph aureus
130
What the most common organisms causing childhood septic arthritis?
Gonorrhoea
Haemophilus influenza
131
What is the most common bug associated with septic arthritis in sickle cell?
Salmonella
132
Why is the ESR high in primary sjogren?
High gammaglobulinaemia
(immunoglobulin)
133
What is the most common form of progression of RA?
chronic
persistent
134
What is osteochondritis dissecans
subchondral crescent sign or loose bodies due to local necrosis and underlying bone
135
What are the 2 most common causes of death in systemic sclerosis?
1. pulmonary fibrosis
2. Kidney disease
136
What are the colonoscopy findings of Crohns?
Rose thorn ulcer
Discrete ulcers
Cobble stone mucosa
Strictures
| Note: associated with enteropathic arthritis
137
What are the 4 invetigation to aid diagnosing sjogrens?
oral labial biopsy
MRI of parotid gland
schirmer's test
anti Ro
138
What are the findings on colonoscopy of UC?
pseudopolyps
crypt abscess
dilatation
| Note: associated with enteropathic arthritis
139
What is the bone profile like in Paget's
isolated ALP rise
| indicating high bone turnover
140
Why does negative temporal biopsy not rule out GCA?
Skip lesions
141
What should women of child bearing age be told before starting methotrexate?
Birth control measures must be in use before (teratogenic)
| if planning conception- stop meds 3-6 months
142
What is the joint aspirate result in reactive arthritis?
sterile
no growth
143
What triggers reactive arthritis?
Enteric infection:
- shigella
- salmonella
- yersinia
- campylobacter
Genital infection:
**- chlamydia**
| arthritis, uveitis, urethritis, keratoderma
144
Which HLA is reactive arthritis associated with?
HLA B27
145
What triggers gonococcal arthritis (type of septic arthritis)
Neisseria gonorrhoea
| tenosynovitis, migratory polyarthritis, dermatitis,
146
What is the most common GI manifestation of SLE?
mouth ulcer
147
What is mononeuritis vs multiplex
Mononeuritis is inflammation of a single nerve
mononeuritis multiplex is inflammation of two or more nerves.
148
What are the symptoms of EDS?
recurrent dislocation
skin laxity
bruising
149
Outline management of Takayasu arteritis
First: steroid
Second: steroid sparing
- methotrexate
- azathioprine
- cyclophosphamide
150
What is the most common hand presentation of psoriatic arthritis?
nail dystrophy
151
What is the investigation of choice to confirm diagnosis of gout/pseudogout
joint aspiration and microscopy
152
Which HLA is associated with RA?
HLA DR4
and DR1
153
How does Behcet manifest the skin?
thrombophlebitis
erythema nodosum
154
What is mixed connective tissue disease?
Systemic sclerosis
SLE
Polymyositis
155
What are the side effects of GOLD in RA treatment?
pancytopenia
pulmonary fibrosis
156
Why does SLE present with normocytic anaemia with low WCC or platelet?
body's immune system mistakenly attacks and destroys healthy blood cells, including platelets and certain types of white blood cells, due to the autoimmune nature of the disease
157
Which DMARD is not used in spinal disease in ank spond
Methotrexate
158
What is rheumatoid factor
IgM that target Fc portion of IgG
159
What is microscopic polyangitis?
small-vessel ANCA vasculitis.
fever, fatigue, weight loss
arthalgia
cough, SOB- pulmonary
haematuria
160
Which autoantibody is microscopic polyangitis associated with?
pANCA (70%)
against MPO
MPO
MicroPoly
161
What type of immunoglobulin is anti GBM
IgG
| Good pastures (IgGood)
162
What are the 3 diagnostic methods for polymyositis?
CK
EMG
**Muscle biopsy**
163
What is the diagnostic imaging for avascular necrosis?
MRI
164
What arthroscopic findings are seen in RA of synovial joint?
vascular proliferation-> permeable
(Inflammation)
165
Which patients are offered DEXA scan?
>50 with fragility fracture
<40 with major fragility fracture
| Note if on long term steroid-no need for DEXA
## Footnote
and start alendronate, calcium, vit D
166
What happens to the complement levels in active SLE?
reduced
167
What are seronegative arthritis?
Psoriasis
Enterpathic arthritis
Ankylosing spondylitis
Reactive arthritis
| PEAR
168
What antibody is associated with mixed connective tissue disease?
anti-RNP
169
Which vasculitis cause nasal bridge dipping, sinusitis, epistaxis, haemoptysis?
GPA
170
What is the pleural tap result of RA effusion?
**low glucose**
high LDH
exudative
low pH
171
What does normal CXR tell you about latent TB whilst on anti-TNF?
cannot rule out reactivation
172
Which chromosome is haemochromatosis defective HFE gene on?
6
173
What is de quervain synovitis?
base of thumb pain
174
Why is allopurinol not given in acute gout?
can worsen the acute phase including worsening joint pain and fever
| give 4-6 weeks after acute management
175
What test is performed for assessing stiffness of the back for ank spond?
schober test
176
What spinal movements are limited in ank spond?
forward flexion
lateral lumbar flexion
177
What should you do with the steroid dose with SLE flare secondary to infection?
double dose for adrenal support
178
Should you continue hydroxychloroquine in acute illness?
yes
179
what do you call a chronic osteomyelitis with abscess near site of metaphysis?
Brodie's abscess
180
What is the radiological feature of Ewing sarcoma?
onion peel
181
What is myasethenia gravis auto antibody?
anti-acetylcholinesterase receptor antibody
182
Outline symptoms of radial, ulnar and median neuropathy
Radial= wrist drop
Ulnar= weak hypothenar
Median= weak thenar
183
What are the 3 nephropathies associated with ank spond?
**AA amyloidosis:**
- enlarged kidney (deposit)
- apple green bifringence
**NSAID nephropathy**
**IgA nephropathy**
- haematuria
- hypertension
184
Which features indicate worse prognosis in RA?
1. female
2. gradual onset over few months
3. postivie IgM RF
4. anaemia within 3 months
5. Anti-CCP positivity
185
What are the risk factors for AVN?
Chemotherapy
Alcohol
Steroid/sickle cell
Trauma
| CAST
186
What is the first line management for pain in ank spond?
NSAID
187
What is the most appropriate management for early ank spond without syndesmophytes?
physiotherapy
Paramount to prevent stiffness early ,!!!
188
What is the prevalence of RA?
1% in western world
0.2% in china japan
189
Outline sequence of spinal changes in ank spond
blurring upper and lower vertebral rims => enthesitis causing bony spurs (syndesmophytes) => fusion and sclerosis => calcification of intervertebral ligament
190
Outline the sequence of bony changes in OA
limited ROM => joint crepitus and instability
LOSS on XR
Loss of Joint Space
Osteophytes
Subchondral Cysts
Subchondral Sclerosis
190
Why is there anaemia in chronic inflammation?
Suppression of EPO
191
Outline the vitamin D activation pathway
Vit D in skin photoactivated forming cholecalciferol-> liver converts to 25 hydrocycholecalciferol -> kidney 1 alfa hydroxylase converts to **1,25 dihydrocycholecalciferol**
192
What is mononeuritis multiplex?
neuropathy of 2 or more peripheral nerves not related anatomically
193
What is the mechanism of action of colchicine?
xanthine oxidase inhibitor
194
How does thoracic outlet obstruction present?
disappearance of pulse on raising arm
195
When is anti-TNF contraindicated?
comorbid MS
active Hep B/C
196
What renal manifestation occurs with SLE?
lupus nephritis
197
What does TNF alfa do to insulin resistance?
increases insulin resistance
198
Which hand joints are most affected in RA?
PIP
MCP
199
What does low volume voltage QRS indicate ?
cardiac tamponade
200
What is the action of tocolizumab for RA?
IL-6 inhibitor
| note TNF alfa also reduced IL 6
201
What is the most common pulmonary manifestation of SLE?
Pleural effusion
202
What is the problem with serum urate levels for gout?
40% can be normal
in those on diuretics can have asymptomatic hyperuricaemia without gout
203
What is the significance of weakly positive RF?
negligible in elderly
204
What does polyarthritis in peripheral joints, red painful swollen suggest?
gout
205
What is a risk factor of raloxifene (serm)
endometrial ca
increased clotting risk
206
What complication can occur in chronic RA of knee?
baker cyst from persistent effusion
207
What is IgA nephropathy also known as?
Berger disease
208
Differentiate between IgA nephropathy and post strep glomerulonephritis?
IgA nephropathy:
- 2 days post URTI
- Associated with HSP (abdo pain, buttock petechiae)
Post strep glomerulonephritis:
- 2 weeks post URTI
209
On rituximab and presents with deranged LFT- what reactivation risk is there?
?reactivation of hep B
210
What is an investigation of choice for Behcet?
pathergy test
shows hypersensitivity reaction at venepuncture site i.e pustule forms
211
Which drug classes can cause drug induced lupus?
AED (carba/valproate)
Abx (linezolid)
Anti-inflammatory (sulfasala/penicillamine)
212
What does gritty red eye with normal vision suggest?
episcleritis
213
Outline management for RA?
**DMARD monotherapy** +/- a short-course of bridging prednisolone.
-methotrexate
-sulfasalazine
-leflunomide
-hydroxychloroquine
**flares** of RA are often managed with corticosteroids - oral or intramuscular
**TNF-inhibitor** is an inadequate response to at least **two DMARDs** including methotrexate.
- AEI (adalimumab, etanacept, infliximab)
Anti-CD20
- rituximab
214
Outline management of SLE
First-line options include: (NHS)
- NSAIDs
- Hydroxychloroquine
- Steroids (e.g., prednisolone)
Treatment options for resistant or more severe SLE include:
- DMARDs
- (e.g., methotrexate, mycophenolate mofetil or cyclophosphamide)
- Biologic therapies
215
Axial ank spond management
DMARD
216
Psoriasis with skin involvement management
methotrexate
217
Psoriasis without skin involvement
sulfasalazine
