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PA MS > MSPA: Rheumatology- Osteoporosis, Fibromyalgia, and Polymyalgia rheumatica > Flashcards

MSPA: Rheumatology- Osteoporosis, Fibromyalgia, and Polymyalgia rheumatica Flashcards

1
Q

What are the risk factors for Osteoporosis?

A
  • Increase in the prevalence of OP due to increase in life expectancy, sedentary lifestyle, and the diet low in Ca and Vitamin-D
  • failure to achieve an optimal peak bone mass by the second decade of life.

*Accelerated loss due to certain chronic diseases or medication toxicities
*nutritional deficiencies
*genetic variables

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2
Q

What is the effect of post menopausal estrogen reduction on bone remodelling ?

A

After menopause, due to lack of oestrogen, osteoblast under fill areas of resorption resulting in thinning of the bone.

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3
Q

How to clinically screen for asymptomatic OP?

A

All patients > 50 should be screened for asymptomatic OP. Their height should be checked every year on bare foot. Spinal inspection should look for kyphotic posture and palpation should aim to identify boney fragility at the thoracic and other spinous processes.

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4
Q

What are the risk factors for osteoporotic fractures?

A
  • Age and gender
  • height and weight
  • Previous fracture
  • Parental Hx of hip fracture.
  • Current tobacco smoking.
  • RA and glucocorticoid use.
  • Secondary OP
  • 3 or more units of alcohol intake/ day.
  • Low BMD and low sex hormone.
  • Low intake of vitamin D and ca
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5
Q

What is the aim of DEXA in OP screening.

A

The current guidelines recommend to measure the BMD of L-1 to L-4 and proximal femur in all men and woman > 50.

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6
Q

What is the BMD , T score indicates ?

A

It indicates the difference in the BMD of the patient as compared to the average BMD of an average healthy 30 year old.

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7
Q

What is the BMD , Z- score indicates?

A

It indicates the difference of BMD of the patient as compared to the average bone density of people of similar age and gender. In post menopausal woman the Z and T scores should be ordered.

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8
Q

What is the normal BMD T score ?

A

> or equal to -1.0.

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9
Q

What is the BMD in Low bone mass or osteopenia?

A

T-score -1.5 to -2.49

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10
Q

What is the BMD in OP ?

A

A T score < or equal to -2.5

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11
Q

What are the 3 ways to clinically diagnose osteoporosis ?

A

1) The presence of a fragility fracture
2) Measurement of bone mineral density (BMD) - DEXA
3)Histomorphometric analysis of tetracycline-labelled Bone biopsy

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12
Q

What category of woman should get their BMD assessed?

A

*Age 65 and older
*Postmenopausal women with secondary osteoporosis regardless of age
*Postmenopausal women >50 with additional risk factors
Postmenopausal women with fragility fractures
Follow-up: Every 2-5 years
*Rate of bone loss is 0.5 T score units every 5 years

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13
Q

What category of men should get their BMD assessed?

A

*Age 70 and older
*>50 years with history of fracture or loss of at least 2.5 cm height
*History of 5mg/day glucocorticoid use for more than 3 months
*Family history of osteoporosis or fractures in absence of trauma

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14
Q

What is the action of anti-resorption agent Bisphosphonates?

A

It Induces osteoclast apoptosis – can cause osteonecrosis.

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15
Q

What is the action of anti-resorption agent Denosumab?

A

It is a Monoclonal antibody that binds to RANK ligand andprevents it activating osteoclasts. It has to be administered subcut, every 6 months. The main side effects are hypocalcemia, skin infection and rash.

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16
Q

What are the indications for estrogen replacement therapy ?

A

It is indicated in woman who reach menopause prematurely and are at increased risk of OP. It acts by promoting osteoclast apoptosis. However, it has an increased risk of breast cancer.

17
Q

What is the benefit of Selective Oestrogen Receptor Modulators Raloxefene ?

A

It acts on oestrogen receptors in bone much like oestrogen but works as an anti-oestrogen in breast tissue without increased breast cancer risk.

18
Q

What is the action of Bisphosphonate ?

A

It Work by inhibiting the activity and shortening the half life of osteoclasts, reducing bone turnover.
It is the First line therapy and reduces fractures by up to 50% in high risk women. > 5 year use may cause atypical fractures. Therefore, clinicians must establish the patient’s baseline before prescribing the drug.

19
Q

What is the action of Teriparatide?

A

It is a Parathyroid hormone analogue which increases osteoblast activity. It is indicated in patients where bisphosphonates were deemed ineffective. It is also
Useful for prevention in patients with risk of glucocorticoid-induced osteoporosis.

20
Q

What is the action of the anabolic agent Strontium?

A

It is a drug Chemicallysimilar to calcium and replaces calcium in bones – activates osteoblasts and inhibits osteoclasts.

21
Q

What is the action of Romosozumab?

A

It is a monoclonal antibody that inhibitssclerostin which is released by osteocytes. This promotes bone formation.

22
Q

What is fibromyalgia ?

A

The most common cause of generalized, musculoskeletal pain in
women between the ages of 20 and 55. It is a disorder of pain regulation a central pain sensitisation disorder. There is an 8.5 times increased risk with a kin having an Hx of FM.

23
Q

What is the presentation of fibromyalgia ?

A

The patients presents with Widespread musculoskeletal pain and fatigue. They may also have headaches, cognitive and mood disturbance.

24
Q

What are the physical signs of Fibromyalgia ?

A
  • reproducible pain and tenderness upon palpation of certain soft-tissue locations.
  • No pain in “control” locations
  • No evidence of joint or muscle inflammation.
25
Q

What is the 1990 American College of Rheumatology Classification Criteria for Fibromyalgia?

A

It has > 85% Sensitivity & Specificity and consist of:
* Symptoms of “widespread pain”
▪ Above AND below the waist
▪ Right AND left side of body
▪ Positive in 11 out of 18 tender points

26
Q

What is the 2010 American College of Rheumatology Preliminary Diagnostic Criteria for Fibromyalgia?

A

1) Wide Spread Pain ≥ 7 and Symptom severity ≥ 5 or WPI 3 – 6 and SS ≥ 9.
2) The symptoms persist for at least 3 months.
3) There is no other explanation for the symptoms.

27
Q

What are the Laboratory work ups in Fibromyalgia ?

A
  • Full Blood Count (FBC)
  • Erythrocyte Sedimentation Rate (ESR)
  • C-Reactive Protein (CRP)
  • Others ( should be normal)
  • Antinuclear antibody
  • Rheumatoid factor
  • Thyroid function tests (TSH, Free T4)
  • Creatine Kinase (CK)
28
Q

What are the goals of Fibromyalgia Tx?

A
  • Reduce widespread pain
  • Reduce fatigue
  • Reduce cognitive dysfunction
29
Q

What is the approach to the tx of FM?

A

Initially,
*Confirm the diagnosis
*Patient education
*Treat comorbidities (mood disorders, sleep disorders)
* In most cases exercise and pharmacological approach will work.
* In some patients Specialty referral, Drug combo therapy, PT, and Psychological interventions (e.g., CBT) may be needed.

30
Q

What are the pharmacological choices in FM ?

A
  • Antidepressants
  • Amitriptyline - TCA
  • Duloxetine - SNRI
  • Milnacipran - SNRI
  • Anticonvulsants
  • Gabapentin
  • Pregabalin
31
Q

What should be the elements of patient education in FM ?

A
  • Fibromyalgia is a real illness
  • Fibromyalgia is not a persistent infection
  • Stress reduction will help
  • Improved sleep hygiene will help
  • Exercise will help
  • Treatment for depression or anxiety will help
32
Q

what is the pathogenesis of Polymyalgia Rheumatica?

A

Genetic factors (HLA DR4), environmental factors, infections such as Parvovirus-B19 or adenovirus generates autoantibodies and induce molecular mimicry triggering T cell mediated immune attack to the large joints and periarticular structures with sparing of muscles. It may co-occur with Giant cell arteritis.

33
Q

What is the clinical presentation of Polymyalgia Rheumatica?

A

The patients are woman > 50. They may present with Pain and stiffness to shoulders and/or hips which often starts unilateral but progresses to bilateral over time. It is worse in the morning and they may experience difficulty dressing and brushing hair. The Physical examination may show decreased ROM, but overall muscle
strength is normal.

34
Q

What are the labs in Polymyalgia Rheumatica?

A

Elevated ESR and CRP with normal CK, which helps to distinguish PR from polymyositis and dermatomyositis

35
Q

What is the Tx of Polymyalgia Rheumatica?

A
  • Low-dose corticosteroids
  • Methotrexate
36
Q
A

PA MS (44 decks)

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