Paulson - Rheumatology Flashcards
what is the mc complaint in gout
my big toe hurts
gout has a __ onset
rapid
what finding is pathognomonic for gout
tophi
what are tophi
deposits of urate
what is podagra
gout of the foot
gout is usually __
and affects the __ of the great toe
monoarticular
MTP
what are the 3 stages of gout
- acute
- intercritical (interval)
- chronic articular and tophaceous
what are 6 rf for gout
- etoh
- red meat
- seafood
- fructose
- HCTZ diuretics
- obesity
what is the diagnostic value for serum urate in gout
>6.8 → not all w. this finding have gout
for the dx of gout, what 2 lab findings must be present
- serum urate > 6.8
- monosodium urate (MSU) must be present for gout to crystallize
what is the soc for gout diagnosis
aspirate of synovial fluid
what does synovial fluid aspirate show with gout
negatively birefringent, needle like, when viewed w. polarized light microscopy
what is the tx for asymptomatic hyperuricemia
lifestyle mods:
wt loss, reduce etoh, diet, enough fluids to urinate at least 2L/day, avoid hyperuricemic meds
should allopurinol be used in for acute gout attacks
no! → but keep pt on it if they are already taking
what are 5 meds that you might use for an acute gout attack
- NSAIDs
- indomethacin/naproxen
- celecoxib (Celebrex)
- colchine
- corticosteroids
what is the soc med for an acute gout attack
nsaids
what is the realistic/better choice soc for acute gout attacks
indomethacin/naproxen
how long should abortive gout meds be given for acute attack
1-2 days after sx resolution → typical course is 5-7 days
what are contraindications for celebrex
ckd w. CrCl < 60
active ulcer
NSAID allergy
anticoags
CVD
when might you use colchicine for an acute gout attack
NSAID intolerance
what are 2 common s.e of colchicine
diarrhea
abdominal cramping
what are contraindications for colchicine
severe hepatic/renal dz w/ colchicine
mod-strong P-pd and/or CYP3A4 inhibitor
when would corticosteroids be used for gout
can’t take NSAIDs or colchicine
what are indications for prophylactic tx in gout
- presence of tophi
- 2 or more gout attacks
- renal insufficiency
- joint damage on imaging
what are 2 steps in prophylactic tx of gout
- address preventie issues during intercritical (asymptomatic) period
- bring uric acid down slowly
what is the serum urate level goal for prophylactic gout tx
< 6
what prophylactic med is used to slowly reduce serum urate
cochicine
OR
low dose NSAID
what class of gout meds reduces uric acid production
xanthine oxidase inhibitors (XOI)
what is the main XOI
allopurinol
how should you administer allopurinol (in terms of titrating)
titrate up every 2-5 weeks
give prophylactic colchicine when initiating
what are s.e of allopurinol
rash
severe cutaneous/toxic epidermal necrolysis (TEN)
what is an example of a uricosurig med
Probenecid
what are uricosurig meds (2)
block tubular reabsorption of urate AND increase rate that uric acid is renally secreted
what are two inclusion criteria for uricosurig meds
- normal renal fxn → CrCl >60
- urinate at least 2 L/day
what is a contraindication for probenecid
G6PD
what do uricase meds do
enzyme from other animals → break down uric acid
what is an example of a uricase med
pegloticase
when is pegloticase used
last line med for pt who has been refractory to all other therapies
what is a contraindication for pegliocase
G6PD
most ppl with gout are __excreters of uric acid
under
what are rf for uric acid underexcretion
- renal insufficiency
- meds: low dose asa, thiazides, loop diuretics
- aidosis (DKA)
- volume depletion
- lead exposure
- etoh!!
overproduction of gout is usually __ or
__
inherited
2/2 to dz process
what is a rf for both underexcretion and overproduction of uric acid
etoh!
what are 2 other names for pseudogout
- calcium pyrophosphate dihydrate deposition dz (CPPD)
- chondrocalcinosis
- pyrophosphate arthropathy
what is pseudogout
precipitation of calcium pyrophosphate dihydrate crystals (CPP)
pseudogout causes
chronic or recurrent arthritis that mimics gout
what is the mc location for pseudogout
knee
also shoulders, wrist, elbow
pseudogout affects __ joints than gout
larger
what is asymptomatic/incidental pseudogout
CPP deposition on radiograph w.o symptoms
what is acute arthritis/pseudogout
self-limited, sudden attacks of pain, redness, warmth, disability/swelling
acute arthritis/pseudogout can be (in terms of location)
and usually affects __ joints
monoarticular or oligoarticular
larger
pseudogout can be triggered by (3)
surgery (esp parathyroidectomy)
trauma
major illness
what is chondrocalcinosis
e.o calcification in cartilage
what is the dx for pseudogout
synovial joint aspiration
what is the positive finding in synovial joint aspiration for pseudogout
weakly positive birefringent rhomboid crystals by polarized light microscopy
what is the tx for acute pseudogout
- aspiration
- intraarticular glucocorticoid injxn
what glucocorticoid is injected for acute pseudogout
triamcinolone
what other meds are used for acute pseudogout besides triamcinolone
NSAIDs → indomethacin
naproxen
salicylates
colchicine
systeic corticosteroids
what is the prophylactic tx for pseudogout
same as for gout →
consider if 3 or more attacks/year
cochicine
NSAID if colchicine intolerant
what is CPP inflammatory arthritis (pseudo RA)
inflammatory arthritis caused by CCP crystals in joint fluid
how is CCP/pseudo RA different from RA
asynchronous waxing and waning symptoms
what are the mc locations for CCP inflammatory arthritis/pseudo RA
wrists, elbows, glenohumeral joint
CCP inflammatory arthritis/pseudo RA usually affects joints in a
symmetric pattern
what is prophylactic tx for CCP inflammatory arthritis/pseudo RA
NSAIDs → naproxen, indomethacin
glucocorticoids → if NSAIDs ineffective
what is the mc location for OA w. CPPD (pseudo OA)
knees
also wrists, MCPs, hip, shoulders, elbow, spine
what are the symptoms for pseudo-OA
same as OA:
tenderness
bony enlargement
crepitus
restricted ROM
what is pseudoneuropathic joint dz
severe joint degeneration from CPP crystal deposition
what is the differentiating factor between pseudo-neuropathic joint dz and neuropathic arthropathy
no neurologic impairment in pseudo neuropathic arthropathy
what are the most common symptoms of fibromyalgia
- flu like pain in neck and shoulders
- HA
- dpn
- anxiety
fibromyalgia can also be associated w
dpn
ibs
cognitive problems
psychiatric symptoms
fibromyalgia mc affects
younger women
what is allodynia
response to nonpainful stimuli perceived as painful
what is hyperalgesia
pain perceived as more intense and lasting longer
pain w. fibromyalgia is commonly felt as
chronic pain/stiffness in all 4 quadrants
what will pe exam findings be for fibromyalgia
exam normal except for pain at tender points
what are tender points in fibromyalgia
soft tissue locations of pain
what are control locations in fibromyalgia
locations where there should be no pain
for dx of fibromyalgia, how many points must be tender
at least 11
labs and imaging for fibromyalgia are generally
unhelpful
+/- CBC, ESR, CRP, TSH
what are the first 2 tx steps for fibromyalgia
sleep hygiene
exercise
what 4 classes of meds might you consider in fibromyalgia
- TCAs
- SNRIs
- SSRIs
- anticonvulsants
what 2 TCAs might you use in fibromyalgia
- Amitryptiline (Elavil)
- Nortriptyline (Pamelor)
what med would be helpful for a pt w. fibromyalgia and dpn
SNRI → Cymbalta (Duloxetine)
what SSRI might you use for fibromyalgia
Prozac
what anticonvulsant might you use for fibromyalgia
Pregabalin (Lyrica)
what meds are not helpful for fibromyalgia
opioids
corticosteroids
NSAIDs
polymyalgia rheumatica (PMR) and what other dz are very similar
trigeminal neuralgia
mc locations for pain/ inflammation in PMR
hips/shoulders
what is the “gel phenomenon,” and what does it make you think of
stiffness after activity
PMR
which is mc, PMR or temporal arteritis
PMR
what is the main symptom in giant cell arteritis (GCA)
ha → classically over temple, but can be generalized
besides ha, what are 3 other symptoms of GCA
jaw claudication
visual symptoms → bilateral OR unilateral
scalp tenderness
almost all pt w. PMR and GCA are > __ yo
50
a major rf assocaited w. GCA is __
a major rf associated w. PMR is __
smoking
DM
in PMR pt’s will have normal __
but impaired __
normal muscle strength
impaired ROM
other than decreased ROM, what is another pe finding associated w. PMR
bursal inflammation in wrists/knees
at least __% patients w. GCA also have __
50%
PMR
a pe for a pt w. GCA may be totally normal; if not, what are 4 associated findings
ill appearing
thickened/prominent temporal artery
cotton wool patches
both PMR and GCA involve polymorphisim of
HLA-DR alleles
what 2 labs will be very elevated in PMR and GCA
ESR/CRP
PMR is a __ dx
and the gold standard for GCA is __
clinical
temporal artery bx
what do you do if the temporal bx for GCA is negative but you have a high suspicion for GCA
bx the other side
the tx for both PMR and GCA is __
but for GCA tx is much more __
steroids
emergent
should you wait for bx results to start tx for GCA
no!
what is the initial starting dose of prednisone for GCA (you need to know this)
AND for PMR
GCA: 40-60 mg po daily x several months
PMR: 15 mg po qd
what is a major rf if you delay tx for GCA
blindness
flares are common in GCA, how should you treat these
increase dose of steroids by 10 mg
what meds should be administered with steroids for GCA
vitamin C
osteoporosis meds
takayasu arteritis is similar to __
and __
GCA
PMR
takayaus arteritis involves chronic vasculitis that mc affects the
aorta and its main branches
name 5 symptoms associated w. takayasu arteritis
skin lesions
claudication
syncope
arthralgias
GI issues
pe for takayasu arteritis may include (3)
bp differential
diminished pulses
anemia of chronic dz
in takayasu arteritis, labs will show elevated (2)
CRP
ESR
dx for takayasu can involve __ and/or
__
clinical features
imaging
what might you see on imaging for takayasu arteritis (2)
arterial luminal narrowing
occlusion w. wall thickening
what is tx for takayasu arteritis (2)
prednisone to taper
+/- surgery → PCT, bypass, grafting, aortic repair
reactive arthritis mc affects
weight bearing joints of lower extremities
what might a pt have 1-4 weeks prior to reactive arthritis
diarrhea (GI infxn) or urethritis
what are skin findings might you see on a pt w. reactive arthritis
rash on palms / toes
what are 3 rf for reactive arthritis
young adult
HLA-B27 gene
STDs
what bacteria are commonly associated w. reactive arthritis
shigella
e. coli
c. diff
campylobacter
salmonella
yersinia
→ from previous GI infxn
dx for reactive arthritis might involve (4)
but there is no single dx test
elevated CRP/ESR
stool culture
urethral swab
synovial fluid analysis
what is mainstay tx for reactive arthritis
NSAIDs → naproxen, indamethacin
steroids/DMARDs if no response
what rheumatologic condition does this make you think of
reactive arthritis
sjiorgen syndrome mc manifests in (2)
lacrimal/salivary glands
eyes
what are the 2 main symptoms of sjorgen syndrome
xerostomia
severely dry eyes
name 5 symptoms of keratoconjunctivitis sicca
diminished tears
dry eyes
AM crust
gritty/sandy feeling
bacterial infxns
name 2 complications of sjorgen’s syndrome related to xerostomia
dental caries
salivary gland enlargement
besides mouth and glands, what 5 other systems can be affected by sjorgen’s
GI
renal
urogenital
neuro → neuropathy
name 5 constitutional symptoms of sjorgen’s syndrome
fatigue
low grade fever
purpura
Raynaud’s
symmetric arthralgia
what do schirmer test and saxon test make you think of
sjorgen syndrome
what is a (+) schirmer test
< 5 mm tears produced in 5 min
saxon test measures
saliva production
causes of sjorgen syndrome can be __
or __
primary
secondary
what 2 labs are often positive in reactive arthritis
ANA
RF
what is gold standard dx for sjorgen’s syndrome
salivary gland bx
what is real life dx for sjorgen’s syndrome (2)
- Schirmer OR Saxon OR imaging showing glandular abnormalities
- (+) anti-Ro/SSSA and/or La/SSB abs, (+) lip bx OR established rheumatoid dz
tx for sjorgen’s syndrome involves good oral hygiene; what drugs may also help
pilocarpine
cevimeline
how do you tx eye symptoms for sjorgen’s
ocular cyclosporine + artificial tears
+/- topical steroid per ortho
+/- punctal occlusion/plugs
what class of drugs may prescribed for systemic management of sjorgen’s
immunosuppressive therapy per rheumo →
hydrochloroquine
methotrexate
name 3 cardinal signs of RA
slow, insidious onset
morning stiffness > 30 min
symmetric swelling of many joints
joints mc associated w. RA (5)
PIPs
MCPs
wrists
ankles
knees
if you see this joint on a rheumatoid condition, you should not be considering RA
DIP → almost never affected
what RA symptoms is only seen in RF (+) patients
RA nodules
mc location for RA nodules
forearms
+/- lungs
name 3 systemic manifestations of RA
keratoconjunctivitis sicca
pulmonary effusions
pericarditis → from chronic inflammation
what are 2 major rf for RA
female
smoking
what do you think of when you see boggy joints, ulnar deviation of MCP and swan neck, boutinniere, and z deformities
RA
what is the most specific lab test for RA
anti-CCP
what elevated labs correlate w. dz severity in RA
ESR/CRP
what will synovial fluid show with RA
inflammatory effusio
leukocytes 1,500-25,000
what is the most specific imaging for RA
x-rays
early, initial, and late xray findings w. RA
early: normal
initial: soft tissue swelling/osteopenia
late: joint space narrowing/erosions
what is this Xray showing and what condition is it associated w.
joint space narrowing/erosions
RA
what is most sensitive imaging for RA
MRI
what are 5 dx factors for RA
inflammatory arthritis involving at least 3 joints
positive RF/anti-CCP
elevated ESR/CRP
duration at least 6 weeks
excluded other causes
can you dx a seronegative pt w. RA
yes!
what are the 3 goals of RA tx
control pain and inflammation
preserve fxn
prevent deformity
early initiation of __ in RA is crucial
DMARDs
name 3 DMARDs
methotrexate
sulfasalazine
leflunomide
what drug might you add to DMARDs with RA pt
TNF inhibitor
what is mc TNF inhibitor used for RA
Etenercept
how should steroids be used in RA tx
as a bridge to start DMARs
NSAIDs should never be used as __ in RA
monotherapy
what should you do if a RA pt is still in pain after initial therapy w. steroids + DMARDs
increase DMARD
how do you tx flares of RA
steroids
how do you treat recurrent flairs of RA in medicated pt
increase DMARD
name 5 pre-screening tests you should do for RA pt before interventions
hep B and C
baseline CBC, SCr, ESR/CRP
ophthalmic screening
latent TB
baseline radiographs
list 4 contraindications for DMARDs
pregnancy
liver dz
etoh
severe renal impairment
what are 3 s.e of DMARDs
GI upset
stomatitis
hepatotoxicity
1st choice TNF inhibitor for RA
etanercept
pro and con of etanercept
well tolerated
expensive, increased risk for infxn
you must screen for __ before starting pt on etanercept
latent tb
what does SANTA stand for and what is it associated w.
felty syndrome
Splenomegaly
Anemia
Neutropenia
Thrombocytopenia
Arthritis (rheumatoid)
felty syndrome is a rare complication of
ra
polyarteritis nodosa (PAN) mc affects
medium to small muscular arteries
what systems does PAN mc affect
skin
muscle
peripheral nerves
kidneys
__ and
__ are usually not affected by PAN
lungs
veins
what organ is mc affected by PAN
kidneys
what do you think of when you see
lower extremity ulcerations, HTN, abdominal pain after meals, foot drop, and arthralgias
PAN
PAN
3 rf for PAN
male
hepB/C
hairy cell leukemia
what dz pathology involves necrotizing vasculitis → decreased blood flow → weakened vessels
PAN
3 dx factors for PAN
bx of involved organ
angiogram
ACR criteria 3/10
bx in PAN will show
necrotizing inflammation of medium sized arteries
what will angiogram in PAN show
rosary sign
what is this angiogram showing and what condition is it associated w.
rosary sign
PAN
if PAN is associated w. viral hepatitis, you should limit __
steroids
tx for mild PAN
monotherapy w. corticosteroids
how do you tx persistent mild PAN
MTX
tx for mod-sev PAN
high dose steroids plus immunosupressant
what immunosuppressant drug is used for PAN
cyclophosphamide
max length of time pt can take cyclophosphamide
12 mo
