Rheu Flashcards
Are Oral corticosteroids Dmards?
No they are not. Oral corticosteroids are not DMARDS
Difference between Methylprednisolone and Prednisolone?
Essentially the same. Prednisolone is administered Orally. Methylprednisolone is administered IV.
According to NICE guidelines, patient needs a DAS assessment
anti TNF therapy
Pneumonitis is well recognized but uncommon complication
Methotrexate
Inhibit both COX-1 and COX-II
NSAIDS
All brands are parenteral
anti TNF therapy
Causes profound B-Cell lymphocyte depletion
Rituximab
Better G.I. safety than the older generation of these drugs
Cox II selective non-steroidals
Can cause temporary azospermia in young men
Sulphasalazine
Azoospermia meaning
The complete absence of sperm from the seminal fluid.
Combination therapy may be more effective than monotherapy
DMARDs
Increased risk of infection with intra-cellular pathogens
Anti TNF therapy
Highly teratogenic and abortifacient
Methotrexate
Efficacy is similar to the older generation of these drugs
Cox II selective non steroidals
Closely related drugs are used to treat Crohn’s disease
Sulphasalazine
Given as adjuvant to other drugs to treat osteoporosis
Calcium/Vitamin D
Given early in disease to slow down progression
DMARDs
Have cardiovascular risk similar to older generation of these drugs
Cox II Selective non steroidals
Helpful for bone metastases induced hypercalcaemia
Bisphosphonates
Also referred as ‘pulse’ therapy
Methylprednisolone
Do not prescribe if allergic to aspirin
Sulphasalazine
Very rapid influence on inflammatory arthritis SLE & vasculitis
Oral Corticosteroids
Well recognised to cause infertility
Cyclophosphamide
Many brands in chewable formulation
Calcium/vitamin d
Narrow therapeutic window
Paracetamol
Minimise fracture risk in people taking steroids
Bisphosphonates
Titrate dose to reduce serum urate level
Allopurinol
More side effects if TPMT enzyme deficient
Azathioprine
Most of them need regular blood monitoring
DMARDs
Osteoporosis with long term use
Oral Corticosteroids
Weight gain very common
Oral Corticosteroids
Drug interaction with allopurinol
Azathioprine
Risk of haemorrhagic cystitis
Cyclophosphamide
Risk of interstitial nephritis and fluid retention
NSAIDs
Risk of oesophagitis
Bisphosphonates
Risk of peptic ulcer
NSAIDs
Should not be stopped during an ‘attack’
Allopurinol
Key treatment for temporal arteritis (gca) and PMR
MethylPrednisolone
Often used as a ‘steroid sparing’ agent
Azathioprine
(I think othere DMARDs too, check…)
reduces hyperuricaemia
Allopurinol
Efficacy due to action on bone and muscle
Calcium/Vitamin D
Used for intra-articular and intravenous injections
Methylprednisolone
Licensed for treatment of lymphoma and rheumatoid arthritis
Rituximab
Weekly doses followed by folic acid
Methotrexate
Alkylating chemotherapeutic drug
Cyclophosphamide
Follow up infusions are not needed many months
Rituximab
Which anti microbial may cause cutaneous hypersensitivity vasculitis?
Penicillin
Do Diuretics decrease uric acid excretion?
Yes. Therefore risk factor for gout.
Which Class of antiarrhythmics can exacerbate Raynards symptoms
Beta Blockers.
The 4 common clinical features of Spondyloarthropathies
- Sacroiliac/axial disease (back/buttock pain)
- Inflammatory arthropathy of peripheral joints
- Enthesitis (inflammation at tendon insertions)
- Extra-articular features (skin/gut/eye)
Common signs and symptoms of SLE
S erositis (pleurisy, pericarditis)
O ral ulcers (usually painless; palate most specific)
A rthritis (small joints nonerosive)
P hotosensitivity (or malar or discoid rash)
B lood disorders (low wcc, lymphopenia, thrombocytopenia, hemolytic anemia)
R enal involvement (glomerulonephritis)
A utoantibodies (ANA positive in >90% of cases)
I mmunologic tests (e.g. low complements)
N eurologic disorders (seizures or psychosis)
Which conditions can have Raynauds Phenomenon as an extra articular sign?
SLE,
Sjorgrens’s,
Systemic Sclerosis (Scleroderma)
Dermatomyositis + Polymyositis
Which drugs can induce Raynauds
Beta Blockers
Risk factors for septic arthritis
diabetes mellitus, pre existing joint disease (e.g. RA), recent joint surgery, immunosuppression, chronic renal failure, Alcoholism
Septic arthritis pathophysiology
Foreign microbe infection of the joint space (capsule) that is associated with rapid joint destruction within days if not adequately treated.
Is septic arthritis typically monoarticular or polyarticular?
Typically monoarticular. Can be polyarticular = very poor prognosis
Most common causative organisms of septic arthritis
Staph Aureus and Streptococci
IVDU can have septic arthritis in strange sites, where?
Axial Sites
In which joint is septic arthritis most commonly affected?
Knee
Gram -ve seen as causative organism for septic arthritis in elderly and IVDU, true or false?
True
In people under 40, what can be the causative organism for septic arthritis?
Gonococcal
Complications of septic arthritis
Degeneration of joint
Death
The 2 specific septic arthritis diagnostic investigations
Aspirate synovial fluid
Blood culture
Management of Septic Arthritis
Antibiotics and surgical washout
Features seen in Spondyloarthropathies (but in different degrees depending in the type of Spondyloarthropathy)
S ausage digits
P soriasis
I ritis (inflammation of the colored part of your eye)
N SAID response is good
E nthesitis (inflammation of sites of tendon to bone)
A rthritis/ arthralgia
C rohns (+other IBDs)
H LA-B27
E levated inflammatory vessels
Dactylitis (sausage digit) is associated with which forms of spondyloarthropathy?
Psoriatic arthritis
Ankylosing spondylitis
What are spondyloarthropathies?
Group of conditions that affect the spine and peripheral joints and are associated with the presence of HLA-B27
Name 4 clinical features that all Spondyloarthropathies tend to have:
Sacroiliac/axial disease (back/buttock pain)
Inflammatory arthropathy of peripheral joints
Enthesitis (inflammation at tendon insertions)
Extra articular features (skin/gut/eye)
Extra-articular manifestations of Ankylosing spondylitis (All the A’s)
Anterior uveitis
AV block
Aortic incompetence
Apical lung fibrosis
Amyloidosis
I.PAIN (=features of inflammatory back pain) tell me them!
Insidious onset
Pain at rest and at night therefore
Age of onset is LESS THAN 40
Improvement with exercise
No improvement with rest
Talk Psoriatic Arthritis in terms of patterns of presentation
Nails can be affected
Can be seen as symmetrical arthritis (like RA)
Can be seen as monoarthritis
Can be seen as asymmetrical oligoarthritis with dactylitis
What xray appearance can be observed in Psoriatic Arthritis
Pencil in cup
Can you get costochondritis with Ankylosing spondylitis?
Yes
In Ankylosing Spondylitis name 3 features seen on the xray of the spine and the SI joint
- Syndesmophytes (seen in ankylosing spondylitis)
- Romanus lesion
- SI joint erosions
(The sacroiliac joints are centrally involved in the SpA (spondyloarthropathy ), most clearly and pathognomonic in ankylosing spondylitis)
Before giving someone Methotrexate what two tests does the patient need
CXR and liver tests
Name two characteristic features of blood tests for someone with SLE?
low WCC and low platelets
(also raised PV with normal CRP)
Lupus urine test would show?
Lupus can attack the kidneys (lupus nephritis). Therefore, can have blood and protein in the urine. (Haematuria and Proteinuria)
Polymyalgia Rheumatica is associated with which other condition?
Giant cell Arteritis
Prednisolone is typically given daily in almost all PMR patients initially, at what dose though?
15mg
Then taper off slowly.
Can PMR patients expect the response to prednisolone to be dramatic or not?
Dramatic diagnostic response within 5 days of starting the medication
What symptom should patients with PMR be watchful for?
Headache (possible GCA)
If GCA is diagnosed what drug is given and at what dose?
60mg Prednisolone daily.
For at least 2 weeks, then taper off.
For acute onset GCA visual symptoms, what drug should be given?
Methylprednisolone IV pulse therapy (1-3 days)
GCA trumps PMR as it requires higher prednisolone. True or False?
True
In PMR prednisolone is given and which other drugs?
Many adverse effects of long term corticosteroid usage.
Calcium/ vit d (prevention of osteoporosis)
PPI (to reduce glucocorticoid risk of [weakly linked with] peptic ulceration and perforation)
Either a biopsy of the temporal artery or …….. can help to diagnose GCA
Ultrasound of the temporal artery
Which NSAID has least risk for cardiovascular adverse events?
Naproxen
Are Heberden’s nodes on the PIPJs?
No they are on the DIPJs
(herbs sprinkling).
Seen in OA
Are Bouchard’s nodes on the PIPJs?
Yes
Seen in OA
If a patient has really tight skin and as a result can no longer fully stretch their fingers, which condition are you thinking of?
Systemic Sclerosis
Sign is called sclerodactyly
Person presents with weird looking nails and DIPJs swelling, whats most likely diagnosis?
Psoriatic Arthritis
Which two tests can be used to diagnose carpal tunnel syndrome?
Tinel’s and Phalen’s
What condition?
Hallux Valgus
Which condition can have nail fold infarcts?
RA
SLE, Vasculitis
Schobers test is used in which Spondyloarthropathy?
Ankylosing Spondylitis
What is Schobers test?
Used to test if theres a decrease in lumbar spine flexion
Test yourself with cover and recall of rheumatology booklet
Look at written notes too
Test yourself with cover and recall of rheumatology booklet
Test yourself with cover and recall of rheumatology booklet
Look at written notes too
Test yourself with cover and recall of rheumatology booklet
Look at written notes too
Test yourself with cover and recall of rheumatology booklet
Look at written notes too
Test yourself with cover and recall of rheumatology booklet
Whats Tophi?
Urate deposits (seen in e.g. pinna, tendons, joints)
A patient has gout. They extract synovial fluid from the affected joint, describe what the urate crystals look like?
Needle-shaped monosodium urate crystals, displaying negative birefringence under polarised light
What conditions lead to saddle nose?
Trauma,
Cocaine abuse,
Relapsing polychondritis,
Vasculitis (e.g. Wegener’s granulomatosis)
Name some forms of Vasculitis
Blood vessels affected:
Large: GCA
Medium: Kawasaki disease
Small: Wegener’s granulomatosis (granulomatosis with polyangiitis)
Variable vessel vasculitis: Behcet’s
From research PMR is and is not considered to be a true vasculitis
Whats arthralgia?
Joint pain (check)
Some tests required for Vasculitis:
ANCA (may be positive),
CRP (raised),
ESR (raised),
Mandated urinalysis: To identify if theres kidney involvement then look for proteinuria and haematuria (sign of glomerulonephritis)
“The presentation of vasculitis will depend on the organs affected”
Whats the most common cause of Thoracic kyphosis in men? In women?
In men Ankylosing Spondylitis
In women Osteoporosis.
Give examples of Hypermobility Spectrum Disorders:
Ehlers Danlos syndrome, Marfan syndrome
Whats Beighton Score
Beighton score is a popular screening technique for hypermobility
Dupuytren’s contracture causes
Diabetes mellitus, Alcoholic liver disease, trauma, anti epilepsy drugs (e.g. Phenytoin)
