Rheum 1 Flashcards
What is gout
metabolic disease with altered purine metabolism causing sodium urate crystal deposits in synovial fluid
Commonly familial
M >30
BUT- chronic uricemia does not mean you will get gout!
RF for gout are
Male age >30 genetics obesity alcohol high purine diet high fructose/sucrose diet HTN CKD Thiazides/loop diuretics
Etiology of gout is
Abnormal deposits of urate cause recurring acute arthritis attacks
What are the types of gout
Primary: occurs 2/2 genetic alterations in how kidneys process urate (under excreter)
Secondary: occurs 2/2 acquired causes of hyperuricemia (on meds, myeloproliferative Dz, hypothyroidism, alcohol abuse)
How does acute gout present
Acute onset intense pain, commonly at nigh t
Swollen, tender joint w/ red, warm overlying skin
Involves first MTP (MC), feet, ankles, and knees
What is Podagra
Gout of the first MTP
How does chronic gout present
Tophaceous gout after 10 or more years
Urate deposits (tophi) in subQ tissue, bone, cartilage, and joints
Surrounded by granulomatous inflammation
Can lead to deforming polyarthritis
How do you diagnose gout
Serum uric acid >6.8mg is supportive (- does not r/o gout)
Synovial fluid showing monosodium urate crystals (diagnostic)
Imaging
What do monosodium urate crystals look like
needle-like
rod shaped
negatively birefringement crystals
How can you tell the difference between gout and septic arthritis
Septic arthritis has way more WBC than gout
What are imaging findings in gout
New: no findings
Established: small, punched out erosions w/ overhanging edges
How do you treat an acute gout attack
Elevate, rest*
Decrease purine and alcohol intake (not suddenly)
Indomethacin 50mg (5-10d, until Sx gone)- or Naproxen 500
Colchicine (if attack w/in 24-36 hours)
Oral/IV corticosteroids, or injection (if 100% positive it is NOT a septic joint)
How do you prophylactically treat gout
Lose weight, avoid alcohol, restrict purine intake
Avoid thiazides, loop diuretics, Niacin, and low dose aspirin
Colchicine (prevent further attacks by lowering urate)
Xanthine oxidase inhibitors (Allopurinon)
Uricosuric agents (Probenecid)- increase uric acid excretion by blocking kidney reabsorption
Side effects of Xanthine oxidase inhibitors
Precipitate acute attack, rash leading to TEN
Dietary modifications to treat gout include
limit all meats (organ meat and seafood)
Cut back on fat
Limit alcohol, esp beer
Limit high fructose corn syrup
Drink plenty of fluids (8-16 cups of water)
High purine foods are
all meats meat extracts yeast beer beans peas lentils, oatmeal, spinach, asparagus, cauliflower, mushrooms -AKA foods with many nuclei and growing
Complications of gout include
Nephrolithiasis
Chronic urate nephropathy
What is pseudogout
Calcium pyrophosphate dihydrate disease affecting peripheral joints with deposits of calcium pyrophosphate
Acute attacks mimic gout
Worse with ate (>60)
MC in knee, wrist, elbow
What are chondrocalcinosis
Calcium pyrophosphate deposits in cartilage
How does pseudogout present
Recurrent, abrupt onset of joint pain
How do you diagnose pseudogout
X-Ray shows fine, linear densities in articular tissues
Joint aspiration shows calcium pyrophosphate crystals- rhomboid shape crystals w/ + birefringement with light microscopy
How do you treat pseudogout
NSAIDs for acute attacks
Colchicine w/ prophylaxis
Intra-articular steroid injection
What is OA
MC joint disease, related to age
Occurs in weight bearing joints of knee (65+ y/o)
<50: M>W
>50: W>M
RF for OA are
Age Women Excess weight Contact sports Bending or carrying occupation Injury Developmental deformities Low vitamin D/calcium intake
What is the pathophys of OA
Progressive cartilage degeneration Reactive hypertrophy of bone Loss of articular bone space, joint destruction Osteophytes, Herbeden and Bouchard nodes Sclerosis of subchondral bone (minimal inflammation)
How does OA present
Insidious onset joint pain, worse w/ activity, better with rest
<30 min morning stiffness
Decreased ROM
Crepitus
Varus knees
Fingers, wrists, hips, knees, and spine affected
How can you tell between OA and RA
OA there are no systemic symptoms!
How do you diagnose OA
*X-Ray- Asymmetric narrowing of joint space, osteophytes, thick subchondral bone, bony cysts
Normal labs, synovial fluid non-inflammatory
How do you treat OA non-pharm
Weight loss aquatic, cardio or resistance exercise heat and cold PT OT bracing canes
How do you treat OA pharm
APAP (good for old people at risk for ADE of NSAIDs
Oral NSAIDs
Topical NSAIDs (diclofenac)
Topical capsaicin (hand)
Intra-articular steroid injections (4xyr)
Intra-articular sodium hyaluronate injection (knee)
How do you treat OA surgically
Arthroscopy (go in and clean joint)
joint replacement
What is RA
Chronic, progressive inflammatory disease with synovitis of multiple joints
F>M
Peak 40-50 women, 60-80 men
Untreated RA causes
joint destruction, disability, and shorter life expectancy
So… treat EARLY and AGGRESSIVELY
What is the etiology of RA
Unknown! maybe due to multiple genetic susceptibilities
What is the pathophys of RA
Chronic synovitis causing erosion or cartilage, bone, ligaments, and tendons
How does RA present
> 30 min morning stiffness
Insidious onset symmetric swelling of multiple joints w/ ttp and pain
Symmetric polyarthritis of small joints or hands and feet (PIP, MCP, wristsm knees, ankles, MTP)
Synovial cysts
tendon rupture
entrapment
RA spares
The spine and SI joints
does not spare the neck
Extra-articular manifestations of RA are
SubQ nodules Ocular Sx Mouth dryness interstitial lung dz pleural effusion pericarditis vasculitis
Common RA complaints include
Pain turning door knob- opening jars- buttoning shirts- in ball of foot Widening of forefoot neck pain and stiffness constitutional Sx
How do you diagnose RA
**X-Rays (most specific)
**Anti-CP antibodies (most specific blood test)- cyclic citrullinated peptides
Rheumatoid factor (- in many)
ANA +
ESR, CRP elevated
Anemia
inflamed joint fluid
+/- septic arthritis
RA x-rays show
early: articular demineralization and soft tissue swelling
joint erosions
joint space narrowing
2010 RA diagnostic criteria includes
and type of joints involved
Serology (RF or anti-CCP)
Acute phase reactants (ESR/CRP)
Sx duration (MIN 6 wks)
RA treatment goals are
Reduce inflammation, pain
Preserve function
Prevent deformity
How do you treat RA
- DMARDs as soon as Dx is confirmed; they take a while to work so in the meantime, also use
- NSAIDs, PO low dose Prednisone, Intra-articular corticosteroid (max 4xyr)
What are the conventional DMARDs
Methotrexate
Sulfasalazine
Leflunomide
Hydroxychloroquin
What are the biologic DMARDs
- Tofacitinib (JAK inhibitor)
- TNF-a inhibitor: Eternacept, Infliximab, Adalimumab, Golimumab, Certolizumab
- Anakinra (IL-1 inhibitor)
- Tocilizumab (IL-6 inhibitor)
- Abatacept (T cell costimulation blocker)
- Rituximab (anti-CD20 B cell depleting MAB)
When choosing a DMARD, consider
CBC, Cr, LFT, ESR, CRP Hep B/C screening Opthalmologic screening Latent TB test CXR
Are NSAIDs magic
No- they can provide Sx relief, but do NOT prevent erosions or alter disease progression
they are NOT dmards and should not be used alone! only WITH dmards
Conventional RA treatment (1st line) is
Methotrexate!
Takes 2-6 weeks
Suppresses bone marrow= low WBC and platelets
Teratogenic
ADE of methotrexate are
GI upset
Stomatitis
Hepatotoxic w/ cumulative dosing
Second line RA Tx used with Methotrexate or alone if Metho doesn’t work is
Sulfasalazine (avoid if ASA sensitivity)
Leflunomide (carcinogen, teratogen)
ADE of second line RA drugs are
Sulfasalazine: Neutropenia, thrombocytopenia, hemolysis if w/ G6PD deficiency
Leflunomide: GI upset, rash, alopecia, hepatotoxic, weight loss
What antimalarial is used to Tx RA
Hydroxychloroquin- MC with Sulfasalazine or Methotrexate
NEED yearly eye exams!
ADE of Hydroxychloroquin are
Pigmentary retinitis- so get YEARLY eye exams!
Are biologics good drugs
Well tolerated usually Increased risk of infection NEED to screen for TB before giving \+/- causes malignancy CAUTION with HF costs 10K/yr
What is the prognosis of RA (after years of Dz)
Chronic systemic inflammation
Ulnar deviation of fingers
Boutonniere deformity (hyperextend dip, flex pip
Swan neck deformity (flex dip, extend pip)
Valgus knees
Volar sublux of MCP
Mortality associated w/ RA 2/2 CVD
What are subtypes of systemic juvenile idiopathic arthritis
Systemic Polyarthritis Oligoarthritis Enthesitis Psoriatic -they are all autoimmune
How does sJIA present
Fever Arthritis (mono, oligo, or poly) Rash LAD ANA & RF rarely see
How do you diagnose sJIA
Diagnosis of exclusion! *Intermittent daily fevers and arthritis Fever 2+ weeks Arthritis 6+ weeks Onset prior to 16 y/o
How do you manage sJIA
Difficult remission.. Send to peds rheumatology!
PT, OT, Dietician, support groups
What are seronegative spondyloarthropathies
Ankylosing spondylitis, psoriatic arthritis, reactive arthritis
M>W
<40
inflammatory arthritis of spine and SI joints
Asymmetric
No antibodies in serum
Associated with HLA-B27 gene
What is ankylosing spondylitis
Chronic inflammatory disease of joints of axial skeleton
M>W, teens-late 20’s
How does ankylosing spondylitis present
Gradual, intermittent back pain
worse in morning (after rest)
better with activity
radiates to buttocks
How does ankylosing spondylitis present
Progressive stiffening of spine Sx start at low back, move towards head Flattening of lumbar lordosis Exaggeration of thoracic kyphosis Decreased chest expansion Total spine fusion Peripheral joint arthritis Swelling of achilles tendon and plantar fasciitis (enthesopathy) Anterior uveitis Cardiac,pulmonary, GI Sx
How do yuo diagnose ankylosing spondylitis
Elevated ESR* Negatie RF and anti-CCP Mild anemia on CBC HLA B27 + (92% of white, 50% of black) Imaging
What are imaging results of ankylosing spondylitis
Early: SI joint erosion, sclerosis (b/l and symmetric)
Bamboo spine: vertebral bodies fuse together
How do you treat ankylosing spondylitis
1** NSAIDs
TNF inhibitors
Corticosteroids (can cause steopenia, not great)
Sulfasalazine
Surgery: Fracture stabilization or joint replacement
PT
Swimming
How does psoriatic arthritis present
Skin psoriasis before arthritis (usually) Nail pitting Onycholysis Asymmetric SI joint involvement Sausage digits
How do you diagnose Psoriatic arthritis
Elevated ESR
RF negative
Imaging (helps differentiate it from others!)
What imaging findings are present with psoriatic arthritis
Erosion and destruction of bone
Osteolysis
Pencil in a cup deformity
Asymmetric sacroilitis
How do you treat psoriatic arthritis
1* NSAIDs
2: Methotrexate (if NSAIDs don’t work)
PDE4 inhibitor (not if erosive dz)
Biologics: TNF-a inhibitors, MAB
What Tx do you avoid in psoriatic arthritis
Corticosteroids
They are less effective, and tapering can trigger a flare
What is Reactuve arthritis (Reiter syndrome)
MC in young men
Usually 1-4 weeks after bacterial GU or GI infection (diarrhea, Chlamydia t, Salmonella, Shigella)
HLA B27 +
How does Reactive arthritis present
Asymmetric oligoarthritis of LE (knee, ankle)
Fever, weight loss
Extra-articular: Urethritis, conjunctivitis, uveitis, balanitis, stomatitis, Keratoderms blennorrhagicum**, cardiac Sx
How do you diagnose reactive arthritis
Synovial fluid is sterile, no cultures! No specific XR findings Stool cultures (if diarrhea) Chlamydia testing \+/-: CBC, ESR/CRP, renal/liver tests, UA, HLA B27, RF, anti-CCP
How do you treat reactive arthritis
NSAIDs
Antibiotics for STI are somewhat prophylactic
Sulfasalazine, Methotrexate, TNF inhibitors
What is the prognosis of reactive arthritis
most SF signs of reactive arthritis clear in days-weeks
Arthritis can last for months
Think of this triad for Reiters/reactive arthritis***
Can’t SEE, can’t PEE, can’t CLIMB A TREE
Uveitis/conjunctivitis
Urethritis
Arthritis
