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Year 6 > Rheum > Flashcards

Rheum Flashcards

1
Q

What are you prescribing for fibromyalgia?

A

Neuropathic meds:

1st - amitryptilline 25mg

Or duloxetine or pregabalin.

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2
Q

List some side effects of alendronate and bisphosphonate?

A

Osteonecrosis of jaw
Oesophagitis - careful posture when taking meds
Gastric ulcers

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3
Q

what are the clincial features of RA?

A

o Stiffness worse in the morning -> better with exercise

o Swan neck, boutonnière (late features), Z-thumb, ulnar deviation at MCPJ

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4
Q

name some exra-articular features of RA?

A

 Eyes episcleritis, keratoconjunctivitis sicca
 Heart pericarditis
 Lungs fibrosis, rheumatoid nodules
 Hands De Quervain’s tenosynovitis, Carpal tunnel, trigger finger
 Spleen splenomegaly [Felty’s syndrome]

Kidney - amyloidosis

Feet - Peripheral neuropathy

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5
Q

what are the features of felty syndrome?

A
  • Splenomegaly !
  • Anaemia
  • Neutropenia!
  • Thrombocytopenia
  • Rheumatoid Arthritis !
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6
Q

how do we ivx RA?

A

o Bloods: FBC (anaemia, ↓PMN, ↑plat), ↑ESR, ↑CRP SJC = swollen JC
 RhF: +ve in 70% JC = Joint Count
 Anti-CCP: 90-95% specific, 80% sensitive
 ANA: +ve in 30%

o Imaging: XR (baseline), USS (synovitis)

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7
Q

How do we monitor disease activity in RA?

A

CRP,
Disease activity score 28; DAS 28
TJC/SJC; tender/swollen joint count (feeds into das28)

  • If DAS-28 >5.1, consider stepping up management
  • If  pain/CRP/DAS, offer simple analgesics
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8
Q

outline of Mx for RA?

A

o 1st line  conventional DMARD (cDMARD) monotherapy ± short course bridging prednisolone

 DMARD medications = methotrexate, sulfasalazine, MMF, hydroxychloroquine, leflunomide,

o 2nd line (DAS/CRP increasing);
[2x DMARDs in combination]

o 3rd line (DAS/CRP increasing):
biologics (bDMARD)
 Etanercept, Infliximab, Adalimumab, Rituximab

± cDMARD (TNFa-inhibitors, B-cell/T-cell depletion)

Once remission is achieved, keep them on a low dose of the dmard

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9
Q

Mx for flare ups in RA?

A

o Corticosteroids (PO, IM; methylprednisolone acetate, triamcinolone acetonide) ± NSAIDs

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10
Q

what are the principles of RA mx?

A

With a new diagnosis, start steroid then wean off steroids starting dmard. Takes 12weeks to kick in hence bridging prednisolone for 6weeks.
If someone is taking methotrexate, they MUST be given folate- take on a different day. Once weekly methotrexate.
If you start methotrexate and they have side effects, just change to another first line eg hydroxychloroquine - not this is the only first line NOT considered an immunosuppressant so no vaccines, regular blood tests needed. Need once yearly flu jab, no live vaccines.
If disease persists after some months on 1st line drug then change to 2nd lines, anti-tnf drugs then make inhibitors.
Doctors DO actually give nsaids with methotrexate, a small amount - some may not though.

Drs usually start pt on 2 dmards straight away. Trial period is 6 months during which remission is expected. If very mild just start on 1 dmard, must try for 6 months before changing to another dmard. If 2 dmards don’t work then biologics.

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11
Q

what are some notable points about RA mx and pregnancy>

A

Notes about methotrexate:

Must stop for 3 months before trying to get pregnant. Swap to sulfasalazine.

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12
Q

list the causes fo fracture?

A

Causes of fracture:
Hypogonadism in males - low testosterone (that’s why we ask if they shave regularly, libido etc)

Osteomalacia- malabsorption; coealiac etc, diet
Medications - steroids, diabetes drugs - gliflozins
Breast cancer drugs - lefloxazole?
Myeloma
Osteoporosis

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13
Q

In osteoporosis, which bisphosphonates do we prescribe?

A

Alendronate, risidronate - 1st line.

Risidronate usually better tolerated.

Teriparatide - very expensive. Only if fractures, unresponsive to bisphophonates.

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14
Q

what counts as significant morning stiffness

A

when it last 30mins more

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15
Q

what do we give upon a new diagnosis of Rheumatoid condition eg polymyalgia?

A

give prednisolone 15mg

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16
Q

Steroid dosing.

What dose of pred given in these circumstances:

  1. Life threatening asthma or cold
  2. Temporal arthritis
A
  1. Life threatening asthma or cold give 40mg prednisolone
  2. Temporal arthritis give 60mg prednisolone.

GCA usually secondary to polymyalgia rheumatica.
GCA is most common vasculitis.

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17
Q

Differentiating features of RA vs OA osteoarthritis on Xray?

A 
Rheumatoid - LESS:
Loss of joint space - proximal joints more
Erosions (periarticular)
Soft tissue swelling
Subluxation & deformity
OA - LOSS:
Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts
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18
Q

Clinical Features of OA?

A

Presents with joint pain and stiffness that is typically worse with activity.

Pain following use, improves with rest
Unilateral
No systemic upset

Weight-bearing joints (knee, hip)
Hands: DIPJ (Herbedens nodes), PIPJ (Bouchards nodes),
CMCJ! (squaring at base of thumb)

Knee giving way/locking sometimes
Reduced ROM

Usually elderly!

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19
Q

How does Polyarteritis nodosa present?

Mx?

A

Polyarteritis nodosa- widespread ischaemic and infarcts -> headaches, gangrene, foot drop etc.

Is a vasculitis

Give Prednisolone and cyclophosphamide

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20
Q

How does Churg Strauss / eGPA present?

ivx?

A
  • Eosinophilia
  • Asthma (late-onset)
  • Vasculitis (incl. RPGN)

ivx: +ve pANCA

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21
Q

How do we mx neuropathic pain?

A

o 1st line neuropathic pain -> amytriptyline, pregabalin
o 1st line diabetic neuropathy -> duloxetine

options include ; gabapentin

o 1st line trigeminal neuralgia -> carbamazepine

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22
Q

Clinical features fibromyalgia ?

A

o Chronic, widespread musculoskeletal pain and tenderness

o Fatigue
o Poor concentration
o Sleep disturbance
o Low mood

o Morning stiffness? - note; in fibro, pain may lead to perceived reduction in ROM but truly can be overcome

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23
Q

ivx and mx of Fibromyalgia?

A

Ex: feel tender points

Ivx: normal

Mx: educate, CBT, graded exercise programmes, amitryptyline/pregabalin/venlafaxine

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24
Q

What are the forms of vasculitis?

A

• Large vessel:
o GCA / temporal arteritis
o Takayasu’s arteritis

• Medium vessel:
o Polyarteritis nodosa
o Kawasaki’s disease Chapel-Hill criteria [2012]

• Small vessel:
o pANCA  Churg-Strauss (eGPA), microscopic polyangiitis
o cANCA  Wegener’s Granulomatosis (GPA)
o ANCA –ve  HSP, Goodpasture’s, cryoglobulinaemia

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25
Q

how would temproal arteritis present?

A

scalp tenderness, jaw claudication, headache, amaurosis fugax (ant. ischaemic optic neuropathy)

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26
Q

How do we mx temproal arteritis?

A

o Ix:
USS temporal artery (halo sign; if -ve -> temporal artery biopsy) ->, ESR raised, ALP raised, plts raised

o Mx:
40-60mg, PO prednisolone (immediately; before ix . taper down)

?Aspirin

-> PPI + alendronate (for 2 years)

 Visual symptoms -> IV methylprednisolone

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27
Q

how would polymyalgia rheumatica present?

A

manifests as PAIN and morning STIFFNESS involving the neck, shoulder girdle, and/or pelvic girdle in individuals older than age 50 years.

NO WEAKNESS

varying degrees of muscle tenderness, shoulder/hip bursitis, and/or oligoarthritis

About 15% to 20% of patients with PMR have giant cell arteritis

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28
Q

IVX and MX for PMR?

A

 Ix: raised ESR, CRP, ALP, normal CK

 Mx: 15mg, PO prednisolone (taper down to 5mg + PPI + alendronate)

29
Q

what is Takayasu Arteritis?

A

A vasculitis of large vessels that particularly affects the aorta and its primary branches eg carotids.

More common in women and typically presents before the age of 40.

30
Q

clinical features of Takayasu Arteritis ?

A

limb claudication on exertion, chest pain, and systemic symptoms of weight loss, fatigue, low-grade fever, and myalgia.

can present with stroke/TIA

31
Q

ex and ivx findings in Takayasu Arteritis?

A

vascular bruits may be audible over the carotids, abdominal aorta, or subclavian vessels.

Unequal blood pressures may be recorded between sides, and a murmur of aortic regurgitation may be heard

IVX:
High CRP,ESR
CT Angiography /MRA; narrowing/occlusion /dilatation of vessel walls

32
Q

Takayasu Arteritis mx?

A

Prednisolone + aspirin + alendronate +- Methotrexate

33
Q

how does wegeners/ GPA present?

A
  • URT – rhinitis, epistaxis, saddle-nose
  • LRT – haemoptysis, cough
  • Renal – RPGN, nephritic syndrome
34
Q

ivx and mx of wegeners/ GPA?

A

Ivx: cANCA (PR3),
dipstick (proteins +, haematuria +, casts +)
CXR (nodules)
creatinine + ESR high

Mx: prednisolone + cyclophosphamide (OR rituximab)

35
Q

how do we ivx and mx dermatologist/polymyosists?

A 
•	Investigations:
o	Muscle enzymes (↑CK (1,000s), ↑AST, ↑ALT, ↑LDH) 
o	EMG
o	Biopsy (definitive)
o	Antibodies (“myositis panel”):
	Anti-Jo1 	
	Anti-Mi2 		DM > PM	
	Anti-SRP		PM
o	Malignancy screen (tumour markers, CXR, mammogram, USS, CT)

• Management:
o Treat skin disease (topical hydrocortisone) and malignancy
o Immunosuppression : PO steroids

2nd line: cytotoxic agents: azathioprine, methotrexate

36
Q

what is the ivx and mx of systemic sclerosis?

A

IVX:
Scl 70 or topoisomerase -> diffuse systemic sclerosis.
Diffuse - skin fibrosis affects the trunk and the skin distal and proximal to the elbows and/or knees.

Anti-centromere; Limited cutaneous

 Immunosuppression
 Raynaud’s: gloves/avoid cold, CCBs (nifedipine), PDE V phosphodiesterase (PDE) inhibitors (sildenafil)
 Renal crisis: intensive BP control (1st line: ACEi – despite this being CI in AKI)

 Oesophageal: PPIs, prokinetics (metoclopramide)
 PHT: sildenafil

Pain relief

37
Q

how do we mx anti-phospholipid syndrome?

A
  • No prev. VTE -> OD low-dose aspirin
  • Prev. VTE -> OD warfarin

severe flare eg pericarditis -> Pred + Cyclophos

38
Q

causes of drug induced SLE / Lupus?

A

 Causes (“Hydralazine PIMP”): Hydralazine, Procainamide, Isoniazid, Minocycline, Phenytoin

39
Q

ivx + mx of sjogrens?

A

ivx;
schirmers test positive- no tears
Anti Ro and Anti La

Mx:
artificial tears, saliva replacement +

NSAIDs/hydroxychloroquine -> immunosuppression

specialist O&G mx

40
Q

recurrent oral and/or genital ulceration,
uveitis, hypophyon,
erythema nodosum, VTE

which condition?

ivx and mx?

A

Behcets

skin pathergy test (pinprick -> papule formation)
Mx: immunosuppression

41
Q

Clinical presentation of Psoriatic arthritis?

A 
	Psoriasis
	Nail (POSh = Pitting, Onycholysis, Subungual hyperkeratosis) 
	Enthesitis (incl. sacroilitis) 
	Dactylitis (swollen fingers) 	
	Arthritis
42
Q

features of arthritis in Psoriatic arthritis?

A
  • Asymmetrical oligoarthritis 20-30%
  • Distal arthritis of the DIPJ 15% (classical)
  • Symmetrical polyarthritis*
  • Arthritis Mutilans ~3% (rare)
  • Spinal
43
Q

Ivx and mx of Psoriatic arthritis?

A

o Ix:

  • > Xray (‘pencil in cup’ deformity, plantar spur)
  • > Fluffy periosteal reaction, erosive changes
  • > Rheumatoid factor: +-
o	Mx: 
1. Methotrexate !
OR ciclosporin OR sulfasalazine
- NSAIDs (just for pain nothing else)
- intra-articular joint injection
- Physio
  1. Anti-TNF
44
Q

clinical features of ankylosing spondylitis?

A 
	Inflammatory Back pain, relieved by exercise		
 Morning stiffness
	Anterior chest pain (costochondritis)	
 Eye pain; iritis/uveitis
	Shortness of breath (pul. fibrosis)		
 Osteoporosis
45
Q

what are the key features of Inflammatory Back pain?

A

early morning back stiffness, improvement of stiffness with exercise,

insidious onset, age at onset <40 years, and back pain lasting >3 months

46
Q

how do we ivx ank spon?

A

 Schober’s test: <5cm increase = +ve

 1st: XR (late changes)

MRI (if XR normal; more sensitive) = sacroilitis > vertebra (corner erosions “shiny corners” of lumbarr vertebra, syndesmophytes),

sclerosis, ankylosis (fusion), bamboo spine (squaring of lumbar vertebrae)
• Syndesmophytes = ligamentous calcifications
• ‘Dagger’ sign = supraspinous tendon ossification

 HLA-B27 testing
 ESR ± CRP (normal results do not rule out AS)

47
Q

how do we mx ank spon?

A

 Conservative (exercise/physiotherapy)

 Medical:
Pain relief; NSAID (ibuprofen) -> NSAID (NAPROXEN) ->

Targetted therapy;
1. anti-TNFa!!! (etanercept, others – see here) -> Secukinumab

 Surgical (hip replacement to ↓ pain and ↑ mobility)

48
Q

what is the management of acute and chronic gout?

A

 Acute management:

  • 1st line = colchicine, NSAIDs (not aspirin)
  • Renal impairment = PO steroids

Do not stop allopurinol if already established
Do not stop aspirin 75mg if for cardioprotection

• Follow-up in 4-6 weeks and check BP, HbA1c, serum urate, U&Es, lipids  consider ULT

 Chronic prevention:
• Conservative (WL, no ETOH excess, avoid prolonged fasting)
o Xanthine oxidase inhibitor  1st = allopurinol; 2nd = febuxostat

49
Q

what are some contraindications to NSAID use?

A

Warfarin - nsaid already have anti-platelet effects

PUD - peptic ulcer

HF - heart failure

CRF - renal failure (bcos nsaids can cause renal dysfunction)

50
Q

How do we mx Osteoarthritis OA?

A
  1. Topical NSAIDs - diclofenac topical 1%

Conservative:
Glucosamine and chondroitin sulfate are dietary supplements (prescription-grade preparations should be sought)

1b. Intra-articular corticosteroid injections (Methylpred)

  1. Oral nsaid* + paracetamol + topical capsaicin
    *naproxen or ibuprofen
    (consider gastroprotection if long-term NSAIDs)

Later:
consider for surgery -> ortho referral -> joint replacement

51
Q

complications of OA?

A
  1. Reduced ability to carry out ADLs
  2. Spinal stenosis (if OA affected there)
  3. Iatrogenic due to nsaid:
    - GI bleed
    - Renal dysfunction
52
Q

what is the motor supply that the median nerve gives?

A

LOAF muscles - supply thenar eminence hence thumb movements:

  • Lat. 2 lumbricals,
  • Opponens pollicis,
  • Abductor pollicis brevis
  • Flexor pollicis brevis

Damaged by supracondylar fractures of humerus and dislocations of elbow

53
Q

what is trigger finger? clinical presentation?

risk factors?

A

Trigger finger, also known as stenosing tenosynovitis, is a disorder characterized by catching or locking of the involved finger.

The underlying mechanism involves the tendon sheath being too narrow for the flexor tendon.

Pain may occur in the palm of the hand or knuckles. The name is due to the popping sound made by the affected finger when moved.

Most commonly the ring finger or thumb is affected.

Risk factors include repeated injury, diabetes, kidney disease, thyroid disease, and inflammatory disease.

54
Q

Mx of trigger finger?

A

Initial treatment is generally with rest, splinting the finger, NSAIDs, or steroid injections

may need surgical release of the A1 pulley

55
Q

What is the Pain ladder in mx of chronic msk pain?

A

1st:
Ibuprofen oral 400 mg tds /topical 5% gel tds
OR naproxen oral 250 mg to 500 mg bd

2nd:
Co-codamol

Further:
Codeine -> morphine

56
Q

Important probing questions in a rheumatology history?

A

Pain
Stiffness
Swelling, Warmth, Redness

Deformity,
Weakness
Fatigue

Popping, locking, giving way
Loss of function
Numbness

57
Q

hack for name of muscles controlling hand movements?

A

Pollicis - thumb

Carpi - wrist

Digitorum - fingers

58
Q

wasting of the muscles of the thenar/hypothenar eminence suggests?

A

median or ulnar nerve pathology

59
Q

atrophy of the dorsal interosseous muscle may be seen in which rheum condition?

A

rheumatoid arthritis

supplied by ulnar nerve

60
Q

Most important differentials to exclude with a presentation of a hot, swollen joint?

A

Hot swollen joint most important considerations;

1. Septic arthritis
2. Crystal arthritis
3. Haemarthroses

crystal arthritis is more common than septic but septic is more important to exclude

61
Q

side effects of hydroxychloroquine?

A

Hydroxychloroquine is not useful in advanced disease.

Severe side effects: VISUAL IMPAIRMENT

62
Q

side effects of Sulfasalazine?

A

Causes discoloured urine and changes to colour of contact lenses.

63
Q

monitoring requirements for methotrexate?

A

Initially 2 weekly; Esr, U&Es, Lfts - affects kidneys

64
Q

how do we council patient for osteoarthritis?

A

No medication that will alter the outcome - only pain relief

Diclofenac topical -> oral said + paracetamol

  1. Physiotherapy
  2. Aids ffor daily life eg bottle openers
  3. Steroid injection
  4. Surgery
65
Q

IVX of gout?

A

Joint aspiration + synovial analysis

FBC, CRP, serum URATE levels

Xray - rat bite erosions (sometimes)

66
Q

councilling advice in gout?

A

You will be given allopurinol long term

Lose weight

Low purine diet; avoid alcohol, seafood, meat like bacon and liver

67
Q

revise reactive arthritis

A

chlamydia is most common cause

68
Q

features of arthiritis mutilans?

A

opera glass hands

telescoping deformity

Year 6 (17 decks)

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