Rheum

Question 1

AI disease on immunosuppression
- general issues for mgmt

Answer 1

IMMUNOSUPPRESS BALNCE (control dis/prevent organ damage v S/E)
1. Ax disease activity regularly
- SLE: ?skin, jt, cytopenias; bloods - C3/C4, dsDNA; urine (nephritis)
2. Monitor for drug toxicity
- HCQ retinopathy (baseline then @5y + annual after), OP, bloods
3. CV RF modification
- Control systemic inflammation +/- minimise steroids
- Esp in RA/SLE
4. Cancer screen
- From dis risk + drug risk
- Annual skin, age/gender, dis specific (DM, Scleroderma)
5. Infection: minimise risk
- Vax (not live MMR, VZV, BCG); all inactivated (Pneumovax 5y)
6. Family planning (even from men: Mycophenolate, MTX)
7. Drug specific S/E (IL6 inh w/ lipids + G perf in RA)

Question 2

Rheum long diseases

Answer 2

1. SLE (multi system) - nephritis + renal disease, skin, inflam arthritis, cytopenias, serositis (20-45y women)
2. Scleroderma (Raynauds, ILD, pulm HTN, GI
3. Systemic vasculitis (inflam myositis - vasculitis of muscles) - multi system (pulm/renal, skin, arthritis) - DM ?underlying malignancy
4. APLS - anticoagulation++
   RA
   Gout
   Drug mgmt & dis F/U

Question 3

SLE - Rx options (Drugs)

Answer 3

• HCQ : 80% on (dis modifying & sx controlling)
• CS : cumulative dose over duration of dis (can fluctuate)
• MMF (if renal)
• MTX (occasionally used, wkly, if arthritis)
• CYC : if hx then SEVERE dis prev (ie. aggressive nephritis or CNS)
• AZA : not commonly used (unless can’t tolerate MMF)
• Analgesia (NSAID)

Question 4

SLE - tests

Answer 4

Disease activity (monitor 3monthy)
1. Anti-dsDNA
2. Low C3/C4
3. FBC - cytopenias
4. URINE

Dx:
ANA
- preceedes dis + must be +ve (>1:80)
- Other dis +ve (RA, SSc, PM/DM, RA, SjS, Graves/Hashimotos, PBC, lymphoproliferative, drugs)
Anti-dsDNA
- Disease activity
- Nephritis (+ TNFinduced SLE)
- Highly specific
ENA
- Ro/La (SjS + neonatal lupus)
- Sm: highly specific (renal & CNS dis)
Anticardiolipin Ab - prognostic

+ UEC, LFT - drug toxicity; ESR/CRP etc

Question 5

Lupus nephritis - stages

Answer 5

2 : microscopic haematuria/proteinuria
3 + 4: H+P +/- HTN, CKD (+/- nephrotic syndrome)
5: Nephrotic syndrome
6: Progressive renal dysfxn, proteinuria, bland urine

Stage 1 is normal urine (only on bx)

Question 6

Nephrotic syndrome

Answer 6

• > 3g/day proteinuria
• Hypo-albuminaemia
• Oedema
• Hyperlipidaemia
• Thrombotic dis

Question 7

RA - Rx options

Answer 7

1. conventional synthetic
   * MTX (W if eGFR<30)
   * SSZ (hypersensitivity, agranulocytosis, azoospermia)
   * AIM to spare Pred - if needed <6mo only
2. Biologic (if >2 synthetic for >6m) - combine with conSyn (MTX)
   * TNF-inh (infliximab, etancercept, adalimumab)
   * RTX; Abatacept, Tocilizumab (IL6 - suppresses CRP)
   * Jak-inh (Tofacitinib, Baricitinib) - C/I++, HZV reactivation, cytopen
   Nb - screen Tb prior (Qferon + CXR, Hep)
   * STATINS

Question 8

RA - imaging

Answer 8

1. Jt space narrowing → fusion/ankylosis
   
   2. Juxta-articular OP
   3. Marginal erosions
2. Deformities (symmetric - ulnar dev, sublux)

Question 9

RA - extra articular fx

Answer 9

• OP
  
  • CVS (IHD risk similar to DM, pericarditis, HF, conduction)
  • Neuro: Entrapment (CTS-Median), MNM
  • Vasculitis
  • Eye: scleritis
  • Lung: pleural effusions (Exud), nodules, ILD (NSIP), Bronchiectasis
  • GI: hepatic (including Rx-related)
  • Renal (GN) w/ proteinuria, +/- Rx -related
  • Haem: Feltys (spleen, Leukopenia, RA), lymphoma (check LN)

Question 10

RA - hx

Specific fx & diagnostic criteria

Answer 10

Specific contributing Fx
* Smoking (dose dependent & in ongoing)
* Dentition
Dx:
* Timeframe >6wks
* Serology
* No. Joints
* Acute phase reactants

Anti-CCP (prognostic including for ILD/CVS)