Rheum

Question 1

RA dx criteria

Answer 1

Four or more:
- morning stiffness
- positive rf or ccp
- crp or esr
- three or more joints esp mcp and pip
- sx over six weeks
Can also have cardiac, lung, anemia with normal mcv, mononeuritis multiplex, skin nodules

Watch out for c1/2 subluxation, check before intubation

Question 2

RA tx

Answer 2

• mtx first (but can cause BM supp, pneumonitis, liver tox)
• anakinra = il1 antag
  -il6 inhib = toci or sarilumab
  -ritux=anticd20
  -leflunomide= pyrimid antag aim to mtx
• abatacept inhibits T cell act
• anti-tnf (inflix, adalimumab, etanercept, certolizumab, golimumab) - add if mtx fails; if tnf fails, check levels. If level ok, check ig, if Lis switch to diff tnf else switch classes
• tofacitinib = Janus kinase inhib for severe ra
• hydroxychloroquine for mild ra (can cause retinopathy)
• sulfasazine to suppress bm
• steroids only in acute disease to bridge to dmard

Question 3

OA tests and tx

Answer 3

Get Ana, esr, rf, ccp, X-ray
Tx - nsaids or acet, dulox for pain, topical diclofenac if worried about systemic nsaid tox, capsaicin, intraartic steroids and hyaluronic

Not glucosamine! It’s placebo

Question 4

Ankylosis spondylitis test and tx

Answer 4

Tests: xr, if neg then mri (more sens), then hla b27 if sx and equivocal mri
Tx: nsaids, then tnf, then il17 antag secukinumab, NOT STEROIDS

Question 5

Whipple disease

Answer 5

• diarrhea, malabs, joint pain, can have cns
• biopsy of bowel with pas pos orgs, stool pcr
• tx: bactrim, iv ctx if cns

Question 6

Lupus sx and testing

Answer 6

Sx - need >=4, skin, arthralgias, low blood ct, renal, some cns, serositis, Ana, dsdna or anti smith

Test - complement, anti smith, antidsdna

Joint xr normal!

Question 7

Lupus tx

Answer 7

Hydroxychloroquine (80% remission with just this)

Steroids for acute flares

Relapse after steroids - azathio, mtx, or belimumab (b cell inhib)

Question 8

Scleroderma three main sx

Answer 8

Fibrous skin thickening, raynaud, joint pain

Diffuse can involve lung fibrosis, colon diverticula and esoph dysmot —> reflux, restrictive cm, kidney injury—>htn

Question 9

Myositis sx and testing

Answer 9

Proximal mm weakness dt inflamm so can’t get up from chair

Dermato is this plus rashes

Testing: cpk, aldolase (both high), Emg, lfts, Ana, biopsy

Most common complication is malig

Question 10

Poly myalgia rheumatica vs myositis

Answer 10

Pmr is pain of próx mm, normal cpk, emg, aldolase and bx
Pm and dm are weakness

Question 11

Fibromyalgia treatments

Answer 11

 Selective serotonin and norepinephrine reuptake inhibitors, gabapentin and pregab

Question 12

Vasculitis common features

Answer 12

B sx, fever, skin lesions, joint pain, neuropathy, normocytic anemia, esr, thrombocytosis

Treatment is steroids, then cyclophosphamide or ritux, then aza/6mercaptopurine or mtx

Question 13

Behcet disease

Answer 13

Oral and genital ulcers, pathergy, ocular involvement, cns stuff, pulm artery aneurysm

Tx: pred and colchicine, can add cyclophosphamide if severe

Question 14

Osteoporosis tx

Answer 14

Bisphos (-dron-) and denosumab (rankl inhib)

Ca and vit d

Second line if not working: serm (eg tamoxifen), pth analog (-paratide)

Third line calcitonin

Note also treat high risk osteopenia (t score -1 to -2.5)

Question 15

Bisphosphonate AE

Answer 15

Jaw necrosis, flu sx

Question 16

Gout first, second, third line tx for acute flare

Answer 16

NSAIDs
If CI, colchicine (kidney disease, HF, peptic ulcer, on AC)
If CI, intrarticular steroid (severe kidney or liver disease, taking a drug that inhibits cyp)