Rheum Flashcards
Meds SE, RA, seronegative spondylo - ank spond, reactive, psoriatic,, SLE, psoriasis, systemic sclerosis, sjogrens, PMR, polymyosits/dermatomyositis, GCA, fibromyalgia
Cautions/ side effects of NSAID use
Gastric ulceration; other GI upset nausea, diarrhoea
Haemorrhage
Renal injury/ failure
Increase risk of MI, stroke (prothrombic effects)
Exacerbate HF ( blood pressure elevation, reduced renal perfusion, fluid retention)
Miscarriage and congenital malformation, fetal renal dysfunction
Side effects of corticosteroids
- increased susceptibility to infection in those >20mg per day > 2/weeks - eg. candidiasis, pneumocystis jiroveci pneumonia
- oesophageal and peptic ulceration
- osteoporosis, fractures
- Cushingoid features: easy bruising, purple striae of skin, cheek telangiectasia, thin skin, acne and hirsuitism, buffalo hump
- growth suppression, adrenal suppression
- depression; mania
- cataract, glaucoma, papilloedema
Side effects of methotrexate and sulfasalazine (dmard)
Both
- GI intolerance - nausea
- myelosuppression - rbc, wcc, platelet
- hepatotoxicity
Methotrexate
- pneumonitis at start
- oral ulcers
sulfasalazine
- allergic rashes, mood changes, hallucinations
Hydroxychloroquine (dmard) SE
- photosensitivity
- retinal toxicity (>5years >5mg/kg/d)
- hyperpigmentation
- cardiotoxicity rare but QTC prolongation
Leflunomide, mycophenolate and azathioprine (dmard) SE
- diarrhoea, myelosuppression, hepatotoxicity
Leflunomide : + hypertension
azathioprine: - diarrhoea
TnFa inhibitor SE eg. Humira, adalimumab, infliximab, remicade
- injection reaction (pain swelling around site)
- worsening heart failure
SE/ cautions of rituximab - monoclonal ab against B cells CD20 (used for nh lymphoma/leukaemia, severe RA)
infections from immunosuppression including TB, septicaemia, Hep B reactivation
caution in hx of cvd/cardiotoxic chemo as causes exacerbation of angina, arrthymia, HF.
progressive multifocal leucoencephalopathy (monitor for cognitive/neurological. psychiatric signs)
transient hypotension - withhold antihypertensives 12 hrs before infusion.
Infusion related reactions 30-120 min after starting infusion -fever, chills, rigors, nausea, vomiting uritcaria, dyspnoea
SE of tocilizumab (actemra)
IL 6 blocer
Infection
GI perforation : UGIB
myelosuppression + hepatotoxicity : fatigue, jaundice
- metabolic derangement : hypertension, weight gain
Presentation of Rheumatoid arthritis - articular, non articular5, rare-7
Articular
- pain, swelling, morning stiffness
Non-articular
- sjogren
- RA nodules
- anaemia
faitgue
- lung fibrosis
Rare:
o Skin – Raynaud’s, ulcers
o Eyes – dry eyes, epi/scleritis, cataracts (from steroids), NOT iritis
o Lungs – dyspnea (pleural effusion), pleuritic chest pain
o Heart – chest pain owing to pericarditis, valve disease
o Hoarseness, sore throat, neck pain from C1-C2 subluxation (atlantoaxial joint disease)
o Neuro – peripheral neuropathy,
mononeuritis multiplex, cord compression, entrapment neuropathy
Systemic features
o anorexia, weight loss, polymyalgia
Exam for RA
General - cushingoids feature
Look
Dorsum -wrist swelling and radial deviation, dorsum wasting and nodules,
MCP swelling, ulnar deviation and subluxation
- Phalanges - swan neck deformity, boutonniere’s deformity, Z-thumb deformity
- Nails - Vasculitic changes
- Volar - Palmar erythema, carpel tunnel scar,
fixed flexion
Feel
- Temperature
- Joints for crepitus, swelling and tenderness
- Nodules for character, mobility, tenderness
Move
- All joints, active ROM\
Function
- Grip strength, key strength, opposition strength, do up a button, hold a pen and
write name
Neurology
Face
- eyes for scleritis, cataracts and pallor
- enlarged parotids in Sjogren’s
- mouth for dryness and oral ulcer
- TMJ for crepitus
Neck
- cervical spine tenderness and reduced ROM
- Cervical lymphadenopathy
Chest
- Lungs for pulmonary fibrosis or effusion
- Heart for pericardial rub or regurg murmur
Abdomen
- Hepato/splenomegaly
- Inguinal lymph nodes
Investigations for RA - bloods , imaging , soft
BLoods
FBC, Hb, ESR , CRP , normocytic anaemia
Rheumatoid Factor + ACPA Anti CCP abs
Imaging
Xray - normal - soft tissue swelling, juxta-articular osteopenia, reduced bone space, bony erosions, subluxation
USS and MRI - synovitis
DAS-28 questionaire use to look at disease activity over time - Tender swollen joint, ESR, and global health (confirmed RA)
Management of RA - non pharm, symptom relief , pharm, monitoring, surgery
Non pharm
- education, regular exercise, alcohol cessation
PT and OT for aids/splints
- Manage for CV risk as RA accelerates atherosclerosis
- DAS 28
- Contraception, even after stopping depending on the drug
- flu vaccine but not live vaccines
Symptom relief
- Steroids - good in acute flares but would avoid giving until seen by rheum - IM or oral not long term
NSAIDS - not for long term use as DMARDS
Pharm
1st line : MTX
If not controlled add another until triple therapy
2nd sulfasalazine, hydoxychloroquine, leflunomide, prednisone
Monitor
- FBC for myelosuppression, LFTS for hepatotoxicity ,
- hydroxy - opthal review 5 years if under 60, no liver disease, no retinal disease) or annual if high risk
Creatinine for azathioprine, ciclosporin
Blood pressure
Biologics if active infection, severe heart failure, haem malignancy
- Anti-TNFa - adalimumab and entanercept
- Rituxamab + mtx if have failed
-tocilizumab
Surgery
- replace joints, carpal tunnel release
What are the shared features of seronegative spondyloarthropathies (ank spond, psoriatic, enteropathic, reactive) (SEA SHED)
-Seronegativity (rheumatoid factor –ve)
- Enthesitis (inflammation of the site of insertion of tendon or ligament into bone) e.g. plantar fasciitis, Achilles tendonitis, costochondritis
- Asymmetrical large joint oligoarthritis (< 5 joints) or monoarthritis
- Spine and SI joints (axial skeleton)
- HLA B27 association
- Extra-articular features (iritis, rashes, oral ulcers, aortic valve incompetence, IBD)
- Dactylitis (inflammation of the entire digit due to soft tissue oedema, tenosynovial and joint inflammation)
What 4 categories are used to diagnose RA
- Joint involvement - # of joints with small joints favoured
- Serology - high positive RF +/- ACPA
- acute phase reactants - abnormal CRP and/or ESR
- Duration of sx - >6 weeks big points
What is the typical presentation and examination of ankylosing spondylitis
-“chronic inflam disease of spine and sacroiliac joints, 1:3 FM
Hx
- lower back pain worse at night + morning stiffness, relieved by exercise
- pain radiates from SI joints to hips/buttocks
- progressive loss of spinal movements
- peripheral arthritis esp in lower limbs oligoarthritis
- symptoms of enthesitis and iritis
Exam
- Looking for deformity - kyphosis & neck hyperextension
- Enthesitis - achilles , plantar, tibial tuberosity, ischial tuberosity, iliac crests
- sacroilitis - pain over SI joint through FABER test
extra joint findings
- - eyes for iritis (red, poorly reactive pupils, photophobia, pain, blurred vision)
-heart for AR
- lungs for apical pulmonary fibrosis
What are the general investigations for ankylosing spondylitis
Bloods – normocytic anaemia, raised ESR, CRP,
HLA-B27
Imaging
– MRI most sensitive.
Look for irregular
erosions and sclerosis around SI joints,
bone marrow oedema, vertebral syndesmophytes
which can fuse with bone above to cause ankylosis, calcification of ligaments leads to bamboo spine.
X-ray will show sacroiliitis but may appear late.
What is the dx and management of ankylosing spondylitis
Diagnosis =Clinical with support from imaging
Management
- Exercise (www.nass.co.uk) and NSAIDS
- TNF a blockers (adalimumab)
- Local steroid injections for short term relief
- Surgery including hip replacement and
rarely spinal osteotomy
How does psoriatic arthritis present in hx and exam
- Skin changes precede arthropathy in 75%
Hx
- symmetrical polyarthropathy OR asymetrical oligoarthropathy
- Can affect DIPS and axial skeleton
- psoriatic arthritis mutilans rare
- skin and nail changes
exam
- look at skin - extensor surfaces, scalp, umbilicus
- nail for onycholysis
- fingers for dactylitis
- examine affected joints for pain, swelling and stiffness
Co morbidities associated with psoriatic arthritis
Ocular involvement: uveitis (7%) and conjunctivitis (20%).
Cardiovascular disease
Inflammatory bowel disease
Metabolic syndrome
Hypertension
Diabetes
Atherosclerosis
Depression and anxiety.
What are the ix and treatment of psoriatic arthritis - dx - exam + xray
Ix
- Xray - assymetric SI joint involvement, erosions of bone next to joint space
-pencil in cup deformity
- ankylosis - fusion of bones together across joint space
management
- NSAIDS
- mTX / sulfasalazine
- anti-TnFa
