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
What is the definition and presentation of reactive arthritis
- can be part of Reiter’s syndrome = triad of urethritis,
arthritis and conjunctivitis
Reactive arthritis = sterile arthritis affecting lower limb 1-4 weeks after urethritis
(eg. chlamydia) or dysenter (campylobacter, salmonella, shigella)
Hx
- chronic or replapsing arthopathy
- hx of infection (may be subclinical)
- iritis , ulcers, enthesitis
Ix and treatment of reactive arthritis
ESR and CRP
stool culture, infectious serology,
sexual health review
Chylamidia and gonorrhoea urine PCR + syphilis blood test
Imaging - Xray or USS = enthesitis with periosteal reaction (he formation of new bone in response to injury or other stimuli of the periosteum surrounding the bone)
Treatment
- rest and splint affected joints
- NSAIDS , local steroid injection
MTX or sulfasalazine if persistent
what is enteropathic arthritis
joint pain associated with IBD or GI bypass
What are 11 diagnostic features of Systemic lupus Erythematosis - DRAMA SIPHON (need 4 for dx)
D: discoid rash
R: renal - lupus (glomerulo-nephritis) cause persistent proteinuria and casts (red, cell, granular, mixed)
A: Arthritis - non erosive >2 peripheral joints
M: malar rash sparing the nasolabial folds
A: ANA positive
S: serositis:
- pleuritis (pleuritic CP + SOB) and pericarditis (rub, CP, ECG)
Immunological
- antiDsDNA
and or
-anti SM +/- Ro, La, U1RNP
Photosensitivity
Haematological - haemolytic anaemia or lymphopenia/leukopenia/thrombocytopenia
Oral Ulcers - painless (or nasopharyngeal
N: neuro - seizures, psychosis in absence of other triggers
What is the aetiology of SLE and what are commonly associated diseases
B cell secretion of autoantibodies to variety of antigens creating immune complexes that deposit in a range of sites
associated with sjogrens, autoimmune thyroid disease,
antiphospholipid syndrome (- anticardiolipid and lupus anticoagulant antibodies cause clots. Coagulation defect, livedo reticularis, recurrent miscarriages, thrombocytopenia)
What are the symptoms you would ask about for SLE + extra history question
Most present with rash
General – malaise, weight loss, fever
- MSK – arthralgia/arthritis,
myalgia/myositis - Derm – rash, alopecia, oral and nasal ulcers
- Neuro – delirium, dementia, convulsions, loss
of vision, stroke, headache, MS symptoms,
anxiety, depression - Renal – haematuria, oedema, high BP
- Resp – dyspnea and pleuritic chest pain
- Cardio – pericarditis, myocarditis, murmers,
angina (premature coronary artery disease) - Haem – lymphadenopathy, anaemia, thrombophlebitis
- GI – nausea, vomiting, pseudo obstruction
- Antiphospholipid – recurrent miscarriage,
DVT/PE - Sjogrens symptoms – dry eyes, mouth,
enlarged parotid
Drug History
- procainamide, hydrasalazine, minocycline can induce
What are the investigations for SLE
Bloods
- anaemia : chronic disease or may be haemolytic (high retics and bili, low haptoglobins, coombs + and high LDH if immune
- high ESR, normal CRP
- platelets, white cells low
- prolonged APTT not corrected by addition of normal plasma
Immunological
- ANA (sens/not spec)
- AntidsDNA and Anti-SM
-low C3 and C4
Other
renal biopsy - glomerulonephritis
Management and maintenance of SLE, lupus nephritis, cutaneous symptoms and antiphospholipid syndrome
Acute flare
- prednisone
- IV cyclophosphamide (life threatening flare)
Maintenance
- NSAIDS + hydroxychloroquine for joint and skin
- steroids for lungs, CNS, heart and haem involvement
- tapering of steroids with other DMARDS - MTX, mycophenolate or azathioprine
- warfarin for hypercoagulability if previous DVT/PE
- Belimumab or Rituxamab for severe
Treatment of lupus nephritis
- steroids + cyclophosphamide, mycophenolate and rituxamab for glomerulonephritis (needs renal r/v)
- Control BP with ACEi or CCB
Cutaneous symptoms
- topical steroids
- sunscreen/ avoiding sun
Treatment of APS - aspirin or warfarin
What are the risk factors and associations of psoriasis
RISK FACTORS/TRIGGERS
- Recent strep infection
- Stress
- Skin trauma
- Drugs (lithium, NSAIDS, B blockers)
- Alcohol, smoking
- Obesity
- Family history (HLA associations)
ASsociated with
- Inflammatory arthritis (30% of psoriasis
patients develop psoriatic arthritis)
- Inflammatory bowel disease
- Uveitis
- Coeliac Disease
- Metabolic Syndrome
Ix and management of psoriasis
DDX
- Eczema
- Tinea
- Mycosis fungoides
- Seborrheic dermatitis
Non-Pharmacological
- Education – control not cure is the aim
- Encourage a support group
- Remove triggers
Pharmacological
- Mild
o Daivobet Cream (Vit D analogue calcipotriol + betamethasone)
o Emollients
o Tar preparations
o Salicylic Acid
- Moderate/Severe
o Warrants treatment with systemic
agent and/or phototherapy
o Methotrexate, ciclosporin, acitretin
o Narrowband UVB, broadband UVB,
photochemotherapy (PUVA)
o Consider biologic drugs e.g.
etanercept if no improvement with
non-biologics + PUVA - Psoriatic Arthropathy
o Etanercept, infliximab or
methotrexate
what is difference from systemic sclerosis / crest /crest syndrome
scleroderma: autoimmune skin fibrosis from over production of collagen
Systemic sclerosis = scleroderma + vascular disease
- can be limited cutaneous (to face and extremities)
or diffuse cutaneous (also affect whole organs
CREST - calcinosis, raynauds phenomena, oesophageal dysmotility, sclerodactyly
What are the risk factors for systemic sclerosis or crest and presentation/ exam findings
Risk factors
- fam hx, silica dust exposure
Hand Exam
Skin
- bilateral skin thickening extending to MCP joints,
- symmetrical thickening of fingers, puffy, sclerodactyly
- prayer signs
-pigmentation
finger tip ulcers, pitting scars
telangectasia
abn nailfold capillaries
- carpal tunnel secondary to flexion contracture
- calcinosis on extensor surface
- raynauds
Other
- GORD
- interstitial lung disease - pul htn
Ix for systemic sclerosis and ongoing monitoring
Bloods
- FBC
o Anaemia
o Reactive thrombocytosis
o Hemolysis
- Renal function (Cr)
- ANA/ENA
o ANA+ (nucleolar pattern)
o RF+ (30%)
o Anti-centromere Ab (75%) - LcSSc
o Anti-topoisomerase (scl70) + (40%)
– DcSSc
o Anti-RNA poly+ (20%) – dcSSc
o Anti-Ro +/-
o ESR N/raised
Echo
- PA pressure and RH enlarged
Lung FTs
- Initial evaluation. Low lung diffusion capacity suggests PAH, decr FVC precede ILD
Monitoring
- FBC, Renal function, ECHO, PFTs
Management of systemic sclerosis features -
Lifestyle
Antifibrotic therapy
- digital ischaemia/ raynauds analgesia, raynauds,
dysphagia, calcinosis, inflam arthritis , acute renal crisis
Lifestyle
- Smoking cessation, reg exercise/PT
- splints decr ROM and CTS
Immunosuppression
- MTX/ hydroxychloroquine (arthritis/myositis)
- Mycophenolate (lung involvement)
- cyclophosphamide
Digital ischaemia
- iloprost or sildenafil
Analgesia
- paracetamol, nsaids
Raynaud
- analgesia
- nifedipine, amlodipine
fluoxetine
topical nitrate
sildenafil
Dysphagia
- supportive, dilitation, PPI if GORD
Calcinosis
- NSAIDS, excision
Inflam arthritis
- hydroxychloroquine, mtx,
- prednisone <5mg daily otherwise renal crisis in pt with diffuse scleroderma rnp 3.
Acute renal crisis ( new onset hypertension, raised Cr, intravascular haemolysis).
Sjogrens presentation
- dry eyes, mouth from lymphocyte infiltrate into lacrimal and salivary glands. Can occur alone (1) or w other AI diseases (2).
- Fatigue, sleep disturbance
- Keratoconjunctivitis sicca >3m
- Xerostoma, (altered swallow/taste)
- Vasculitis (skin rash)
- Dental carries, incr oral infections
- arthralgia, myalgia
- Interstitial kidney disease (RTA)
- corneal ulceration, no saliva pool
- trigeminal neuralgia
- peripheral neuropathy (sensory)
- VTE Hx (incr risk)
Management of Sjogrens
Dry Eyes – optometry review
- Meds
o artificial tears
o ciclosporin ophthalmic drops BD
o Cholinergic pilocarpine 5mg TDS
CI: resp disease, HTN - spectacle eye shield, humidifiers
- Punctal plugging
Dry Mouth – dental review
- gels, lozenges, gum, mouthwash
- Pilocarpine
- Lip balm
MSK Sx
- Paracetamol, NSAIDs
- Prednisone 15mg daily for 2/52
- Hydroxychloroquine, methotrexate
Vasculitis
- prednisone 1mg/kg OD or
- IV Ig 0/4mg/kg/day IV 5days
RTA
- Kt repletion, alkali
Ix for sjogrens and diagnosis
Schirmer’s test - <5mm wet in 5mins
Bloods
- RF+ close to 100%
- ANA+ (70%)
- anti-RO (SSA), anti-La (SSB)
Urine
- deranged P, K, Ca,
Salometery - decrd
/Salivary gland Bx
Lisamine green test, fluorescein
Criteria for diagnosis
- Clinical diagnosis – no clear criteria
- Objective findings of ocular or oral dryness
or of glandular parenchymal damage
- Serologic or histopathologic evidence of
autoimmunity
Presentation - Polymyositis / dermatomyositis
- Rare. Insidious onset of progressive symmetrical
proximal muscle weakness, autoimmune striated
muscle inflam, myalgia/arthralgia +/- skin
involvement.
Proximal muscle weakness
- Gottren’s papules (pathognomic);
Violaceous fat-topped plaques on dorsal
knuckles/wrists/knees/elbows/malleoli
- Heliotrope rash: dusky-red rash periorbital, symmetrical
- Macular violaceous rash:
o Gottren’s sign
o Shawl sign: neck, shoulders
o V sign: neck, chest
o Holsters sign: lateral thigh
o Linear extensor erythemas
o Facial rash, perioral sparing
o Scalp rash - Finger tips: periungal erythema, nailfold
capil dilatation, cuticle overgrowth - mechanic’s hands – hyperkeratosis
- sub cute proximal symmetrical weakness
- photosensitive, pruritis
- poikiloderma vascular atrophicans
- fatigue, malaise, minor weight loss
- Sob (2 to weakness)
Ix for polymyositis/dermatomyositis
INVESTIGATIONS
Bloods
- raised serum CK (more with polymyositis), LDH, aldolase
- ANA+, anti-Jo+, anti-Mi2 (ILD, acute)
EMG
- abnormal spontaneous activity, abnormal
voluntary movements
Muscle Bx
- perivascular or interfascicular inflam, endo
hyperplasia
Imaging
- MRI: muscle oedema, fibrosis, calcification
- CXR: interstitial changes
- echo/ECG: arrhythmias, conduction defects
Management of polymyositis, dermatomyositis
May need to screen for malignancy
Severe/acute flare
- IV prednisone 1g OD
- IV Ig
Derm manifestations
- Conservative
o moisturiser
o sunscreen
o exercise – PT
o healthy diet - Meds
o topical Urea
o topical doxepin
o topical tacrolimus
o oral prednisone
o DMARDs
What are the complications of polymyositis/ dermatomyositis
COMPLICATIONS
Steroid toxicity
Respiratory infection, ILD
Cardiac disease
dysphagia
MONITORING
- Specialist r/v of muscle strength and markers of
severity
- regular assessment for development for
pulmonary and cardiac involvement
Gout presentation, investigations, diagnostic criteria
Presentation
- rapid onset severe pain (w/I 1hr)
- morning stiffness
- monoarticular or oligo
- 50% 1st MTP (podagra)
- red, hot, swollen, tender
- tophi: elbows, knees, Achilles
Ix
Arthrocentesis
- raised WBC
- negative bifringent needle crystals
Bloods
- raised WBC, +/- raised serum Urate
Xray
- periarticular erosions, Normal joint space,
ST swelling
Dx
Monosodium urate crystals in joint
fluid/tophus
- Plus >6 of;
o >1 attack acute arthritis
o developed w/I day
o monoarthritis, redness observed
o 1st MTP painful/swollen
o tophus
o hyperuricaemia
o unilateral 1st MTP or tarsal joint
o abnormal swelling on x-ray
o subcortical cyst w/o erosion
Management of Gout - prophylaxis and acute attack
Acute Attack
- Naproxen 500mg PO BD 10-14d
or Celecoxib 100-200mg PO BD or prednisone 1mg/kg stat (renal)
or colchicine 1.2 PO, then 0.6mg (GI bleed)
- Steroid injection of affected joint can be
very effective.
Prophylaxis
- Allopurinol starting dose 1.5mg x eGFR,
max 100mg
o SE: decr WBC, rash, fever
o Don’t stop during flare
o May trigger attack initially, cover w NSAID or colchicine
- Probenecid
- Febuxostat
Lifestyle
- Lose weight, if overweight/ avoid fasting/alcohol excess/ /low dose aspirin.
Presentation and investigations of Polymyalgia rheumatica
- Inflam syndrome of pain and morning stiffness in
neck/shoulder/pelvic girdles, >50yrs, +/- GCA.
Presentation
- Subacute onset (<2/52)
- Bilateral ache, tenderness, morning stiffness
(>1hr)
- Shoulder girdle (~80%); Pelvic (~60%)
- Tenosynovitis, CTS
- Low-grade fever, fatigue, anorexia, depress
- Response to steroids
- Think about rheumatoid arthritis if there is
significant peripheral joint involvement. Approx.
10% of RA presents initially like PMR.
Investigation
Bloods
- CRP, ESR >40 (emerging IL-6)
- FBC, Serum electrophoresis (r/o myelo)
- TSH, CK normal
Management and monitoring of polyyalgia rheumatica
MANAGEMENT
Meds
- Prednisone 15mg PO OD (taper to 10mg
over 4-6wks, then 1by 1mg/month)
- Cholecalciferol 1.25mg monthly
Alendronate 70mg PO weekly – if BMD low
- Omeprazole 20mg PO OD
- Methotrexate – ask advice
Advice
- Warn pt. of GCA Sx – seek advice
MONITORING
- monthly for 3m; exam, Hx, ? ESR. If methotrexate do bloods.
Giant cell arteritis
- presentation and investigations
Granulomatous vasculitis of large & medium
arteries (branches of ECA). Serious consequence is
irreversibly vision loss of optic nerve d/t ischemia.
PRESENTATION
- New Headache
- Scalp tenderness
- Jaw claudication
- visual loss- painless, uni-/bilateral,
amaurosis fugax (disc pallor, oedema)
- temporal artery thickening/nodule/tender
- upper extremity claudication
- Other CN abnormalities
INVESTIGATIONS
Bloods
- ESR >50, CRP raised
- FBC:
o normocytic, normochromic anemia
o raised plts
o mild WBC raise, ALP rise
Biopsy
- Temporal artery, w/I 7 days starting steroid (beware skip lesions)
Imaging
- Thickening of temporal artery
Dx, management and monitoring of GCA
CRITERIA
3/5; age >50, new HA, ESR >50, temporal artery
abnormality, abnormal Bx
MANAGEMENT
- If suspected – do ESR and start
o Prednisone 1mg/kg PO OD 4weeks
Taper over 6-12m
w Sx /ESR improvement
o IV Prednisolone if visual/neuro Sx 1g 3 days
- If confirmed – aspirin 75mg OD
- Consider bone protection (vit D, BP)
MONITORING
- for steroid SE: BP, DM, bones
- FBC
- incr. risk abdo aneurysms (? USS, echo, CXR)
Fibromyalgia -how is it diagnosis, risk factors, associations,
Fibromyalgia is a condition characterized by
chronic widespread pain and fatigue.
Commonly associated with depression, anxiety, and
PTSD
Part of same diffuse group of diseases as chronic
fatigue syndrome, however more orientated around
the pain. Many doctors consider them to be the
same disease.
Essentially a functional diagnosis. Investigations are
ALL normal.
Scoring systems for how many painful joints are present are used for diagnosis.
Must be chronic and widespread.
Important to rule out other pathological causes of
pain.
RISK FACTORS
FMHx, rheumatological conditions, 20-60y, F
Presentation and investigations for fibromyalgia
PRESENTATION
- Chronic, diffuse pain
diffuse tenderness o/e
- fatigue unrelieved by rest
- sleep & mood disturbance (d, A)
- cognitive dysfunction
- HA – axial, extend to neck, shoulders
- numbness, tingly – variable nature
- stiffness, swelling feeling
- fluid retention (not observed)
- incr sensitivity to sensory stimuli
Investigations
Clinical
- Chronic, widespread pain in muscles &
joints
- Fatigue, wakening unrefreshed, cognitive sx
- >11/18 tender points - lower neck in front. edge of upper breast, below side bone of elbow. inside of knee, hip bone, upper outer buttock. upper inner shoulder, neck and shoulder, base of skull
Bloods
- ESR, TFT, FBC, RF, anti-CCP, vit D NORMAL
- ANA – sometimes positive
Management of fibromyalgia
MANAGEMENT
Education
- Thorough explanation about nature of
‘disorder’ – relapsing-remitting (discuss
with chronic pain service)
- No simple cure
- Reassurance no serious pathology, mindful of patient’s perspective of sx
Medication
- Nortriptyline 10mg nocte
- gabapentin 300mg OD then titrate up
- Pregabalin 75 PO BD
- High dose Venlafaxine
Psychology
- CBT
Lifestyle
- Exercise
- Good sleep hygiene
