Rheum conditions Flashcards
Types of Spondylarthropathies & how Rx differs
- Axial Spond - NSAIDs & exercise
i) nonRadiographic Axial Spond (Golimumab)
ii) Ank Spond (has radiographic sacroillitis)
- antiTNF (adalimum, Certolizum, Etanercept, IFX, Gol) improves XR
- IL 17A blocker (Socukinumab, Ixekizumamb) but WORSENS IBD - use IL12/23 - Peripheral Spond (mostly peripheral jts - O/L w/ PsA) - antiTNF & IL17 as above
+ Anti IL12/23 (Ustekinumab) - good for IBD sx but not for spinal sx
Uveitis: only TNFi & not Etanercept
Skin: IL17 effective
CPPD - MoA, Fx, Rx
CPPD - 3 types (acute, chronic, OA w/ CPPD)
Acute - self limiting monoarthritis lasting ~2wks
KNEE (>50%), v 1st MTP for gout,
Assoc w/ chondrocalcinosis (XR), OA (in jts not usu affected like MCP, wrist, elbow)
CPP crystals activate NLRP3 inflamasome
Look for metabolic disorders: hypoMg/PO4, HyperPTH, haemochromatosis
Rx: NSAIDs, Pred/intra-art CS, low dose colchicine prophylaxis
Types of IBD-assoc arthritis
3 types:
Peripheral
- Classic: IBD associated (single, usu LL lrg jt) - correlates w/ dis activity
- Sml polyarthritis: more RA like & doesn’t correlate w/ dis. Use sulfa, anti-TNF
Axial: spinal & sacroiliitis - rule out AS (MRI & HLAB27) then Anti-TNF
GCA - ix (highest sens/spec)
- USS - halo sign (dbl contour in gout) - 80% spec, 50% sens
- MRI - 80% spec, 94% sens
- FDG PET = 90% spec, 98% sens
- PMR shows more uptake in liver than shoulder
GCA - ESR cut off
>50
GCA - bx findings
- multinucleated giant cells
- mononucleare cell infiltration or granulocyte inflammation
- Vasculitis
Bx only useful to ddx b/w vasculitis forms
GCA - Rx
Steroids for years (start hard & taper - maintain for yrs)
- steroid sparing agents eg MTX, cyclophosphamide, AZA
Aspirin 75mg
IL6 Tocilizimab - more effective if added to Pred - GI perf (blunts CRP response) IL 17 (Secukinumab, Ixekizumab) can dec GC dose
Ank Spond + IBD
- Anti-TNF
- adalimum, Certolizum, Etanercept, IFX, Gol
- Could use IL-12/23 although not great for spine
- Avoid IL 17
- If nR-AxSpA - Golimumab
Ank Spond + joints
- DMARDs (Sulfasalazine, MTX) -peripheral dis but NOT effective for axial dis
- IL-17 (if no IBD)
- TNF-inh
Ank Spond + uveitis
TNF-inh (not abatecept)
RS3PE
Remitting, seronegative, symmetric synovitis w/ pitting edema syndrome
- Oedema of dorsum of hand/foot (‘boxing glove’ appearance)
- Tenosynovitis
- Seronegative for RF & ACPA
- Excellent response to glucocorticoids (low dose)
- Can be paraneoplastic
IDIM Rx
1 yr high dose GC
Steroid sparing agents (MTX, Mycophenolate is good if ILD)
IVIG if IMNM
(taper til normal CK)
SRC - RF
- GC: Pred >15mg (hence try to use low dose GC only)
- Men
- Early dSSc (<5y)
- RNA polymerase Abs
- (Higher BP assoc w/ BETTER prognosis, on ACEi prior is bad)
SRC - Fx
- Tendon friction rubs (Contracture at large joints - specific)
- Inc BP= BETTER outcome; ACEi Rx prior to SRC has worse
- MAHA (40%) w/ new pleural/pericardial effusion/HF
- ⅓ progress to ESKD and 20% die
SRC - Rx
- ACEi - Captopril
- PLEX if MAHA
- Involve nephrologist for bx etc
- IV nitroprusside if CNS involvement
Ssc - Raynauds
- CCB - DHP long acting : Nifedipine/Amlodipine
- PDE5 inh: Sildanefil
Topical nitrates
ARBs (not ACE)
Antiplt/statin - IV Prostacyclin: PGI2 ilioprost
AbN SI joints
Ank Spond
(rarely - PsA)
DIP v PIP joints
OA & PsA: DIP
(RA more commonly affects PIP & MCP rather than DIP)
OA: Heberdens nodes (DIP), Bouchards nodes (PIP)
RA: boutionneres (PIP can’t straighten - L shape)
Jt space narrowing, subchondral cysts, Osteophytes
OA,
BUT can be CPPD if in non-OA joints (eg knee, wrist, shoulder, ankle)
- might not see osteophyes & would see crystals
Chondrocalcinosis
CPPD
Haemachromatosis (CPPD like fx but sml jts eg MCP)
“pencil in cup” on XR (usually hands)
PsA
Enthesitis
Dactylitis
Enthesitis
- Inflammation of insertion point of tendon
- typically heel
- Found in PsA, AnkSpond
Dactylitis
- Sausage finger
- PsA, Reactive Arthritis (Ank Spond rare)
