Rheumatic Disorders Flashcards
seronegative spondyloarthropathies
seronegative spondyloarthropathies are a group of inflammatory arthritides sharing many clinical, radiographic, and genetic features. They include ankylosing spondylitis (AS), reactive arthritis (ReA, formerly called Reiter syndrome), psoriatic arthritis (PsA), enteropathic arthritis associated with inflammatory bowel disease (IBD-SpA), and undifferentiated spondyloarthritis (uSpA)
Ankylosing spondylitis Presentation
Chronic back pain / stiffness, especially due to sacroilliac joints - hip, low back
Begins in lumbosacral spine, but spreads up
Periods of worsening and poorly localized
Improves with exercise, worse with rest
Sleep disturbance
Low grade fever and fatigue is less common
AS Diagnosis
presence of sacroiliitis on radiographic examination associated with one clinical criterion is considered to be diagnostic
Bone fusion occurs late
Rule out other inflammatory arthritis, degenerative back disease, strain
AS Treatment
Exercise NSAIDs Immunomodulators Physical therapy (expensive) Refer severe symptoms that impair function or patients with chronic back pain under 45 years old
Reactive Arthritis
ReA is an acute sterile inflammatory arthropathy that follows an infection in which there is no microbial invasion of the synovium or joint space and the prior infection is remote from the joint
urethritis, arthritis, and conjunctivitis are the classic triads - GI symptoms rare
Dx is by synovial aspiration and culture; x-ray may show joint puffiness of new bone formation
Rule out lupus with ANA test
Refer to Rheumatologist
Psoriatic Arthritis
inflammatory arthritis associated with the dermatologic condition of psoriasis. Occurs with, before, or after the rash.
Severe inflammation and swelling of joints, especially fingers may occur
radiographic changes in hands and feet are distinctive. Subchondral erosions and erosions with new bone formation, periostitis, and ankylosis of joints may be seen. In late disease, radiographs of the DIP joints may show whittling and a “pencil in cup” appearance
Arthritis of IBD
Joint pain is the most common extra-intestinal symptom of IBD
Type 1 - large joints during flare, Type 2 - many small joints at any point
Referral to a rheumatologist and a gastroenterologist is indicated for confirmation of the diagnosis or treatment suggestions
NSAIDs, DMARDs are the usual treatment
Rheumatoid Arthritis
symmetric, inflammatory polyarthritis of unknown etiology; it affects at least three joints, including small joints of hands and feet; does not affect DIP joints or thoracic/lumbar spine
Diagnosis requires ESR/CRP/RF/Synovial fluid analysis, Hep screening, Kidney/Liver panel
RF titer may be negative until later in disease
RA Symptoms
- Symmetric Joint stiffness on rising, lasting >1 hr; often improves with activity
- Affected joints are red, swollen, and warm
- Ulnar drift or deformities of fingers (swan neck, boutonniere) often present
- Malaise and/or fatigue often present
- May have extra-articular manifestations but not early in the disease (e.g., pleural effusion, HF, A-fib, anemia, vasculitis, neuropathy)
RA Treatment
- Referral: to a rheumatologist Diagnosis must be determined before DMARDs
- Monitor patients taking immunosuppressive agents for signs of HF and skin cancers
- No live vaccines (e.g., for shingles) if taking biologic DMARD agents (e.g., Enbrel, Humira)
- Consider O.T. referral for splinting and help with ADLs
- Paraffin baths can help with hand and foot pain
Usual meds - methotrexate, hydroxychloroquine, short run of corticosteroids for flares
NSAIDs increase CV risk but may improve quality of life - consider topical NSAIDs
A patient is diagnosed with ankylosing spondylitis and begins taking a COX-2 inhibitor with minimal pain and inflammation relief. What will the primary care provider order initially to manage this patient’s symptoms?
Biologic antitumor necrosis factor agents
Changing to a COX-1 inhibitor medication
Corticosteroid injections every three months
A trial of sulfasalazine and methotrexate
Switch to COX-1. NSAIDs have been shown to reduce pain and stiffness, and reduce progression of structural damage if administered continuously. Patients should try at least two NSAIDs with food before other medications are attempted.
Polymyalgia rheumatica
The most remarkable features are the stiffness and aching of the shoulder girdle, pelvic girdle, and neck. Inflammatory in origin, the pain tends to be worse at night and may radiate distally to the elbows and the knees. Morning stiffness lasting longer than 1 hour and even all morning is common
Systemic corticosteroids remain the standard drug therapy
Temporal arteritis / giant cell arteritis
An inflammation of blood vessels, called arteries, in and around the scalp
Symptoms include headaches, jaw pain, vision loss, fever and fatigue. Diagnosis usually requires biopsy of the temporal artery. or color doppler.
The condition needs prompt treatment with steroid medication to prevent permanent vision loss start steroids before confirmation of biopsy - usually a high dose like 60mg daily!. REFER!
Which dose of prednisolone will be given initially for a patient who is diagnosed with polymyalgia rheumatica with giant cell arteritis?
15 mg daily
20 mg daily
30 mg daily
60 mg daily
Although the usual starting dose to treat PMR is 15 to 20 mg daily, a higher dose of 60 mg daily is used when there is evidence of concomitant giant cell arteritis.
Raynaud Treatment
Mild - Sildenafil for vasodilation
Severe with digital ischemia - Intravenous prostaglandin E1
Mild spasms - Nifedipine is used to prevent vasospasm
