Rheumatological Conditions Flashcards
Erythema nodosum (causes, investigations, management)
Causes/associations ● Sarcoidosis (most common) ● Infections (streptococcal, viral, TB) ● Inflammatory bowel disease (Crohn’s) ● Drugs (tetracyclines, oral contraceptives) ● Malignancy ● Pregnancy
Investigations Reasonable to investigate possible causes to treat underlying issue ● FBE ● ESR ● UEC ● Throat swab ● ASOT ● CXR
Management
- Manage lesions (first line) - bed rest, leg elevation and NSAIDS
- Severe symptoms - prednisolone 25mg PO daily for two weeks and then taper
Fibromyalgia (management, when to refer)
Discussion points
● Pain experienced is real but not caused by tissue damage
● Not a progressive or deforming disease
● Chronic pain can affect the way they feel but does not necessarily indicate a problem with their mental
health
● The overarching goal is not to achieve a pain-free state but to reduce effects on daily activities
Lifestyle and nonpharmacological
● Regular graded aerobic exercise
● CBT - coping strategies and goal setting
● Good sleep practices
Pharmacological
● TCAs (low-dose) - first-line but not approved by TGA for this indication
○ Amitriptyline 10 to 25mg PO evening
● Gabapentanoid - if above not well tolerated
○ Gabapentin 100mg to 300mg PO in early evening
● SNRI - if TCA not well tolerated
○ Duloxetine 30mg PO daily
When to refer
If patient has atypical presentation or refractory symptoms
Gout - non-pharmacological management
Non-pharmacological management:
● Limit alcohol intake
● Reduction in high purine food
● Reduction of fructose containing beverages
● Regular exercise of at least 150 mins/week
● Avoid dehydration
● Maintaining ideal BMI
Gout - symptoms relief
First-line
● Local corticosteroid infection (up to two affected sites)
● NSAID regularly for 3-5 days
● Prednisolone 15-30mg daily for 3-5 days
Second-line
● Colchicine 1mg STAT then 500 microg 1 hour later
Gout - treatment
First-line urate-lowering therapy
○ Allopurinol 50mg orally daily for 4 weeks (increase by 50mg every 2-4 weeks, max dose 900mg)
■ Common ADR: skin rash
■ Allopurinol hypersensitivity syndrome (rare but fatal): erythematous desquamating rash,
fever, hepatitis, eosinophilia and worsening renal function
○ Probenecid 250mg PO twice daily for 1 week, then 500mg BD (if above maximised)
■ Risk: urate nephrolithiasis
Notes: Renal impairment not a contraindication. Need to monitor UEC more closely. Should continue allopurinol even
during acute attack.
Gout - prophylaxis
Key points
○ Colchicine has the strongest evidence
○ If has had multiple recurrent attacks despite prophylaxis then consider combination therapy
○ Length of therapy unknown but ideally when no further attacks occur and target serum uric acid
level reached
Medications
○ Colchicine 500 microg daily
○ NSAID (lower end of dosage)
○ Prednisolone 5mg PO daily
Gout - gouty tophi
Management often requires adjunct surgical intervention
○ Start allopurinol 50 mg/day
○ Adjust diet with low purine intake
○ Acute flare up plan with colchicine
○ Monitor serum urate to achieve the target
○ Increase water intake
○ Surgical incision and drainage of joint
Gout - asymptomatic hyperuricaemia
Key points
○ No evidence of treating
○ Renal function and cardiovascular risks should be monitored
○ If secondary to thiazide or loop diuretic then consider reducing dose or switching to another agent
Potential consequences: gout, urate nephropathy and nephrolithiasis
Risk factors for hyperuricaemia: male, advanced age, ethnicity, diet, alcohol, soda, hypertension, CKD,
thiazide/loop diuretic, postmenopausal.
XR findings - RA vs. OA vs. gout
RA
- cysts
- joint destruction
- subluxation
- erosion joint margins
- osteoporosis
OA
- periarticular bone sclerosis
- cyst
- marginal osteophytes
- loss of joint space
Gout
- punched out erosions
- cyst
Rheumatoid arthritis (specific advice, investigation, treatment, when to refer)
Specific advice
● Rest and splinting
● Exercise
● Smoking cessation
● Referral to physiotherapist and occupational therapist
● Joint movement
● Diet - avoid animal fats and use fish oils
Investigation: Anti-CCP more specific for RA than RF
Treatment:
● Methotrexate
○ Requires folate supplementation on days not taking methotrexate
○ Need to review every 4 weeks initially until steady dose achieved
○ ADRs: stomatitis, alopecia, diarrhoea, nausea/vomiting, flu-like symptoms etc.
○ Monitor: FBE, aminotransferases, albumin and creatinine every 4 weeks for the first 3 months.
● Corticosteroids
When to refer to a rheumatologist?
● Early/immediate if there is a possibility of rheumatoid arthritis to prevent irreversible joint damage
Polymyalgia rheumatica (features, management, complications, monitoring)
Features:
● Common - >50 years, bilateral shoulder aching, elevated ESR +/- CRP
● Supportive - morning stiffness lasting longer than 45 mins, absence of involvement of other joints apart from
hip and shoulder
Management: Requires treatment for > 12 months.
● Prednisolone 15mg PO daily for 4 weeks and then taper
Complications if poorly managed:
● Giant cell arteritis
● Functional disability
● Mental health impact
● Stroke
Monitoring: ESR diagnostic. Monitor monthly for the first 3 months, then every 2-3 months thereafter.
Giant cell arteritis (classic symptoms, examination, investigation, management)
Classic symptoms: jaw claudication, severe headache, polymyalgia rheumatica, scalp tenderness and malaise.
Physical examination: temporal artery abnormality (tender, enlarged, difficult to compress, pulseless).
Investigation:
● GP - ESR (elevated, can be normal initially).
● Specialist - temporal artery biopsy.
Management:
1. Urgent referral if suspected.
2. Prednisolone 40-60mg PO daily for minimum of 4 weeks
● Generally need to continue treatment for > 2 years
3. Aspirin 100 mg PO daily (prevention of ischaemic events)
