rheumatology

Question 1

what levels of uric acid would you expect to find on bloods to riskk seeing gout occur?

Answer 1

Gout occurs when the serum uric acid concentration is sufficiently elevated (usually greater than 0.42 mmol/L

Question 2

which medications can lead to accumulation of uric acid?

Answer 2

thiazides, ARB, look diuretics, ciclosporin.

Question 3

risk factors for gout include?

Answer 3

HTN, CKD, DM, dyslipidaemia, obesity, hyperinsulinaemia (endogenous).
Any changes which rapidly raise OR lower serum uric acid can precipitate a flare

Question 4

How does the first acute gout incident typically present?

Answer 4

Monoarticular, often 1st MTP or other part of foot. Severe, mimics septic arthritis, fever, malaise, leucocytosis and raised CRP.
* In women the first attack may be polyarticular, often in hands with gouty tophi

Question 5

If after the first acute gout attack uric acid lowering treatment isn’t commenced what is the likely course?

Answer 5

Repeat attack often within 2 years. Further untreated attacks don’t fully resolve resulting in a crippling arthritis, oligo or polyarthritic, symmetrical mimic of RA, plus deposits in kidneys causing CKD.

Question 6

Diagnosis of gout requires?

Answer 6

aspiration of the joint on first attack to exclude septic arthritis and Dx uric acid crystals.
Recurrent attacks do not require aspirate.
+ check serum uric acid
+ renal function

Question 7

What is the treatment of acute gout?

Answer 7

1. steroid injection max 2 sites
OR
2. PO NSAIDs 3-5 days 
OR
3. pred 15-30mg OD 3-5 days

Question 8

What is the target serum uric acid level for those with gout?

Answer 8

<0.36mmol/L
- dissolves deposits in tissues and kidneys
<0.3 for those with tophi

Question 9

What’s first line in uric acid lowering medications?

Answer 9

allopurinol 50mg PO OD for 4 weeks, increasing dose by 50mg every 2-4 weeks, or by 100mg every 5 weeks to achieve serum targets.
Max 900mg daily
* measure uric acid monthly

Question 10

Your patient is on 900mg of allopurinol daily but their serum uric acid is still >0.4mmol, what do you add?

Answer 10

probenedid 250mg BD for 1 weeks, then increase to 500mg BD.
Increase by 500mg every 4 weeks to serum uric acid targets.
Max 1g BD.
* avoid if known urate nephrolithiasis.

Question 11

if allopurinol is not tolerated what is second line in gout prevention/uric acid lowering?

Answer 11

febuxostat 40 mg orally, daily for 2 to 4 weeks; then increase the daily dose by 40 mg every 2 to 4 weeks to achieve the target serum uric acid concentration, up to a maximum maintenance dose of 120 mg daily

Question 12

As starting urate lowering can precipitate an attack, what flare prophylaxis will you commence?

Answer 12

1. colchicine 500mcg PO BD (reduce dose if renal imp) 
OR
2. nsaid PO lower end of dosing
OR
3. pred 5mg PO OD

for at least 6 months, longer if tophi present.

Question 13

Your patient has an aspirate of calcium pyrophosphate dihydrate crystals from a joint, what risk factors might they have for pseudogout?

Answer 13

Male aged 65-75 years.
OA
Previous joint injury.
Primary parathyroidism.
Haemochromatosis
Hypomagnesaemia
Loop diuretics

Question 14

Treatment of pseuodogout includes?

Answer 14

Steroid injection (once septic joint is excluded)
nsaids

Question 15

What are the indicators of poor prognosis in RA?

Answer 15

a high RF titre and/or a positive anti-CCP antibody test
sustained raised inflammatory markers (CRP or ESR)
swelling in more than 20 joints
impaired function early in disease
bony erosions evident on X-rays early in disease
smoking

Question 16

Standard dosing for methotrexate is what, and includes what additional medication?

Answer 16

methotrexate 10mg once weekly, increasing to 25mg PO or SC
PLUS
folic acid 5-10mg per week

Question 17

A patient presents with joint pains and a malar rash which spares the nasolabial fold, which specific bloods do you order?

Answer 17

ANA, anti dsDNA and anti-smith

Question 18

dsDNA is sensitive to which connective tissue disorder?

Answer 18

SLE

rare in others

Question 19

ENA Ro is found in which disease?

Answer 19

40% of SLE patient

Common in Sjogrens

Question 20

ENA La is found in which disease?

Answer 20

15% of SLE patients

common in Sjogrens

Question 21

ENA smith is seen in which disease?

Answer 21

10-50% of SLE patients

rare in other disorders

Question 22

A young woman presents with painful swollen peripheral joints, painless mouth ulcers, photosensitivity and a discoid rash. What do you suspect and what tests do you order?

Answer 22

SLE
ANA, anti ds DNA and anti-smith

Refer to rheum