Rheumatology Flashcards
what is the recommended dosage for GCA steroid therapy w/ no visual loss?
60 mg oral prednisone for 2 weeks, then taper to 2 weeks of 50 mg
what is the recommended dosage for GCA steroid therapy for high risk patients or those w/ visual loss?
high dose steroids for 3 days (500-1000 mg methylprednisone) followed by 60 mg prednisone for 2 weeks, then taper to 50 mg prednisone for 2 weeks
GPA is diagnosed by…
tissue biopsy
pathology w/ drug induced vasculitis is caused by…
molecular mimicry (so would expect to see lots of different random antibodies to be (+) so would see c-ANCA and p-ANCA (+) for example)
SLE criteria is >*** for ANA to meet criteria
40
vasculitis stroke pattern looks like…
more scattered pattern
inflammatory monoarthritis etiologies tend to be either:
crystal-induced or infectious etiologies
acute inflammatory oligoarthritis may be caused by either…
gonorrhea or rheumatic fever
chronic non-inflammatory oligoarthritis is usually caused by…
osteoarthritis
how much involvement does genetics have in the etiology of RA?
60% risk
the most important genetic risk factor for RA is:
class II HLA group, especially HLA-D alleles (codes for specific protein that binds CCP)
one of more specific markers for RA
anti-CCP
most important environmental risk factor for RA
smoking (can lead to lung inflammation and activation of PADI, which promotes local protein citrullination)
important infectious risk etiology for RA development
periodontal dx (porphyromonas gingivalis) (others include mycoplasma species, EBV and parvo B19)
are hormones related to development of RA?
yes, but incompletely understood. there are estrogen receptors on synovial fibroblasts that may drive cartilage destruction
classic presentation of RA includes pain in the ** (morning/evening) that lasts at least ** minutes
morning, lasting at least 30-45 minutes (stiffness is worse following rest)
RA mostly affects which joints?
MCPs and MTPs, and proximal interphalangeal joints of the hands and feet, but spares the distal interphalangeal joints. RA tends to affects joints symmetrically as well (but severity can be asymmetric)
what is RF?
it is a Ig (usually IgM) that targets the Fc portion of IgG. it occurs in 70% of RA patients (so it is not a great marker for RA, cause it has the same sensitivity as anti-CCP and is very non-specific, it is present in other inflammatory dx)
*** is most predictive of erosive dx in patients already diagnosed w/ RA
anti-CCP
typical radiographic changes in patients w/ RA
peri-articular osteopenia, marginal erosions and joint space narrowing (remember to get radiography of the cervical spine as well if C1-C2 subluxation is suspected)
extra-articular manifestations and complications of RA include…
rheumatoid nodules, dry eye and scleritis, ILD, pleural effusions, and anemia of inflammation
*** is the first line DMARD in RA
MTX (15 mg weekly but can be titrated up to 25 mg)
what supplement should always be given w/ MTX?
folic acid
*** is another DMARD option if patient is not able to tolerate MTX
leflunomide
when do you use biologic DMARDs for RA?
when there is high dx activity despite being on MTX (always try MTX first). TNF-a inhibitors are most common and have evidence of synergy w/ MTX
NSAID use in RA..
only use when waiting for DMARDs to kick in (they are NOT disease modifying and do NOT prevent joint damage)
when to use glucocorticoids in RA
low dose (5-15 mg) prednisone can be used to improve RA sx while bridging to a DMARD, and can be used short term for dx flares
important adverse effects of glucocorticoids to keep in mind
osteoporosis w/ long term use, diabetes mellitus, and infection
most important modifiable risk factor for OA
obesity (specifically OA of the knee)
osteoarthritis is a chronic progressive disorder characterized by…
cartilage and meniscal degradation, subchondral bone changes, osteophyte formation, and low-grade synovitis
Erosive OA is a subset of primary hand OA and typically affects which joints?
DIP and PIP
*** is a non-inflammatory condition characterized by calcification and ossification of the spinal ligaments (especially the anterior longitudinal ligament) and entheses (tendon and ligament attachments to bone)
diffuse idiopathic skeletal hyperostosis (DISH)
typical description of pain pattern w/ OA
insidious onset of sx, joint pain is exacerbated by activity and relieved by rest, can have morning stiffness lasting less than 30 minutes (as opposed to RA, which is >30 min)
radiographic findings in OA include…
asymmetric joint space narrowing, subchondral sclerosis, osteophytes, bone cysts (remember, radiographic findings are NOT necessary to diagnose OA)
when are pharmacologic agents for OA considered?
when non-pharmacologic therapy does not work (since there are no DMARDs specifically for OA). drug options include NSAIDs, acetaminophen, duloxetine, and tramadol (try topical NSAIDs first, or capsaicin especially in older patients)
*** is recommended pharmacologic therapy for hip and knee osteoarthritis when conservative measures have failed, acetaminophen is suggested as an add-on therapy
NSAIDs and duloxetine
fibromyalgia pathophys
not well understood, but thought to be related to central sensitization, so there is abnormal processing and pain perception, and amplification of pain signaling in the central nervous system
what tests are specific to the dx of fibromyalgia?
none
initial management of fibromyalgia
reassurance that sx are real, and pain will not lead to tissue injury. aerobic exercise can improve pain. patients should also be assessed for psych stressors and psych illness.
pharmacologic options for fibromyalgia (remember: no studies have directly compared efficacy of medication therapy for fibromyalgia)
gabapentin and pregabalin (short term), low dose amitriptyline is an option, SNRIs (evidence does NOT support use of NSAIDs for fibromyalgia)
genetic association w/ ankylosing spondylitis
HLA-B27
spondyloarthritis is a blanket term that includes…
ankylosing spondylitis, psoriatic arthritis, reactive arthritis, and enteropathic arthritis
*** is a chronic inflammatory disease affecting the axial skeleton (including sacroiliac joints), entheses, and peripheral joints
ankylosing spondylitis
