Rheumatology Flashcards
What need to take alongside methotrexate
Folic acid- taken weekly at least 24 hours after methotrexate dose
What drugs avoid if on methotrexate
Trimethoprin and co-trimoxazole as increases risk of BM aplasia
Aspirin as increases risk of toxicity
Treatment of methotrxate toxicity
Folinic acid
Side effects of methotrexate
Myelosuppression
Liver fibrosis
Pulmonary fibrosis
Pneumonitis
Mucositis
Antibody for limited cutaneous systemic sclerosis
Anti-centromere
Antibody for diffuse cutaneous systemic sclerosis
Anti-scl-70
Rfx for pseudogout
Haemochromatosis
Hyperparathyroidism
Acromegaly
Wilsons
What are pseudogout crystals made of
Calcium pyrophosphate
Management of pseudogout
Do aspiration of fluid to exclude septic arthritis
NSAIDS
If severe can do intra-articular or oral steroids
Joint aspiration of pseudogout
Positive birefringence rhomboid shaped crystals
Reactive arthritis presentation
4 weeks post STI
Asymmetrical oligoarthritis of lower limbs
Urethritis
Conjunctivitis or anterior uveitis
Skin changes- circinate balanitis, keratoderma blenorrhagica
Skin changes in reactive arthritis
circinate balanitis
keratoderma blenorrhagica
Lateral epicondylitis presentation
Pain and tenderness over lateral epicondyle
Pain worse on extension of wrist against resistance with elbow extended or supination or wrist
When may not need a DEXA scan to diagnose osteoporosis
Someone aged over 75 with a fragility fracture
First line for osteoporosis
Alendronate and calcium/vitamin D supplements if intake not satisfactory
Management options for osteoporosis
All patients will receive a bisphosphonate and calcium/vitaminD replacement if intake not satisfactory. Women can start HRT if want
Second line options include other bisphosphonates- risedronate or etidronate
Third line options- strontium or raloxifene
4th line denosumab
If do not tolerate alendronate then what are second line bisphonates available
risedronate or etidronate
Have to have a lower T score to warrant (much stricter)
Third line options for osteoporosis
Raloxifene
Strontium ranelate
MOA of raloxifene
Selective oestrogen receptor modulator
Risks of raloxifene
Increased VTE risk
How is denosumab given
Subcut injection every 6 months
Which bones does pagets affect
Skull
Spine
Pelvis
Long bones
What causes a V shaped osteolytic lesion
Pagets
Typical presentation of pagets
Bone pain
Pathological fracture
Bossing of skull
Deafness
Complications of pagets
Deafness
Sarcoma
Fractures
High output heart failure
Management of pagets
Bisphosphonate
MOA of bisphosphonates
Inhibit osteoclasts
Side effects of bisphosphonates
Osteonecrosis of jaw
Oesophagitis if do not drink enough water
Acute phase reaction
What must do before giving bisphosphonate
Correct vitamin D or calcium deficiency
When is only time give calcium in osteoporosis
If not enough dietary intake
What should all patients with osteoarthritis do
Local muscle strengthening and weight loss
2nd line for osteoarthritis
Oral NSAID and PPI
What can be used if analgesia unsuccessful for OA
Intrarticular steroids injections
What is it after starting bisphosphonate develop fever, myalgia and N&V
Acute phase reaction- normal
What is main precipitating factor for polyarteritis nodosa
Hep B
PAN presentation
Fever
Weight loss
Renal failure signs
Livedo reticularis
Rfx for osteoporosis
CKD
Endocrine disorders- most
Cancer
Malabsorption
Non antibody blood findings of SLE
ESR up
CRP can be normal
Low complement levels in active disease
What gel and coombs is contact dermatitis
IV
Management of PMR
Prednisolone
What is response of PMR to prednisolone
Very good- if no response then consider other diagnoses
Presentation of PMR
Older demographic
Rapid onset within 1 month
Aching and morning stiffness in proximal limb muscles
(weakness not a sx)
Can also get depression, fatigue, low grae fever
Investigation results for PMR
ESR and inflam markers up
CK normal
EMG normal
What needs to be monitored when on hydroxychloroquine
Visual acuity as it causes retinopathy (bulls eye)
RA X ray findings
Periarticular erosions
Lossof joint space
Subluxation
Juxta articular osteoporosis
What must do if likely to take steroid over 3 months
Take a bisphsophonate
Main side effect of colchicine
Diarrhoea
Stills disease presentation
Cyclical fever worse in evening
Salmon pink rash
Lymphadenopathy
What is classical blood finding in stills disease
Raised ferritin
Which DMARDS can take in pregnancy
Hydroxychloroquine
Azathioprine
Sulfasalazine
What is bamboo sign seen in
Ank spond
Best rule out test for SLE
ANA
Management of discoid SLE
Topical steroid cream
2nd line- hydroxychloroquine
Management of reactive arthritis
Start NSAID and rheum referral
What must do in all cases of dermatomyositis or polymyositis
Do a malignancy screen
What is rash that spares nasolabial folds
Malar rash
What is seen on early x ray of ank spond
Evidence of sacroiliitis- subchondral erosions and sclerosis
Squaring of vertebrae
First line for ank spond
NSAID and regular- exercise like swimming
Physio also recommended
Presentation of psoriatic arthritis
Most common- symmetric polyarthritis similar to RA
Asymmetrical oligoarthritis affecting hands and feet
Sacroiliitis
DIP joint disease
Arthritis mutilans
What should be given to patients with persistent very severe ank spond
Anti-TNF such as adalimumab and etanercept
What is pencil and cup deformity seen on x ray in
Psoriatic arthritis- describes periarticular erosions
How do schobers test
Identify L5
Mark 10 cm above and below this point
Ask to bend forward and touch toes with straight knees
Remeasure distance between points and if doesnt increase by 5 then indicative of reduced lumbar flexion
What demotes a positive schobers
Less than 5cm
Extra articular features of psoriatic arthritis
Skin lesions
Enthesitis
Dactylitis
Nail changes
What is management of psoriatic arthritis
Managed by rheumatologist
If mild -NSAID
More moderate/severe then methotrexate
Can consider ustekinumab (IL-12 and IL-23) or secukinumab (IL-17)
What is the underlying pathophysiology in GCA retinopathy
Anterior ischaemic optic neuropathy
How does aspirate appear in RA
Yellow and cloudy
What is main Ig in breast milk
IgA
Most common causes of drug induced lupus
Procainamide
Hydralazine
Isoniazid
Phenytoin
How manage drug induced lupus
Stopping the drug normally eradicates sx
What is cause if develop tingling, muscle aches and N&V after starting a bisphosphonate
Underling vitamin D or calcium defic which has been exacerbated by taking bisphosphonate
What is the Z score from DEXA scan adjusted for
Age
Gender
Ethnicity
How differentiate pseudogout from gout on X ray
Chondrocalcinosis in pseudo
Also can see same changes as in OA
Most common site of septic arthritis in adults
Knee
How monitor RA treatment
CRP
Disease activity score- DAS28
What is first line for RA
DMARD and short course of bridging prednisolone due to DMARD taking time to taking effect
First line DMARD options for RA
Methotrexate
Sulfasazine
Leflunonamide
How manage a RA flare
IM methylprednisolone
OR
Oral corticosteroids
When can start biologics in RA
Failed response to 2 DMARDS
What biologics recommended currently for RA
TNF inhibitors
- etanercept
- infliximab
- adalimumab
How does methotrexate pneumonitis present
Fever
SOB
Cough
What HS type is SLE
III
Most common SE of bisphosphonates
Dyspepsia from oesophageal ulcers and oesophagitis
Skin features of dermatomyositis
Photosensitive rash
Heliotrope rash in periorbital area
Gottrons papules on extensor surface of hands
MOA of sulfasalazine
5-ASA
Side effects of sulfasalazine
Oligospermia
SJS
Pneumonitis
Management of raynauds
Refer to rheumatology
First line: CCB nifedipine
What can do if no response to nifedipine in raynauds
IV prostacyclin which can last weeks/months
What does T score of -2.5 mean
Bone density of 2.5 standard deviations below that of average healthy young adult
Management principles of SLE
NSAIDs
Sunblock
Management of SLE if internal organ involvement
Prednisolone
Cyclophosphamide
Gout X ray findings
Tophi
Joint effusion
Punched out erosions
X ray skull features in pagets
Thickening
Early on get lytic lesions these then develop into mixed lytic and sclerotic lesions
What is the mutation in in marfans
Fibrillin
Which wrist movements exacerbate lateral epicondylitis
Supination of wrist
Extension of wrist
What do if biopsy for GCA negative
Continue steroids regardless
How manage GCA
If eye involvement give IV methylprednisolone and then start high dose prednisolone
Oral prednisolone if no eye involvement
Do BEFORE biposy
Opthalmology review
Counselling for taking of bisphosphonate
Swallow with lots of water
Take 30 mins before breakfast
Sit upright for 30 mins after taking
To avoid oesophageal reactions
Complications of diffuse systemic sclerosis
Pulmonary fibrosis
Renal disease- severe glomerulonephritis with crises
Hypertension
How manage renal disease in diffuse systemic sclerosis
ACEi
How does osteomalacia present
Bone pain
Muscle tenderness
Proximal myopathy leading to waddling gait
Easy fractures
Which muscles are involved in abduction of arm
First 20 degrees= supraspinatus
Next part= deltoid
What is thromboprophylaxis used in anti-phospholipid syndrome
Primary prevention= low dose aspirin
Secondary prevention= lifelong warfarin
What is affected in ehlers danlos syndrome
Type III collagen
Features of ehlers danlos
Elastic, fragile skin
Joint hypermobility
Easy brusing
Aortic regurg, mitral valve prolapse
Sub arachnoid
What is celecoxib
NSAID
What type of WCC is seen in RA aspirate
Neutrophils
Side effects of azathioprine
Bone marrow depression
Pancreatitis
Features of SLE
General features
- fatigue
- fever
- mouth ulcers
- lymphadenopathy
MSK
- arthritis
Cardiovascular
- pericarditis
- myocarditis
Resp
- pleurisy
- fibrosis
Renal
- glomerulonephritis
- proteinuria
Neuropsych
- anxiety and depression
- psychosis
Management of fibromyalgia
CBT
Aerobic exercise
Medications- amitriptylline, pregabalin, duloxetine
Presentation of fibromyalgia
Chronic pain at multiple sites
Fatigue
Brain fog
How diagnose fibromyalgia
Clinical diagnosis using america college of rheum criteria
Eye complicatinos of RA
Keratoconjunctivitis sicca most common
Episcleritis and scleritis
Cardiac risk of RA
Increased risk of IHD- similar to that of DM
Start new drug and develop oral ulcers
Methotrexate due to mucositis
How to tell if hip pain is referred from the lumbar spine
Positive femoral nerve stretch
Most early x ray finding in RA
Juxta articular osteopenia/porosis
What are syndesmophytes seen in
Ank spond
If a young male presents with osteoporosis what is important to check
Testosterone
What are the 2 types of raynauds
Raynauds disease (primary)
Raynauds phenomena (secondary)
Typical presentation of primary raynauds disease
Women under 30
Bilateral disease
Causes of secondary raynauds
Connective tissue diseases
Leukaemia
What suggests secondary raynauds
Auto-antibodies
Rash
Unilateral
Ulcers
Arthritis
Management of sjogrens
Symptomatically
- Artifical tears
- Can use pilocarpine to stimulate saliva production
Hydroxychloroquine if arthritis
What connectie tissue diseases are associated with raynauds
Systemic sclerosis
RA
SLE
Sjogrens
What is risk of sjogrens
Lymphoma
Person on chemo develops acutely painful joint, most likely cause
Gout as chemo increases urate production
What medication consider for housebound patients
Vitamin D
X ray findings of osteoarthritis
Loss of joint space
Osteophytes
Subchondral cysts
Subchondral erosions
Skin finding of behcets
Erythema nodosum
Other than shoulders, where else does PMR affect
Hip girdle muscles
Presentation of meralgia parasthetica
Burning sensation over antero-lateral aspect of thigh caused by compression of the lateral cutaneous nerve
What nerve is affected in meralgia parasthetica
Lateral cutaneous nerve of thigh, comes straight off spinal chord
How many different NSAIDs have to be on before trying a TNF alpha inhibitor for ank pond
2 12 weeks apart
Arthritis with one very swollen finger
Psoriatic arthritis due to dactylitis
When measure urate in a gout attack
2 weeks after inflammation settles as urate levels can be low, normal and high during an attack
Poor prognostic factors in RA
Anti- CCP antibodies
Early erosions on X ray
RF positive
HLA DR4
Insidious onset
Extra articulate features like rheum nodules
Poor baseline at presentation
What is most important investigation to monitor marfans
Echocardiogram to look for aortic root dilation as predisposes to aortic dissection
Features of osteogenesis imperfecta
Pathological fractures
Blue sclera
Hearing loss from otosclerosis
Dental problems
How can a RA flare present
Acute worsening of stiffness and pain
Fever
Malaise
What does raised CRP in SLE suggest
Underlying infection
Which DMARD causes a low sperm count
Sulfasalazine
What is chronic fatigue syndrome
Where have excessive tiredness for over 3 months which is debilitating physically and mentally with no obvious cause
Features of chronic fatigue syndrome
sleep problems, such as insomnia, hypersomnia, unrefreshing sleep
muscle and/or joint pains
headaches
painful lymph nodes without enlargement
sore throat
cognitive dysfunction- brain fog
physical or mental exertion makes symptoms worse
general malaise
dizziness
nausea
palpitations
Management of chronic fatigue syndrome
Refer to CFS specialist for
- CBT
- exercise with expert
- energy management
TB drug causing drug induced lupus
Isoniazid
What investigation need to do prior to doing surgery on a RA patient
Cervical X rays to rule out atlanto-axial instability
If this was present could lead to cervical compression during ventilation
Uses of denusomab
Osteoporosis
Prevention of fractures in bone mets
Contraindications for bisphosphonates
Reflux
eGFR<30
What can be used to prevent pathological fractures in bony mets
Bisphosphonates
Denusomab
What is presentation of trochanteric bursitis
Pain and tenderness over lateral hip/upper thigh
Pain on resisted movement
Can’t lie on it while sleep
In people who overuse legs- runners
Also main demographic is 50-70 year old women
X ray finding in psoriatic arthritis
Pencil in cup appearance
Periarticular erosions
What is antisynthetase syndrome
Advanced myositis where get fibrosis of the lungs
Additionally can get scleroderma and raynauds
Polyarthritis causes
SLE
RA
Seronegative spondyloarthropathies
Sarcoid
TB
HSP
Pseudogout
Patient from subcontinent has 3 month history of fever, weight loss and polyarthritis
TB
What are codmans triangle and sunburst appearance seen in
Osteosarcoma
What is onion skin appearance on x ray
Ewings sarcoma
Inheritance of marfans
AD
Causes of dactylitis
SCD
Seronegative spondyloarthropathies
- reactive arthritis
- psoriatic arthritis
Antibodies seen in myositis’
Anti-jo
ANA
What is anti-scl 70 same as
Anti topoisomerase
What is the management of reactive arthritis
Analgesia
If refractory use steroids
If persistent can use methotrexate and sulfasalazine
What use for NSAID refractory reactive arthritis
Oral pred
Which joints most commonly affected in OA of hands
Carpometacarpal
DIP
Painful purple lesion on finger of someone with SLE
Oslers nodes
Causes of osler nodes
SLE
Endocarditis
Gonorrhoea
Typhoid
Haemolytic anaemia
Presentation of osler nodes
Painful purple nodes on fingers
First line for RA
Methotrexate with bridging prednisolone
Where do majority of shoulders dislocate
Anteriorly
Management of shoulder dislocation
Reduction in all cases
If recent then can do without sedation/analgesia
If longer duration then may require analgesia/sedation
Presentation of medial epicondylitis
Pain and tenderness in medial epicondyle
Symptoms worsened by wrist pronation and flexion
Numbness and tingling in 4th and 5th fingers as ulnar nerve compression
Medial vs lateral epicondylitis
Medial- golfers elbow
Lateral- tennis elbow
What is cubital tunnel syndrome
Compression of the ulnar nerve
Presentation of cubital tunnel syndrome
Tingling in the 4th and 5th fingers
Worse when resting elbow on a surface
What causes tingling/numbness in 4th and 5th fingers after resting elbow on a flat surface
Cubital tunnel syndrome
Which movements exacerbate golfers elbow
Wrist flexion and pronation
Differential for PMR where have shoulder pain and restricted movement
Supraspinatus tear
Characteristics of spondyloarthropathies
Sacroiliitis
Large joint arthritis
Enthesisi
Iritis
Dactylitis
Which organisms are associated with reactive arthritis
Shigella
Neisseria
Yersinia
Campylobacter
Chlamydia
Which T-score reading is used for FRAX tool
Neck of femur reading
Most specific antibody for SLE
Anti-dsDNA
What use for osteoporosis if very low eGFR
Denosumab
When can consider biologic for RA
Trialled at least 2 DMARDs and still have moderate disease activity
Monitoring for methotrexate
FBC, U&Es and LFT every 3 months
If no response to NSAIDs for ank spond what use
Adalimumab or secukinumab
Dose of pred for PMR
15mg
What imaging most indicated to confirm ank spond
MRI whole spine
What needs to be given alongside allopurinol when start giving for gout prophylaxis
Low dose allopurinol alongside colchicine to prevent acute flares as allopurinol can precipitate attacks
What measure when give allopurinol for gout prophylaxis
Urate levels
Most important side effect to warn people about when starting allopurinol
Rash as very common cause of SJS
What is alternative to allopurinol in prophylaxis
Febuxostat- also a xanthine oxidase inhibitor
What medications may be used for fibromyalgia
Antidepressants
- fluoxetine
- amitryptylline
- duloxetine
What biologics use for RA, alternatives to anti-TNF alpha
Anti-IL6
Jak inhibitor
Anti-CD20 (rituximab)
What test for pre TNF a inhibitors
HIV
Hep B,C
TB
If have anorexia, what is most likely to improve bone density
Putting on weight
Periods returning
What happens when stop denosumab
Rebound increase in bone turnover
What need to do for patients stopping denosumab
Give bisphosphonates as stopping associated with rebound increased bone turnover
Markers of SLE disease activity
Dropping C3 and C4
Raising ESR
Raising dsDNA titre
What is p-ANCA actually
Anti myeloperoxidase
What is c-ANCA actually
Anti proteinase 3
Significance of CRP in SLE vs RA
SLE- not indicator of disease activity, if raised likely to be infectious cause
RA- indicator of disease activity
Stepped approach for OA
Topical NSAID
Oral NSAID with PPI
Avoid strong opiates but can use co-codamol if exacerbation
Intrarticular steroids
Joint replacement
Ank spond associations
5 A’s
AV block
Apical fibrosis
Anterior uveitis
Aortic regurg
Anaemia of chronic disease
Spirometry findings of ank spond
Restrictive- most typically due to kyphosis and not fibrosis as a late complication
Extra presentations of ank spond
Plantar fasciitis
Vertebral fractures
Chest pain from inflammation from inflammed sternocostal joints
Dactylitis
What is discoid lupus erythematosus
Chronic autoimmune skin condition which presents with inflammed, dry and scaly patches plus are highly photosensitive on the face and scalp
Chronic effects of discoid lupus erythematosus
Scarring
Hyperpigmentation and hypopigmentation
Complications of lupus
Infection risk
CVD risk
Anaemia- from haemolytic anaemia, ACD, kidney disease
Lupus nephritis
Pleuritis and pericarditis
Interstitial lung disease
Neuropsychiatric complications
VTE from recurrent miscarriage
What is main course of SLE
Relapsing remitting
Most common cause of death in SLE
CVD
Management principles of SLE at all times
Hydroxychloroquine
Good sun protection
Management of SLE relapses
Steroids
If more severe then DMARDS- methotrexate, mycophenolate motefil, cyclophosphamide
Biologics- rituximab, belimumab
Sclerodactyly meaning
Skin tightening around hands which reduces movement and function
How does calcinosis appear
White deposits under skin
Consequence of oesophageal dysmobility in systemic sclerosis
Dysphagia
Acid reflux
How manage GI problems in systemic sclerosis
PPIs for GORD
Metoclopramide helpful for dysphagia
Management of systemic sclerosis
Principles around symptom control like CCB for raynauds, metoclopramide for dysmobility
If diffuse disease then consider DMARDs like methotrexate
Principle drug management of pulmonary HTN
Bosentan- endothelin receptor antagonists
Diagnosing GCA
ESR up
USS will show halo sign where occluded temporal artery
Biopsy diagnostic performed by vascular surgeons
Management of myositis
Refer to rheumatology
- do malignancy screen in new cases
- corticosteroids first line
Antibodies in APL
Lupus anticoagulant
Anti beta 2 glycoprotein I
Anti cardiolipin
Investigations for sjogrens
Schirmers- hold paper under eyelid and assess moisture travel
Antibodies- anti Ro and La
Salivary gland biopsy may be used to confirm diagnosis but not necessary
First, 2nd and third line for gout
1st Naproxen
2nd Colchicine
3rd Prednisolone
When start allopurinol for gout prophylaxis
Do after even 1 attack
Start a few weeks after attack
When taking a bisphosphonate when reassess need
3-5 years
When encourage HRT for osteoporosis
If early menopause
What are looser zones seen on x ray in
Osteomalacia
Osteomalacia management
Just vit D- cholecalciferol
First line imaging for ank spond
MRI whole spine
What imaging use for RA
USS and MRI will demonstrate inflammation
X rays will show bony changes
