Rheumatology Flashcards
1
Q
Risk factors for septic arthritis
A
- Recent joint surgery/replacement
- Pre-existing joint disease = RA
- Diabetes mellitus
- Immunosuppression = HIV
- CKD
- IV drug abuse
- Recent intra-articular steroid injection
- Direct/penetrating trauma
2
Q
Bacterial causes of septic arthritis
A
- Staphylococcus aureus
- Group A Streptococci (strep. Pyogenes)
- Neisseria gonorrhoea = sexually active young adults
- Haemophilus influenzae = children
- E.coli
3
Q
Most common sites for septic arthritis
A
knee>hip>shoulder
4
Q
Presentation of septic arthritis
A
- Agonisingly painful, red, hot, swollen joint
- Stiffness and reduced range of motion
- Systemic: Fever, lethargy, sepsis
- In elderly and immunosuppressed and RA = Articular signs may be muted
- In children = limping or protecting joint
5
Q
Gold standard investigation for septic arthritis
A
- Urgent joint aspiration and synovial fluid sampling
o Always aspirate before antibiotics given
o Send fluid for urgent gram-staining, culture, Abx sensitivities
o Fluid will be purulent/opaque/thick/pussy due to high WCC (Normal fluid is clear yellow and thin)
6
Q
Kocher criteria for septic arthritis
A
- Fever
- Non-weight bearing
- Raised ESR
- Raised WCC
7
Q
Management of septic arthritis
A
- Empirical IV Abx until sensitivities known (switch to oral after 2 wks, continue 4-6 weeks)
1. Flucloxacillin
2. Clindamycin (penicillin allergy)
3. Vancomycin + rifampicin = penicillin allergy, MRSA, prosthetic joint - Stop immunosuppression temporarily
- Joint should be immobilised early = followed by early physiotherapy to prevent stiffness and muscle wasting
- Needle aspiration joint drainage repeatedly until no recurrent effusion can help relieve pain = Surgical washout is more pleasant
- NSAIDs = ibuprofen for pain
- Arthoscopic lavage may be required
8
Q
What is osteomyelitis
A
Infection of bone and bone marrow (usually long bones)
9
Q
Risk factors for osteomyelitis
A
- Open bone fracture
- Orthopaedic surgery
- Immunocompromised = HIV, TB, sickle cell anaemia
- Diabetes mellitus
- Peripheral vascular disease
- Malnutrition
- Inflammatory arthritis
- Prosthetic material
10
Q
Causes of osteomyelitis
A
- Staphylococcus aureus (90%)
- Salmonella = complication of sickle cell anaemia
- Pseudomonas aeruginosa and Serratia and marcesans in IVDU
11
Q
Presentation of osteomyelitis
A
- Onset over several days
- Dull pain worse on movement
- Fever, sweats, rigors and malaise
- Tenderness, warmth, erythema and swelling
- Draining sinus tract = associated with deep/large ulcers that fail to heal despite treatment
12
Q
Investigations of osteomyelitis
A
- Plain X-ray may show osteopenia
- MRI = marrow oedema from 3-5 days (done after x-ray)
- Blood culture to determine cause
- Raised ESR/CRP and WCC
13
Q
Management of osteomyelitis
A
- Immobilisation
- Prolonged antibiotic therapy = IV flucloxacillin
- Drainage and Debridement
- IV Teicoplanin
- Oral fusidic acid
- Stop treatment guided by ESR/CRP monitoring
14
Q
What is pseudogout
A
Microcrystal synovitis caused by calcium pyrophosphate dihydrate crystals deposited in joint
15
Q
Risk factors for pseudogout
A
- Diabetes
- Osteoarthritis
- Joint trauma/injury
- Metabolic disease = Hyperparathyroidism, Haemochromatosis
- Intercurrent illness
- Surgery = parathyroidectomy
- Blood transfusion, IV fluid
- T4 replacement
- Joint lavage = going into joint and shaking around crystals
- Acromegaly
- Wilson’s disease
- Low magnesium, low phosphate
16
Q
Presentation of pseudogout
A
- Severe hot, pain, stiffness, swelling joint
- Fever
- Typically distributed to knee > wrist > shoulder > ankle > elbow
17
Q
Investigations of pseudogout
A
- Joint fluid aspiration and microscopy
o Small weakly- positively birefringent rhomboidal calcium pyrophosphate crystals
o Joint fluid looks purulent sent for culture to exclude septic arthritis - X-ray = chondrocalcinosis (linear calcification parallel to articular surfaces)
- Bloods = Raised WCC
18
Q
Management of pseudogout
A
- High dose NSAIDs (ibuprofen)
- Oral/ IM/ intra-articular corticosteroid = prednisolone
- Colchicine
- Physiotherapy
- Joint washout
19
Q
What is gout
A
Inflammatory arthritis associated with hyperuricaemia and urate crystals deposited in joint lining
20
Q
Epidemiology of gout
A
- Rises in post-menopausal women
- Chinese, Polynesian, Filipino = uncommon in native country but increased if westernised diet
21
Q
Risk factors for gout
A
- High alcohol intake
- Purine rich foods = red meat, seafood
- High fructose intake = sugary drinks, cakes, sweets and fruit sugars
- High saturated fat diet
- Drugs = low-dose aspirin, diuretics
- Family history
- CVD, CKD, Hypertension, DM
- Obesity
22
Q
Presentation of gout
A
- Sudden hot, painful, swelling and redness of usually one joint
- Typically base of big toe, wrists, base of thumb
- Precipitated by excess food, alcohol, dehydration or diuretic therapy, cold, trauma or sepsis
- Smooth white deposits (tophi) in skin and around joints
23
Q
Gold standard investigation of gout
A
- Joint fluid aspiration and microscopy
o Long needle shaped crystals
o Negatively bifringent under polarised light
o Monosodium urate crystals
24
Q
XR findings in gout
A
o Joint effusion (early sign)
o Space between joint is maintained
o Lytic lesions in bone
o Punched out erosions
o Erosions have sclerotic borders with overhanging edges
25
Bloods tests in gout
- Serum uric acid raised measure 2 weeks after episode as may be high, normal or low during attack
- Serum urea and creatinine + estimated glomerular filtration rate
26
Management of acute flare of gout
1. NSAIDs (ibuprofen)
2. Colchicine renal impairment or heart disease
3. Oral prednisolone
4. Intra-articular steroid injection
27
Side effects of colchicine
diarrhoea and abdo pain
28
Long term management of gout
o Allopurinol
Colchine cover considered when starting allopurinol
o Febuxostat
29
Side effects of allopurinol
fever, rash, low WCC
30
Prophylaxis of gout
o Lose weight
o Less alcohol and good fluid intake
o Avoid purine rich food
o Dairy and increased vitamin C can reduce gout
o Stop diuretics and switch to ARB
31
Complications of gout
- Hypertension
- Renal disease
- CVS disease
- DMT2
- Osteoarthritic damage to joints
32
What is osteoarthritis
Mechanical degenerative non-inflammatory disease of the joints
33
Risk factors for osteoarthritis
- Age
- Joint hypermobility
- Diabetes
- Family history
- Obesity
- Occupation = manual labour (small joints of hand), farming (hips), football (knees)
- Local trauma
- Inflammatory arthritis = RA
34
Presentation of osteoarthritis
- Gradual in onset and progressive
- Joint pain and stiffness (<30 mins in morning)
- Worsened by activity and relieved by rest
- Functional impairment = walking, AoDL
- Bouchard’s nodes = bone swelling at PIPJs
- Heberden’s nodes = bone swellings at DIPJs
- Squaring at base of thumb
- Limited joint movement/range of motion
- Weak grip
- Muscle wasting of surrounding muscle groups
- Crepitus (grating) = crunching sensation when moving joint due to disruption of normally smooth articulating surfaces of joints
- Alteration in gait
- Joint swelling = bony enlargement, effusion, synovitis (inflammatory)
35
Joints must commonly affected in osteoarthritis
o DIPJs and first carpometacarpal joints of hands
o First metatarsophalangeal joint of foot
o Weight-bearing joints = vertebra, hips and knees
o Sacro-iliac joints
36
XR findings in osteoarthritis
Loss of joint space,
Osteophytes forming at joint margins,
Subarticular sclerosis,
Subchondral cysts,
Abnormalities of bone contour
37
Conservative management of osteoarthritis
- Lifestyle changes Weight loss, Exercise
- Physiotherapy = improve strength and support joint
- Occupational therapy = support activities and function
- Local heat or ice packs applied to affected joint may help
38
Medical management of osteoarthritis
- Analgesia
1. oral paracetamol, topical NSAIDs, topical capsaicin
2. oral NSAIDs + PPI (omeprazole)
3. opiates (codeine/morphine)
- Intra-articular corticosteroid injections = short term improvement
39
Surgical management of osteoarthritis
o Arthroscopy = Scope inserted into joint to assess damage and remove loose bodies bone or cartilage fragment that cause ‘knee lock’
o Arthroplasty (knee or hip replacement)
o Osteotomy = Cut bone to change shape/length
o Fusion = Usually of ankle and foot to prevent painful grinding of bone
40
What is rheumatoid arthritis
Chronic systemic inflammatory autoimmune disease of the joints characterised by symmetrical, deforming, peripheral polyarthritis
41
Risk factors for rheumatoid arthritis
- Females = Before menopause women are affected 3x more than men
- Family history
- Genetic factors (HLA-DR4 and HLA-DR1) = increased susceptibility and severity
- Smoking
42
Presentation of rheumatoid arthritis
- Symmetrical swollen, painful and stiff joints
- Worse in morning and cold = Morning stiffness lasting >30 mins
- Pain worse after rest but improves with activity
- Fatigue, sleep disturbed
- Slowly progressive
- Weight loss
- Flu-like illness
- Muscle aches and weakness, wasting
- Symmetrical involvement of small joints of hand, metacarpophalangeal, proximal interphalangeal (not DIP), metatarsophalangeal of feet, (Wrists, elbows, shoulders, knees and ankles)
- Hand deformities = Ulnar deviation, Swan neck, Z thumb, Boutonniere deformity
- Joints usually swollen, warm and tender
- Movement limitation
- Synovitis and effusions in knees
- Tenosynovitis = inflammation of tendons
43
Antibodies in rheumatoid arthritis
- Positive rheumatoid factor (70-80%)
- Positive anti-cyclic citrullinated peptide (30%) = presents early
44
XR findings in rheumatoid arthritis
o Early Loss of joint space, juxta-articular osteoporosis, soft-tissue swelling
o Late periarticular erosions, subluxation
45
Bloods in rheumatoid arthritis
ESR/CRP raised
Raised platelets
Normochromic normocytic anaemia
46
Analgesia in rheumatoid arthritis
NSAIDs (+ PPI)
47
Management of rheuamtoid arthritis
- 1st line = DMARD monotherapy (methotrexate) ± short course prednisolone
- 2nd line = methotrexate + leflunomide/sulfasalazine
- 3rd line = methotrexate + anti-TNF (infliximab)
- Intra-articular injection (semicrystalline steroid)
48
Monitoring requirements for rheumatoid arthritis
DMARDs = monitor FBC and LFT
Disease monitoring = CRP and disease activity
49
Side effects of DMARDs
myelosuppression, liver cirrhosis, pneumonitis
50
Flares of RA
oral or IM corticosteroids
51
Surgery in RA
relief pain, improve function and prevent deformity
52
Complications of rheumatoid arthritis
- Lungs = Pleural effusions, Fibrosing alveolitis, Pneumoconiosis, Interstitial lung disease, Bronchiectasis
- Heart (rare) = Pericarditis, Pericardial rub, Raynaud’s, Pericardial effusion
- Eyes = Dry eyes, Episcleritis (non-severe mild redness of eyes), Scleritis (severe pain, can’t look at bright lights)
- Neurological = Peripheral sensory neuropathies
o Compression/entrapment neuropathies = carpal tunnel
o Cord compression = sensory loss, weakness and disturbed bladder function
- Kidneys = Amyloidosis, Nephrotic syndrome, CKD
- Skin = Subcutaneous nodules
53
Side effects of corticosteroids
Osteoporosis
54
Side effects of methotrexate
Nausea
Mouth ulcers
Diarrhoea
Neutropenia
Thrombocytopenia
Renal impairment
Liver fibrosis
Pulmonary fibrosis
55
Contraindications of methotrexate
Pregnancy – avoid for at least 6m after Tx stopped
56
What is ankylosing spondylitis
Chronic inflammatory disorder of spine, ribs and sacroiliac joints
57
Epidemiology of ankylosing spondylitis
- Males aged 20-30
- High incidence in Native North Americans
58
Risk factors for ankylosing spondylitis
- HLA-B27 (88%)
- Family history
59
Presentation of ankylosing spondylitis
- Gradual onset of lower back pain
o Pain radiates from sacroiliac joints to hip/buttocks
o Worse at night with spinal morning stiffness
o Usually improves towards end of day
o Pain worse with rest and improves with movement
- Asymmetrical joint pain = normally oligoarthritis (1/2 joints)
- Progressive loss of spinal movement resulting in reduced thoracic expansion
- Loss of lumbar lordosis (normal inward curve of spine)
- Increased kyphosis = curvature of spine that causes top of back to appear more rounded than normal
- Schober test = Reduced spinal flexion <5cm
60
Associations of ankylosing spondylitis
- Apical pulmonary fibrosis
- Anterior uveitis = inflammation of middle layer of eye
- Aortic regurgitation/aortitis
- Achilles tendonitis
- AV node block
- Amyloidosis
- Anaemia
- Cauda equina syndrome
- Peripheral arthritis
- Weight loss and fatigue
- Chest pain = costovertebral/costosternal joints
- Dactylitis = inflammation of finger/toe
- Enthesitis
- Restrictive lung disease = restricted chest wall movement
- Inflammatory bowel disease
61
XR findings in ankylosing spondylitis
o Squaring of vertebral bodies
o Sacroiliitis: Subchondral sclerosis and erosions
o Syndesmophytes = areas of bone growth where ligaments insert into bone
o Bamboo spine (late and uncommon)
o Dagger sign radiodense line related to ossification of supraspinous and interspinous ligaments
o Ossification of ligaments, discs and joints
o Fusion of facet, sacroiliac and costovertebral joints
62
Respiratory investigations in ankloysing spondilitis
- CXR apical fibrosis
- Spirometry restrictive (pulmonary fibrosis, kyphosis, ankylosis of costovertebral joints
63
Complications of ankylosing spondilitis
Vertebral fractures
64
Management of ankylosing spondilitis
- Physiotherapy
- Exercise and mobilisation
- Avoid smoking
- NSAIDs
- Steroids during flares
- Anti-TNF (etanercept) or monoclonal antibody against TNF (infliximab)
- Secukinumab (monoclonal antibody against interleukin-17)
- Bisphosphonates = osteoporosis
- Surgery = hip replacement to improve pain and mobility
65
Presentation of psoriatic arthritis
- Stiffening and soreness of joint
- Symmetrical polyarthritis (F>M) Hands, wrists, ankles, DIP joints
- Asymmetrical oligoarthritis Fingers and toes and feet
- Spondylitic pattern (M>F)
o Back stiffness
o Sarcoiliitis
o Atlanto-axial joint involvement
- Arthritis Mutilans (severe)
o Progressive shortening of digit due to osteolysis
o Skin folds as digit shortens = telescopic finger
- Plaques of psoriasis on skin
- Pitting of nails
- Onycholysis = separation of nail from nail bed
- Dactylitis = inflammation of full finger
- Enthesitis = inflammation at points of tendon insertion
- Tenosynovitis
66
Screening for psoriatic arthritis
Psoriasis Epidemiological Screening Tool (PEST)
67
XR findings in psoriatic arthritis
o Periostitis = thickened irregular outline of bone
o Ankylosis = bones joining together cause joint stiffening
o Osteolysis = destruction of bone
o Dactylitis = soft tissue swelling
o Pencil-in-cup appearance = central erosions of bone beside joints
68
Management of psoriatic arthritis
- Managed by rheumatologist
- NSAIDs (mild)
- DMARDs (methotrexate) mod/severe
- Anti-TNF medications (etanercept, infliximab, adalimumab)
- Intra-articular corticosteroid injections
- Psoriasis treatment
69
Risk factors for reactive arthritis
- Male (post-STI)
- HLA B27
70
Causes of reactive arthritis
- Gastroenteritis = salmonella, shigella, campylobacter
- STI = chlamydia, gonorrhoea
71
Presentation of reactive arthritis
- “Can’t see, can’t wee, can’t bend my knee”
- Typically develops with 4 wks of initial infection
- Acute monoarthritis usually of knee Warm, swollen and painful joint
- Bilateral conjunctivitis, Anterior uveitis
- Circinate balanitis = dermatitis of head of penis
- Keratoderma blennorrhagica = raised waxy yellow/brown plaques and pustules on palms and soles
- Nail dystrophy
72
Investigations for reactive arthritis
- ESR/CRP raised
- Sexual health review
- Aspirate joint = gram staining, culture, sensitivity
o Exclude gout/pseudogout with crystal examination
- Urethral swab
- Stool culture
- X-ray = enthestitis
73
Management of reactive arthritis
- NSAIDs and analgesia
- Steroid injections into affected joints
- Systemic steroids and Abx
- Recurrence = DMARDs (methotrexate) and anti-TNF
- Screen sexual partners
74
What is SLE
Inflammatory autoimmune connective tissue disease affecting multiple systems
75
Risk factors for SLE
- Family history
- Pre-menopausal women
- Genetics = HLA genes linked with SLE
- Drugs = Hydralazine, isoniazid, procainamide and penicillamine
- UV light = trigger flares
- Epstein-Barr virus = potential trigger
- Commoner in African-Caribbeans and Asians
76
Presentation of SLE
- Fatigue
- Weight loss
- Joint pain and non-erosive arthritis
- Muscle pain
- Fever
- Shortness of breath
- Pleuritic chest pain
- Photosensitive malar rash (butterfly rash), spares nasolabial folds
- Discoid rash scaly, erythematous, well demarctated rash in sun exposed areas
- Lymphadenopathy
- Splenomegaly
- Mouth ulcers
- Hair loss (non-scarring alopecia)
- Livedo reticularis
- Raynaud’s phenomenon
77
Antibodies in SLE
- ANA positive = most sensitive
- Anti-double stranded DNA (anti-dsDNA) positive = most specific to SLE
- Anti-RO, Anti-Smith, anti-a, Rheumatoid factor
78
Bloods in SLE
- ESR raised and normal CRP
o Raised CRP may indicate underlying infection
- FBC = normocytic anaemia of chronic disease
- Leucopenia, lymphopenia and thrombocytopenia
- Complement levels (C3 and C4) decreased during active disease
- Immunoglobulins raised
79
Other investigations in SLE
- Urine protein: creatinine ratio = proteinuria in lupus nephritis
- Renal biopsy in lupus nephritis
80
Management of SLE
- NSAIDs
- Hydroxychloroquine (anti-malarial)
o Baseline opthalmological examination and annual screening
- Steroids (prednisolone) if internal organ involvement
- Sun cream and sun avoidance
- Other immunosuppressants = Methotrexate, Mycophenolate mofetil, Azathioprine, Tacrolimus, Leflunomide, Ciclosporin
- Biological therapies = Rituximab, Belimumab
- Reduce CVD risk factors = Smoking cessation, Weight loss, Treat blood pressure and give statins
81
Side effects of hydroxychloroquine
Bull’s eye retinopathy
82
Complications of SLE
- Lung Recurrent pleural effusions, pneumonitis and atelectasis, Pulmonary embolism, Interstitial lung disease pulmonary fibrosis
- Heart Pericarditis and pericardial effusions, Arrhythmias, Arterial and venous thromboses, Increased frequency of IHD and stroke, Abnormal clotting, myocarditis
- Kidneys Glomerulonephritis with persistent proteinuria, Renal failure = lupus nephritis
- CNS Seizures, Psychosis, Depression, Epilepsy, Migraines, Cerebellar ataxia
- Eyes Retinal vasculitis, Episcleritis, Conjunctivitis
- Sjogren’s (15%)
- Obstetrics Recurrent miscarriage, intrauterine growth restriction, pre-eclampsia and pre-term labour
83
What is sjogren's syndrome
Autoimmune disorder affecting exocrine glands resulting in dry mucosal surfaces
84
Presentation of sjorgren's syndrome
- Dry eyes keratoconjunctivitis sicca
- Dry mouth
- Vaginal dryness
- Arthralgia
- Raynaud’s, myalgia
- Sensory polyneuropathy
- Recurrent episodes of parotitis
- Renal tubular acidosis
- Positive Schirmer’s test
85
Antibodies in sjogren's syndrome
- Rheumatoid factor positive (50%)
- ANA positive (70%)
- Anti-Ro (SSA) antibodies (70% with PSS)
- Anti-La (SSB) antibodies (30% with PSS)
86
Other investigations in sjogren's syndrome
- Schirmer’s test filter paper near conjunctival sac to measure tear formation
- Histology focal lymphocystic infiltration
- Hypergammaglobulinaemia
- Low C4
87
Management of sjogren's syndrome
- Artificial saliva and tears
- Pilocarpine may stimulate saliva production
88
Complications of sjogren's syndrome
Lymphoma
89
What is fibromyalgia
Widespread MSK pain after other diseases have been excluded
90
Risk factors for fibromyalgia
- Low household income
- Divorced
- Low educational status
91
Associations of fibromyalgia
- Depression
- Chronic headache
- IBS
- Chronic fatigue syndrome
- Myofascial pain syndrome
- Rheumatoid arthritis
92
Presentation of fibromyalgia
- Symptoms present for at least 3 months and other causes have been excluded
- Widespread chronic pain
o Predominantly neck and back but may be all over
o Aggravated by stress, cold and activity
o Associated with generalised morning stiffness
o Paraesthesiae of hands and feet
- Extreme fatigue occurring after minimal exertion
- Non-restorative sleep
o Frequent waking during night
o Waking unrefreshed
- Poor concentration and forgetfulness
- Low mood, irritable and weepy
- Pain at 11/18 tender point sites on digital palpation
93
Exclusion investigations in fibromyalgia
- Thyroid function test = exclude hypothyroidism
- ANAs and DsDNA = exclude SLE
- ESR and CRP = exclude PMR + inflammatory arthritis
- Ca2+ and electrolytes = exclude hypercalcemia
- Vit D = exclude low vit D
94
Management of fibromyalgia
- Educate patient and family = Explain real symptoms but pain doesn’t always mean damage
- Reset pain thermostat
- Improve aerobic fitness = tire them to improve sleep
- Low-dose antidepressants and anticonvulsants amitriptyline, pregabalin
95
What is polymyalgia rheumatica
Common condition in older people characterised by muscle stiffness and raised inflammatory markers
96
Risk factor for PMR
- SLE
- Polymyositis/ dermatomyositis
97
Presentation of PMR
- Rapid onset <1m
- Mild polyarthritis of peripheral joints
- Sudden onset of severe pain and stiffness of shoulders and neck, hips and lumbar spine = limb girdle pattern
- Symptoms worse in morning, lasting from 30 mins to several hours
- Fever (low-grade)
- Weight loss and anorexia
- Depression
- Lethargy
- Night sweats
98
Investigations in PMR
- Both ESR and CRP raised = diagnostic
o ESR >40mm/hr
- Serum ALP raised
- Temporal artery biopsy Shows giant cell arteritis in 10-30% cases
- Creatinine kinase and EMG normal
99
Management of PMR
- Prednisolone 15mg OD
o Produce dramatic reduction of symptoms of PMR within 24-48 hours of starting treatment
o If improvement doesn’t occur then diagnosis questioned
o Decrease dose slowly
- GI and bone protection lansoprazole and alendronate and Ca2+ and vit D
100
What is polyarteritis nodosa
* Necrotising vasculitis that causes aneurysms ad thrombosis in medium sized arteries
* Leading to infarction in affected organs
101
Associations of polyarteritis nodosa
- Hep B
- RA, SLE, scleroderma
102
Presentation of polyarteritis nodosa
- Numbness
- Tingling
- Abnormal/lack of sensation
- Inability to move part of body
- Abdo pain due to arterial involvement of abdominal viscera
o Mimicking acute cholecystitis, pancreatitis or appendicitis
- GI haemorrhage due to mucosal ulceration
- haematuria and proteinuria
- Hypertension and acute/chronic kidney disease
- Coronary arteritis = MI and heart failure
- Subcutaneous haemorrhage and gangrene occur
- Fever, malaise, weight loss and myalgia
o Initial symptoms followed by dramatic acute features (organ infarction)
103
Investigations of polyarteritis nodosa
- Bloods Anaemia, WCC raised, ECR raised
- ANCA negative
- Biopsy of kidney
o Hypertension and other damage
o Can be diagnostic
- Angiography Demonstrates micro-aneurysms in hepatic, intestinal or renal vessels
104
Management of polyarteritis nodosa
- ACE-inhibitors = Ramipril
- Corticosteroids = prednisolone
o In combination with immunosuppressive drugs = azathioprine or cyclophosphamide
- Hep B Should be treated with antiviral after initial treatment with steroids
