Rheumatology

Question 1

Which breast cancer drugs are protective vs increase risk of osteoporosis

Answer 1

Tamoxifen - oestrogen agonist in bone - protective
Note: While Tamoxifen is protective for bone in postmenopausal women (acts as an estrogen agonist on bone), it can slightly reduce bone density in premenopausal women (acts as an estrogen antagonist).
Increase:
Hormonal therapies (e.g. letrozole, Anastrozole, Exemestane, Goserelin, Leuprolide)

Question 2

First-line management for ankylosing spondylitis?

Answer 2

Exercise therapy and NSAIDs

Question 3

What bones do Paget’s tend to affects?

Answer 3

Paget’s disease of the bone generally affects the skull, spine/pelvis, and long bones of the lower extremities

Question 4

Why must CXR be done before starting biologics in RA patients?

Answer 4

Risk of TB activation

Question 5

What three organisms are the most implicated in reactive arthritis?

Answer 5

Chlamydia trachomatis, Salmonella enterica and Campylobacter jejuni

Question 6

Topical NSAIDs are only indicated in OA of which joints?

Answer 6

Knee or hands

Question 7

Which patients should be started on bisphosphonate after a fragility fracture before DEXA scan?

Answer 7

Those with fragility fracture above the age of 75 (you would still arrange to get a DEXA scan done later)

Question 8

How long do patients require antibiotics for in septic arthritis?

Answer 8

4-6 weeks

Question 9

What is an important thing to do before starting bisphosphonates to prevent symptoms of muscle spasms/cramps, tingling in lips fingers and feet?

Answer 9

Correct underlying calcium and vitamin D deficiency first as bispohosphonates can reduce serum calcium by reducing bone turnover

Question 10

Explain the concept of bisphosphonate ‘holidays’

Answer 10

After a five year period for oral bisphosphonates (three years for IV zoledronate), treatment should be re-assessed for ongoing treatment, with an updated FRAX score and DEXA scan.

This guidance separates patients into high and low risk groups. To fall into the high risk group, one of the following must be true:
Age >75
Glucocorticoid therapy
Previous hip/vertebral fractures
Further fractures on treatment
High risk on FRAX scoring
T score <-2.5 after treatment

If any of the high risk criteria apply, treatment should be continued indefinitely, or until the criteria no longer apply. If they are in the low risk group however, treatment may be discontinued and re-assessed after two years, or if a further fracture occurs.