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SPRING16 757 PC Adults > Rheumatology > Flashcards

Rheumatology Flashcards

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

1
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Common rheumatological diseases

A
  • Autoimmune / inflammatory arthritis
    • Rheumatoid arthritis
    • Psoriatic arthritis
    • Gout
  • Infectious arthritis
    • Gonococcal
    • Viral
    • Bacterial
    • Fungal
    • Lyme Disease
  • Other Diseases/Disorders
    • Osteoarthritis
    • Systemic lupus erythematosus
    • Scleroderma (systemic sclerosis)
    • Autoimmune Myositis
    • Polychondritis
    • Vasculitis
    • Behcet’s disease
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Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Muscles are composed of…

A

Myocytes

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3
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Ligaments are composed of…

A

collagen, connects bone to bone

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4
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Tendons are composed of…

A

collagen, connects muscle to bone

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5
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Bone is composed of…

A

osteoblasts, osteoclasts, mineral matrix

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6
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Cartilage is composed of …

A

chondrocytes, water, glycosaminoglycans, acts as shock absorber

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7
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

  • Synarthroses are…
A

non-moveable joints (skull)

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8
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Amphiarthroses are …

A

joints with fibrocartilage in between (spinal vertebrae)

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9
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Diarthroses are…

A

Synovial lined (synovial joints)

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10
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Bursae are…

A

synovial sacs that allow muscles and tendons to glide during movement.

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11
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Types of synovial joints

A
  • Plane joint: bones slide past each other (patellar-femoral)
  • Hinge joint: moves in one plane (elbow)
  • Pivot joint: moves in 2 planes (atlanto-occipital)
  • Condyloid: moves in multiple planes (knee)
  • Ball and socket: hip
  • Saddle joint: carpometacarpal joint
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12
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Spine landmarks

A
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13
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

hand and wrist anatomy

A
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14
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Knee anatomy

A
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15
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Key Rheumatology Joints

A
  • Proximal interphalangeal (PIP)
  • Distal interphalangeal (DIP)
  • Metacarpophalangeal (MCP)
  • Carpometacarpal (CMC)
  • Metatarsals
  • Metatarsophalangeal joint
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16
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Important rheum history Qs

A
  • Inflammation, swelling
  • Fever/chills or other systemic symptoms
  • Previous episodes
  • Rash, lesions, ulcers
  • Insect bite, Thyroid disease
  • Pain, stiffness
  • Parotid swelling
  • Dry mouth, dry eyes
  • Headache, jaw pain, vision changes
  • Irritable bowel symptoms
  • Recent infection
  • Profound fatigue
  • Weakness
  • Assistance needed?
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17
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Important rheum PMH/PSH Qs

A
  • Meds: statins, minocycline, nontraditional remedies, allergies?
  • Other illness
  • Developmental problems
  • Prior surgery
  • Trauma, fractures
  • Reproductive history in females
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18
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Important rheum FH/SH Qs

A
  • Systemic inflammatory illness
  • OA
  • Spondyloarthropathy (PS, PSA)
  • Alcoholism, depression, migraines, panic attacks
  • Coping ability
  • Litigation pending(worker’s comp)
  • HLA B27
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19
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Common rheum diagnostic tests

A
  • RA factor
  • ESR and CRP
  • Anti CCP (anti-cyclic citrullinated peptide antibody)
  • ANA, C3 and C4 (Antinuclear antibodies)
  • DS DNA (double stranded DNA)
  • CMP
  • CBC
  • HLA-B27 (Human Leukocyte Antigen (HLA)
  • Imaging studies
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20
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Common Rheumatologic Treatments

A
  • NSAIDs or Cox II inhibitors
  • Steroids
  • DMARDs :disease-modifying antirheumatic drugs (methotrexate, sulfasalazine, Hydroxychloroquine, Leflunomide)
  • TNF alpha inhibitors or biologics
    • Remicade
    • Orencia
    • Rituxan
    • Enbrel
    • Humira
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21
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Classification of Musculoskeletal Conditions

A
  • Systemic inflammatory (RA, SLE)
  • Degenerative mechanical (OA)
  • Nonarticular muscular (Fibromylagia, tendonitis)
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22
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

T/F: Very often there is some kind of trauma that sets off central pain processing of fibromyalgia

***exam

A

true

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23
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

how is fibromyalgia diagnosed?

***exam

A

R/O other causes - dx of exclusion

  • Pain 3 months, wide spread
  • Technically 11/18 at 4 kg of pressure ( blanch thumb) tender points other associated symptoms (rarely done in practice - not all pts have)
  • fatigue, sleep disturbance, stiffness, anxiety.
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24
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

T/F: fibromyalgia is common in people over 80yo

***exam

A

False: not usually seen >80yo

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25
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Common symptoms of fibromyalgia

***exam

A
  • Fatigue
  • Poor sleep
  • Headaches
  • Mood disturbances
  • Allergies
  • Dizzy
  • Bowel problems
  • Cognitive problems “Brain Fog”
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26
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

What to expect on PE for fibromyalgia

***exam

A
  • Focus on neuromuscular
  • Usually no OA, joint deformity
  • Function is good, able to get to exam table, put coat on , open door
  • Resistance during PE patient usually gives way
  • Reflexes normal
  • Tender points more in women
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27
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

What are the tender points of fibromyalgia?

***exam

A
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28
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

ACR 2010 guidelines for diagnosing fibromyalgia

***exam

A
  • A widespread pain index score ≥7 and a symptom severity scale score ≥5 or a widespread pain index score of 3–6,
  • a symptom severity scale score ≥9
  • Symptoms that are present for at least 3 months
  • The patient does not have another disorder that would explain the pain

In practice, however, many clinicians feel that the 1990 ACR criteria did not provide adequate diagnostic guidance

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29
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Pharm tx for fibromyalgia (general)

***exam

A
  • Rheumatologists: one study showed that some providers used over 60 drugs
  • Classically:
  • TCA, SE : weight gain
  • SSRI
  • SNRI
  • Antielpticics
  • Sedative- hypnotics
  • “The kitchen sink”
  • Antidepressants
  • Sedative hypnotics
  • Tramadol
  • Muscle relaxants
  • Low dose naltrexone
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30
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Approved drugs for fibromyalgia, as of 2009

***exam

A
  • Pregbalin 2007 ( lyrica) SE: sedation, weight gain, good if there is a sleep issue
  • Duloxetine 2008 ( cymbalta), biggest bang for the buck , used most, treats pain and depression, nausea, dose slowly, be careful when weaning off , dissociated sense during weaning,( patients often feel they are out of their body, go very slowly
  • Minaciprin 2009( savella) dose kit, not too popular, tolerance is issue, nausea, headache
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31
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Non pharmacological tx for fibromyalgia

***exam

A
  • Mind body often overlooked, but patients need the guidance and the tools.
  • CBT: strong in literature
  • Coping strategies
  • Progressive muscle relaxation
  • Breathing techniques
  • Mindful meditation
  • Tai chi or yoga study in NEJM. So it is becoming more accepted, but is it sustainable?
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32
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Considerations for exercise w/fibromyalgia

***exam

A
  • Combined with education
  • Supervised , but have patient start up slowly and gradual
  • Use PT as a way to jump start some exercise
  • Get them motivated, and improve lifestyle
  • Walking pool, strength training
  • Maximize health, see it as an opportunity, remember this is mainly in young pt
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33
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

CAM for fibromyalgia

***exam

A
  • Acupuncture: conflicts in literature may conflict with your own experience and part of EBP
  • Massage
  • Manipulation
  • Magnesium: studies are weak
  • Malic acid; studies are weak
  • Chlorella: green algae, super food, some discussion
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34
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

What is Myer’s Cocktail?

***exam

A

For fibromyalgia

  • Yale preventive research study using CAM, naturopaths, IV micronutrient used for a variety of conditions
  • 12,000 patients, magnesium, B Vitamins , vitamin C, 500 mg at a time ( more than that is only excreted)
  • IV Micronutrient Therapy
  • Mg
  • Calcium gluconate
  • Pyridoxine
  • B complex
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35
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Most common form of arthritis

A

osteoarthritis

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36
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

What is osteoarthritis?

A

Degeneration of joint starting with degradation of the cartilage and eventually including bone

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37
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

RFs for osteoarthritis

A
  • 50% of people >65yrs have x-ray evidence, most w/o symptoms
  • More common women> 55
  • Risk factors: Obesity, repetitive use, trauma, previous inflammation
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38
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Signs in the hands of osteoarthritis?

***exam

A

Heberden’s and Bouchard’s nodes

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39
Q
A

Heberden’s nodes: associated with OA

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40
Q
A

Bouchard’s nodes: associated with OA

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41
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

S/S of OA

***exam

A
  • Pain: worse after using joint
  • Stiffness: n< 1 hour in the morning, severe after immobility
  • Loss of movement
  • Restricted ROM
  • Tenderness
  • Bony swelling
  • Soft tissue swelling
  • Joint crepitus
42
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Clinical, laboratory, radiographic features of OA

***exam

43
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Causes of secondary OA

A

Endocrinopathies diabetes may be prone to osteoarthritis. Other endocrine problems also may promote development, including acromegaly, hypothyroid, hyperparathyroid, obesity

Metabolic dz: e.g., Wilson’s

44
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

What is Wilson’s disease?

A
  • An inherited disorder of copper metabolism that results in an abnormal accumulation of copper in the body. accumulation of copper begins at birth
  • symptoms of the disorder do not appear until later in life, between the ages of 6 and 40.
  • A diagnostic feature of the disease is a Kayser-Fleischer ring, a deep copper-
colored ring around the edge of the cornea that 
represents copper deposits in the eye.
45
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Nonpharm mgmt of OA

A
  • Weight reduction
  • Education
  • Exercise
  • Physical therapy
46
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Pharm mgmt OA

A
  • NSAIDs
  • Acupuncture
  • Topical creams: i.e.Voltaren gel
  • Steroid injection
  • Limbrel (Flavinoid)
    • Flavocoxid is comprised primarily of the flavonoids such as baicalin and catechin. These or similar ingredients can be found in common foods such as soy, peanuts, cauliflower, kale, apples, apricots, cocoa and green tea.
  • Synvisc injections
  • Glucosamine/chondroitin?
47
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Surgical mgmt of OA

A
  • Arthroscopic lavage and debridement
  • Osteotomy
  • Total joint replacement
48
Q
A

osteoarthritis

49
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

What is gout?

A
  • AKA “Podagra”
  • Inflammation related to increased urate
    • (> 6.0 mg/dL)
    • overproduction or underexcretion
  • metabolic disease
  • familial
50
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Who gets gout and why?

A
  • On the rise in USA
  • Men, 5th decade, (women after menopause)
  • Alcohol, purines, fructose rich drinks, diuretics, asa, niacin, cyclosporines
  • myeloproliferative diseases
  • At least 5% of asymptomatic Americans manifest hyperuricemia at least once as an adult
    • Not everyone with Hyperuricemia has gout! But everyone with gout has hyperuricemia
51
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Why is gout incidence increasing and how to avoid

A
  • Western diets, sedentary lifestyle, obesity and hypertension, increased use of diuretics and aspirin
  • modifiable risk factors: lifestyle and dietary factors (obesity, alcohol, fructose, purine-rich fatty food), certain drugs (thiazide and loop diuretics), and disease conditions (hypertension, renal insufficiency, and heart failure), heavy drinking
52
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

How is gout diagnosed?

A
  • *Needle aspiration of affected joint: r/o infection, gold standard, but not always needed, can use to differentiate from RA
    • Tophi that contain urate crystals (PE)
  • X-ray findings
  • elevated serum uric acid >6
    • Uric acid in flare will be normal
  • WBC might be elevated
53
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

How is gout treated?

***exam

A
  • Patient education
  • Immobilization
  • NSAIDs, steroids (intrarticular or oral), Colchicine 1.2mg start, then .6 in one hour then 0.6 mg up to TID,
  • Indocin (50 mg TID) watch for GI bleed
  • Later/Maintenance:
    • Allopurinol (200-600 mg in divided doses) prophylactically ( lifetime) block the final enzyme step in the production of uric acid
    • OR – Uloric ( febuxostat) 40-80 mg daily $$
  • May need to give prednisone first
54
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Goal of gout tx, expectations for success

***exam

A
  • lowering serum uric acid (SUA) levels with the urate-lowering therapies (ULTs) allopurinol or febuxostat.
    • lifelong
  • Inadequate dosing /nonadherence/intolerance: often lead to treatment failure.
  • American College of Rheumatology: TAILOR Tx, target SUA level (traditionally <6, but may need to be lower in some)
  • Hyperuricemia in non symptomatic patients need not be treated (>6)
55
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

What is pseudogout?

A
  • Calcium Pyrophosphate Dihydrate Deposition Disease (CPPD)
  • Acute , gout-like inflammation
  • CPPD crystals in synovial fluid (not urate crystals)
56
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Who gets pseudogout?

A
  • Occurs with age
  • Genetics
  • History of orthopedic trauma, surgery, anesthesia
  • Also associated with metabolic disease
57
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

How is pseudogout treated?

A

nSame as with gout, although less effective.

58
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

What is rheumatoid arthritis?

***exam

A
  • Chronic systemic inflammatory disease affecting diarthroidal joints
  • Most common autoimmune (joint) disease
  • Over production and over expression of TNF: drives synovial inflammation and joint destruction
59
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Who gets RA?

***exam

A
  • 2.5X more likely in women
  • Genetic predisposition for certain groups: HLA DR4, Native Americans ,Europe & Asian
  • 30% concordance rate in monozygotic twins
  • Not documented until the mid-18th century
  • Typical onset 55 yrs
  • In USA, lifetime risk is 3.6% women, 1.7% male
60
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Clinical features of RA: articular

***exam

A
  • Symmetrical polyarthritis
  • Joint swelling ( hands and feet)
  • Morning stiffness >1 hour
61
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Extra-articular manifestations of RA

***exam

A
  • Skin: nodules, palpable purpura
  • Eyes: Scleritis
  • Lungs: Interstitial fibrosis, pleuritis, , nodules, laryngeal cartilage
  • Heart: pericarditis
  • Hematologic: Anemia, RA factor
  • Neurologic: Atlanto-axial subluxation, single nerve involvement (mononeuritis)
62
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

To what extent is RA associated with disability?

A
  • >33% become disabled
  • Decrease in life expectancy 3-5 yrs
  • Often serious treatment adverse effects from drugs needed to treat
  • 50% greater risk for MI and HF
63
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

What was the problem with the 1987 criteria for IDing RA?

A
  • Poor sensitivity and specificity for Early inflammatory arthritis,
  • Fails to ID early cases.
  • Effective treatment in early RA delays response.
  • Erosive joint damage and extra articular disease are late changes that can be prevented
64
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

How are criteria for identificatio of RA evolving?

A
  • *Data driven and consensus driven
  • *Assess Joint involvement
  • *Auto antibody status
  • *Acute phase response
  • *Symptom duration
  • *Want to determine benefit from starting methotrexate
  • *Last phase will summarize all data to arrive at a prediction model and cut off for probability score
65
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Treatment goals of RA

A

Goals: to decrease inflammation, prevent progression, pain, loss of function

66
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Non-pharm tx of RA

A

Education, PT, OT, SW, swimming

67
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Pharm tx of RA

A
  • NSAIDs and COX Iis ( caution on COX Inh)
  • Methotrexate, other DMARDs
  • Steroids ( use as bridge treatment)
  • TNF inhibitors
68
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Each of the following symptoms is commonly reported in patients with rheumatoid arthritis (RA) except:

a. Pain and stiffness in multiple joints
b. Distal interphalangeal joints and sacroiliac joints pain and stiffness
c. Morning stiffness lasting at least 45 minutes
d. Joint pain accompanied by anorexia

***exam

A

b. Distal interphalangeal joints and sacroiliac joints pain and stiffness

69
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Clinical Criteria for Rheumatoid Arthritis

1987 ARA criteria

A

Four for a Minimum of 6 Weeks

    1. Morning stiffness in and around joint lasting at least 1 hour before maximal improvement
    1. Arthritis of 3 or more of the following joints simultaneously: right or left PIP, MCP, wrist, elbow, knee, ankle, and MTP joints including soft tissue swelling or fluid
    1. Arthritis of hand joint including swelling of wrist, MCP, or PIP joint
    1. Symmetric involvement of joints on both sides of the body
    1. Rheumatoid nodules over bony prominences, or extensor surfaces or in juxtaarticular regions
    1. Positive abnormal serum rheumatoid factor
    1. Radiographic changes including erosions or bony decalcification localized in or adjacent to the involved joints
70
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Fever and RA

A

. Low-grade fever occasionally occurs (temperature, 37° to 38°C; 99° to 100°F), but a higher fever suggests another illness, and infectious causes must then be considered.

71
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

atypical presentations of RA

A
  • intermittent joint inflammation that can be confused with gout or pseudogout
  • proximal muscle pain and tenderness mimicking polymyalgia rheumatica
  • diffuse musculoskeletal pain seen in fibromyalgia.
72
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

All of the following should be included in the differential diagnosis for RA in a patient with swollen joints except:

a. Systemic lupus erythematosus
b. Seronegative spondyloarthropathies
c. Infectious disease (tuberculosis, cytomegalovirus or HIV)
d. Fibromyalgia

A

d. Fibromyalgia

73
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Differential Diagnosis for Rheumatoid Arthritis

A
  • Connective tissue diseases Scleroderma and lupus
  • Fibromyalgia: Evaluate for trigger points ( although this is controversial)
  • Hemochromatosis: Iron studies and skin coloration changes
  • Infectious endocarditis: Murmurs, high fever, and history of intravenous drug use
  • Polyarticular gout: Joints often erythematous; podagra commonly found; gout and RA rarely coexist, but calcium pyrophosphate deposition disease can accompany RA
  • Polymyalgia rheumatica: Pain in the proximal joints of the extremities only
  • Sarcoidosis Granulomas: hypercalcemia, and x-ray findings
  • Seronegative spondyloarthropathies, reactive arthritis: Asymmetric involvement of the joint and may include the spine. Evaluate for history of psoriasis, Reiter’s comorbidities, inflammatory bowel disease. Reactive arthritis can be postinfective, sexually acquired, or related to gastrointestinal disorders
  • Still’s disease: Fever, leukocytosis with left shift, sore throat, splenomegaly, liver dysfunction, and/or rash
  • Thyroid disease: Consider TSH
74
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Which one of the following RA drugs is associated with an increased risk for cardiovascular complications:

a. Biologic DMARDs
b. Traditional (synthetic) DMARDs
c. Glucocorticoids
d. All of the above

A
  • d. All of the above
  • DMARDs (MIs, valves, sclerosis – cause arterial vessel inflammation), Traditional and biologic, and glucocorticoids (fluid, sugar) – all increase risk for CVD
75
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

most common comorbidities accompanying RA include

A

cardiovascular disease, malignancy, peptic ulcer disease, and chronic lung disease.

On average, the established patient with RA has 2 or more comorbid conditions

76
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Considerations when initiating glucocorticoids in RA pts

A
  • associated with increased cardiovascular risk, and should be avoided.
  • Prior to glucocorticoid use, RF assessment should include family history of diabetes, PMH hypertension or diabetes
  • may be associated with adverse effects including body weight changes, infection, osteoporosis, mood or sleep disturbance, and reduced wound healing.
  • patients should be counseled about potential side effects, the importance of taking the medication only as directed, limiting the dosage and duration of glucocorticoid use, difficulty of discontinuing prednisone in patients with active RA, and dangers of abrupt cessation of the medication after long-term use.
  • medical alert bracelet should be worn by patients receiving long-term glucocorticoid therapy.
77
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

RA and CV risk

A
  • twice the risk for heart failure when compared with individuals of the same age and sex without RA
  • cardiovascular health prevention steps are important to improve life expectancy in patients with RA
    • smoking cessation and reduction of cholesterol intake to minimize cardiovascular risk factors
  • At risk even after controlling for other RFs
78
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Which laboratory and/or imaging tests are least likely to be positive in RA in the early stages (may be more than one)

a. X-ray imaging
b. Rheumatoid factor (RF)
c. C-reactive protein (CRP)
d. CRP and erythrocyte sedimentation rate (ESR)
e. ESR and RF

***exam

A

a. X-ray imaging
b. Rheumatoid factor (RF)

  • CRP and ESR more informative. X-rays taken early in the course of RA may show only soft tissue swelling
  • RF not specific: also detected with lupus, scleroderma, Sjögren’s syndrome, neoplastic disease, sarcoidosis, and various viral, parasitic, and bacterial infections & chronic antigenic stimulation (prolonged infection caused by bacterial endocarditis, tuberculosis, cytomegalovirus, or HIV)
  • A positive test for RF is present in 70% to 90% of patients with RA, and indicates presence of antibodies directed against the Fc portion of immunoglobulin G (IgG).
  • false positive RF titers may be detected in the serum of apparently normal people, especially those older than 70 years, where prevalence ranges from 10% to 25%.
  • Patients with RA and a high-titer RF are more likely to have erosive joint disease, extra-articular manifestations of RA, and greater functional disability. In contrast RF-negative patients with RA may exhibit a milder disease course.
79
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

How does x-ray imaging change in course of RA?

***exam

A
  • early in the course of RA may show only soft tissue swelling,
  • With progression of disease, narrowing of the joint space is caused by loss of cartilage,
  • characteristic erosions appear, generally at the point of synovium attachment.
  • In end-stage RA disease, even large cystic erosions of bone may be seen and bony proliferation may occur.
80
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

What combination of laboratory tests is most specific and accurately predicts disease progression in patients with early RA symptoms:

a. RF and CRP plus swollen joints
b. ESR and CRP plus swollen joints
c. Anti-cyclic citrullinated peptide-2 (ACPA) assay, RF, CRP, and swollen joints
d. RF and ESR

***exam

A
  • c. Anti-cyclic citrullinated peptide-2 (ACPA) assay, RF, CRP, and swollen joints
  • evidence of anti-CCP antibodies alone can occur years before disease onset
  • no single diagnostic test definitively confirms the diagnosis of RA or predicts the disease course
81
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

When is ESR useful in diagnosing RA?

***exam

A

if the diagnosis is questionable and evidence of inflammation might affect therapeutic decisions

82
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Usefulness of ANA in diagnosing RF

***exam

A

The anti-nuclear antibody (ANA) test is sometimes included in the laboratory workup for RA. Although ANA is positive in 20% to 30% of patients with RA, it is more common in patients with extra-articular manifestations of disease

83
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Recommended testing in RA workup

***exam

A
  • a complete blood cell count with differential, RF, and ESR or CRP to assess acute-phase inflammatory response, anti-CCP2 assay
  • To help direct medication choices, baseline evaluation of renal and hepatic function is also recommended.
84
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

What additional treatment should be prescribed for the patient with RA whose symptoms persist or worsen after 3 months:

a. Glucocorticoids in addition to NSAIDs
b. Disease-modifying anti rheumatic drug (DMARD) therapy
c. Surgical treatment
d. Increased dosage of NSAIDs

***exam

A

b.Disease-modifying anti rheumatic drug (DMARD) therapy

early aggressive tx w/DMARDs recommended. (steroids would be used as a bridge – not long-term)

85
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Humira vs Enbrel in RA

A

Adalimumab (Humira) and etanercept (Enbrel) are equally effective as tumor necrosis factor (TNF) inhibitors in the treatment of patients with active rheumatoid arthritis

( November 2012 ACR Conference Washington DC)

86
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Considerations before starting TNF inhibitors

***exam

A

(rheumatologist starts these)

  • Tumor necrotizing factor alpha inhibitor
  • Screening considerations prior to start: PPD (latent can become active)
  • Hep B titer (anti-TNFs can cause reactivation of infection in carriers of the virus)
  • Avoid live vaccines during TNF therapy
  • Monitoring
  • Risk vs benefits (previous lymphoma risk) new data disputes this concern: no apparent association w/lymphoma, +risk for crohn’s, colitis
87
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

What is Raynaud’s phenomenon?

How is it treated?

A
  • Vascular ischemia
  • White (ischemia)
  • Blue (Cyanotic)
  • Red: hyperemia
  • Treatment: vasodilators, eliminate vasoconstrictors, control disease
88
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

What is SLE?

***exam

A
  • Multiorgan, multisystem, all components of Immune system
  • Differentiate from cutaneous lupus or drug-induced lupus
  • Relapsing-remitting
89
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Who gets SLE?

A
  • >Women 8:1
  • Onset ages 15-44, African Americans more than Caucasians
  • Socioeconomic correlation?
  • Associated with Raynaud’s phenomenon
90
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

WBC/RBC abnormalities in SLE

A
  • may be related to the lupus treatment, infection
  • For example, leukopenia is found in 15% to 20% of people with lupus
  • Thrombocytopenia occurs in 25% to 35% of people with lupus.
91
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

How is SLE diagnosed?

***exam

A

(4 or more of 11)
1982 and revisited in 1987

  • Malar rash
  • Discoid rash
  • Photosensitivity
  • Oral ulcers
  • Arthritis
  • Serositis
  • Renal disorder
  • Neurologic disorder
  • Hematologic disorder
  • Immunologic disorder (DS DNA, antiphospholipid antibodies)
  • ANA
92
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

SLE: describe malar rash, discoid rash, photosensitivity

***exam

93
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

SLE: describe oral or nasopharyngeal ulcers, arthritis, serositis

***exam

94
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

SLE: describe associated renal, neuro, and hematologic disorders

***exam

95
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

SLE: describe associated immunologic DOs, ANA test

***exam

96
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

SLE: describe characteristics of nervous system Dos

***exam

97
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Drugs associated with lupus-like syndrome

***exam

98
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

SLE treatment

A
  • Plaquenil 200 mg daily or BID
  • NSAIDs
  • Possibly Methotrexate
  • TNF alpha inhibitors
  • Prednisone for flares
99
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

Pain mgt for elderly with OA

***exam

A

acetaminophen

(short term nsaids or topical nsaids may be considered, opioids if pain is severe)

100
Q

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus

How should gout treatment be altered in CKD?

***exam

A
  • Be careful with colchicine in CKD - CrCl <30 mL/minute: Dosage ↓ not required but may be considered; treatment course should not be repeated more frequently than every 14 days. If someone is receiving it prophylactically don’t also give for flare
  • Allopurinol: Dosage reduction of 50% is recommended in renal impairment
  • No NSAID

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