Rheumatology Flashcards
What 2 drugs would you avoid prescribing to a patient on methotrexate?
Trimethoprim or cotrimoxazole
What is the monitoring of methotrexate?
FBC, U+E and LFT before starting, repeated weekly until therapy stabilised, then every 2-3 months.
What is the triad of Felty’s syndrome?
- RA
- Neutropenia
- Splenomegaly
What is the acute mx of gout?
- NSAIDs (avoid in warfarin- GI bleed)
- Colchicine (SE: diarrhoea)
- Intra-articular steroid injection
- Oral steroids (pred) if others CI
What are the indications for allopurinol prophylaxis?
- Recurrence
- Tophi
- Renal disease
- Uric acid renal stones
- If on cytotoxic or diuretics
At what time should allopurinol be prescribed if indicated? Co-prescribe? Dose?
2 weeks after an acute attack has settled (may prescip further attack)
Initially 100mg OD, titrate to uric acid <300
NSAID or colchicine cover when starting
What are the red flags for sinister causes of back pain?
- <20yrs or >55
- Acute onset in elderly people
- Constant or progressive pain
- Nocturnal apin
- Pain worse on being supine
- Fever, night sweats, weight loss
- Hx of malignancy
- Abdo mass
- Thoracic back pain
- Morning stiffness
- Bilateral or alternating leg pain
- Neurological disturbance (inc sciatica)
- Sphincter disturbance
- Immunosuppression
- Lew claudication or exercise-related leg weakness/numbness (spinal stenosis)
What nerves are tested in the straight leg raise?
L4, L5, S1
What nerves are tested on the femoral stretch test?
L4 and above
What are the features of acute cauda equina compression?
= Neurosurgical emergency
- Alternating or bilateral root pain in legs, saddle anaesthesia, low of anal tone on PR, bladder +/- bowel incontinence
What are the features of acute cord compression?
- Bilateral pain
- LMN signs at level of compression
- UMN and sensory loss below
- Sphincter disturbance
What pain and weakness would an L2 lesion cause?
Pain: across upper thigh.
Weakness: hip flexion and adduction
What pain and weakness would an L3 lesion cause?
Pain across lower thigh
Weakness: Hip adduction, knee extension
Dec knee jerk
What pain and weakness would an L4 lesion cause?
Pain: across knee to medial malleolus
Weakness: Knee extension, foot inversion and dorsiflexion
Dec knee jerk
What pain and weakness would an L5 lesion cause?
Pain: lateral shin to dorsum of foot and great toe
Weakness: hip extension and abduction. Knee flexion. Foot and great toe dorsiflexion.
Dec great toe jerk
What pain and weakness would an S1 lesion cause?
Pain: posterior calf to lateral foot and little toe
Weakness: knee flexion. Foot and toes plantar flexion. Foot eversion.
Dec ankle jerk.
What are the signs and symptoms of localised osteoarthritis?
- Localised disease is typically knee or hip
- Pain on movement and crepitus
- Worse at end of day
- Background pain at rest
- Joint gelling- stiffness after rest up to 30 mins.
What are the signs and symptoms of primary/general osteoarthritis?
- Heberden's nodes (DIPs) (+ Bouchard's nodes (PIPs)) - Commonly affected: DIPs, thumb CMJ, knees - Joint tenderness - Bony swelling - Dec ROM - Mild synovitis
What are the typical findings on plain x-ray in OA?
Loss of joint space
Osteophytes
Subarticular sclerosis
Subchondral cysts
What is the most common joint affected by septic arthritis?
Knees >50%
What are the RF for septic arthritis?
- Pre-existing joint disease, especially RA
- DM
- Immunosuppression
- CKD
- Recent joint surgery
- Prosthetic joints
- IVDU
- > 80
What is the most important Ix in suspected septic arthritis?
Urgent joint aspiration for micro and culture
What empirical abx would you use for septic arthritis?
- Fluclox
- Clindamycin if allergy
- Vancy IV if MRSA or hx of
- Cefotaxime if gonococcal or gram -ve suspected
What is the typical presentation in RA?
Other presentations?
- Symmetrical swollen, painful and stiff small joins of hands and feet, worse in the morning
- Less commonly: sudden onset, widespread arthritis
- Palindromic RA = recurring arthritis of various joints
- Systemic illness with fever, weight loss, pericarditis and pleurisy, with few joint symptoms initially.
What antibodies are most specific for RA?
Anti-CCP
What scale is used to measure disease activity in RA? What is the target score?
DAS28
<3
What is the first-line treatment in RA?
DMARDs - should be started within 3 months of persistent symptoms. Can take 6-12 weeks for symptomatic benefit.
What is typically the best combination of DMARDs in RA?
Methotrexate, sulphasalazine and hydroxychloroquine
What are the potential SE of methotrexate?
Immunosuppression -> pancytopenia, neutropenic sepsis (monitor FBCs)
- Pneumonitis
- Oral ulcers
- Hepatotoxicity
What are the potential SE of sulfasalazine?
- Rash
- Dec sperm count
- Oral ulcers
What are the potential SE of leflunamide?
- Teratogenic (M and F)
- Oral ulcers
- HTN
- Hepatoxicity
What is the potential SE of hydroxychloroquine?
Irreversible retinopathy (annual opthal review)
What is the first-line agent for active RA after failure to respond to 2 DMARDs and with a DAS28 >5.1?
TNF-alpha inhibitors (Infliximab, etanercept etc)
Can also be used as mono therapy if methotrexate CI - used adalimumab or etanercept.
What is the agent of choice in severe, active RA where DMARDs and a TNF-alpha have failed/ CI?
What would you use if this is ineffective or CI?
B cell depletion - Rituximab
then
IL-1 and IL-6 inhib: Tocilizumab in combo with methotrexate.
What are the SE of biologics?
- Serious infection, inc reactivation of TB and hep B
- Worsening heart failure
- Hypersensitivity
- Injection site-reactions
- Blood disorders
- ANA and reversible SLI-type illness
What antibody is associated with diffuse cutaneous systemic sclerosis?
Scl-70
What antibody is associated with limited cutaneous systemic sclerosis?
Anti-centromere
What are the skin features of dermatomyositis?
- Photosensitive
- Macular rash over back and shoulder
- Heliotrope rash in periorbital region
- Gottron’s papules - roughened red papules over extensor surfaces of fingers
- Nail fold capillary dilatation
What are the common antibodies in dermatomyositis?
Majority are ANA positive
25% anti-Mi-2 positive
What is the triad of Reiter’s syndrome?
- Urethritis
- Conjunctivitis
- Arthritis
(Reactive arthritis)
What is HLA-B27 associated with?
Reactive arthritis
Ankylosing spondylitis
What antibody is commonly associated with antiphospholipid syndrome?
Anti-Cardiolipin antibody
What is anti-DsDNA highly specific for?
SLE
What is anti-mitochondrial antibody associated with?
Primary biliary cirrhosis
What is chondrocalcinosis?
What does this suggest?
Loss of joint space, with linear calcification of the articular cartilage
Pseudogout.
What would you see on joint aspiration in pseudo gout?
Weakly-positively birefringent rhomboid shaped crystals
When would you start bone protection in a patient with PMR?
Straight away, as it is likely that they will be on a significant dose of pred for >3 months.
Give Vit D, calcium supplements and oral bisphosphonates (alendronate)
In general what would you do as a result of the following T-scores?
- > 0
- Between 0 and -1.5
- Less than -1.5
- > 0: Reassure
- Between 0 and -1.5: Repeat scan in 1-3 years
- Less than -1.5: Offer bone protection
What is the first-line drug treatment for Raynauds?
Nifedipine
What antibody is fairly specific to polymyositis?
Anti-Jo1
What is Takyasu’s arteritis?
Symptoms?
An inflammatory, obliterative arteritis affecting the aorta and branches
- Upper limb claudication
- Diminshed/absent pulses
- Raised ESR
- F>M
What is Buergers disease?
Signs and symptoms?
Segmental, thrombotic occlusions of the small and medium sized lower limb vessels. Commonest in young, male smokers.
- Proximal pulses present, loss of pedal pulses.
- Tortuous, corkscrew shaped collateral vessels may be seen on angiography.
In what condition and what two allergies might you be cautious of prescribing sulfasalazines?
GP6D deficiency
Allergy: aspirin or sulphonamides
Give 2 common and 3 less common causes of drug-induced lupus?
- Procainamide
- Hydralazine
Less common:
- Isoniazid
- Minocycline
- Phenytoin
