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Basic Physician's Training Monash > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

Best anti-hypertensive for Gout

A

Losartan
-Uricosuric effects with modest decease in serum urate level

Amlodipine also urate lowering

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2
Q

What are the most reliable signs of disease activity in RA

A
  • Synovitis

- ESR/CRP

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3
Q

RCT proven benefits of MTX in RA

A
  • Faster onset of action and greater long term tolerance compared to other non-biologic DMARDs
  • improves survival (both cardiovascular and all cause mortality)
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4
Q

MOA of Allopurinol and Febuxostat

A

Inhibits Xanthine oxidase

  • Allopurinol (purine analogue)
  • Febuxostat (Non-purine and has hepatic metabolism so not dose reduction needed for renal impairment)
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5
Q

Side effects of allopurinol

A

Nausea and vomiting, rash, altered taste, diarrhoea

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6
Q

The only benefit of Febuxostat over Allopurinol

A

FACT Trial
-Higher reduction in serum urate level with Febuxostat compared to Allopurinol. Similar proportion of gout flares and reduction in tophi though.

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7
Q

Drugs associated with Drug induced Lupus

A 
Procainamide
Hydralazine
Quinidine
Isoniazid
Minocycline
Methyldopa
Chlorpromazine
TNF alpha inhibitors
Mesalazine
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8
Q

Name the Condition:

A Turkish man with conjunctivitis, arthritis, thrombophlebitis, oral and genital ulcers.

A

Bechet’s Disease

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9
Q

Rheumatoid factor antibodies are directed against which antigenic component?

A

The Fc portion of immunoglobulin G

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10
Q

Triad for Lofgren’s Syndrome

A
  • Erythema nodosum
  • Bilateral hilar lymphadenopathy
  • Polyarthritis/arthralgia – most commonly affecting the ankles
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11
Q

Risk Factors for poor outcome with scleroderma renal crisis

A

Male, Age >55yrs, Creatinine >300 at diagnosis

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12
Q

XR Findings for RA

A 
LOSE: 
Loss of Joint Space
Osteopenia 
Soft Tissue Swelling
Erosions
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13
Q

XR Findings for OA

A 
LOSS: 
Loss of Joint Space 
Osteophytes 
Sclerosis 
Subchrondral Cysts
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14
Q

Condition associated with double contour sign on USS

A

Gout
Double contour sign:
A hyperechoic linear density overlying the surface of joint cartilage (urate deposition over hyaline cartilage)

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15
Q

Which structures is pain generated through in OA

A

Subchondral Bone and ligamentous insertions. Not the cartilage as it is aneural.

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16
Q

XR Changes in Gout

A

Soft tissue swelling
Eccentric opacities (tophi)
Juxta-articular erosions (“punched out”, sclerotic margins, overhanging edges)

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17
Q

Diagnosis of Gout

A

Urate crystals on aspiration

-Yellow, negative birefringent, needle/rod shaped crystals

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18
Q

MOA of Colchicine

A

Inhibits neutrophil migration, chemotaxis, adhesion and phagocytosis in inflamed tissue

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19
Q

Side effects of colchicine

A

Diarrhea, N+V, neuromyopathy (especially in renal impairment)

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20
Q

MOA and Contraindications for probenecid

A

Uricosuric agent - prevents reabsorption of uric acid in renal tubules

Contraindicated in reduced renal function and Hx of renal calculi

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21
Q

Target Uric Acid levels

with and without tophi

A

no tophi: <0.36 mmol/L

Tophi <0.30 mmol/L

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22
Q

Interaction between allopurinol and AZA

A

Allopurinol reduces metabolism of azathioprine and mercaptopurine, increasing the risk of severe bone marrow toxicity

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23
Q

HLA type associated with Allopurinol hypersensitivity

A

HLA-B*5801

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24
Q

Side effects of Febuxostat

A

Diarrhea, renal impairment, angioedema, transaminitis/hepatotoxicity

Increased risk of CVS mortality compared to allopurinol

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25
MOA of uricase and indication
Pegylated uricase; catalyses oxidation of uric acid to allantoin (which is 10x more soluble, thus improving excretion) Current indication: Tumor lysis syndrome (rasburicase), but can be used in the short term for those intolerant of conventional gout therapy
26
Indications to commence urate lowering therapy
Hyperuricemia + Gouty arthritis plus: - Tophi - Erosions on XR - >2 attacks/year - urate nephropathy or renal insufficiency - Urate calculi
27
Features of Sacro-iliitis on MRI
- Bone marrow oedema (active inflammation) - Erosions (can be detected earlier than XR) - Synovitis, enthesitis
28
HLA Gene associated with RA
HLA DRB1*0404 | -Associated with production of anti-CCP antibodies
29
Felty's Syndrome Triad
Chronic arthritis + neutropenia + splenomegaly
30
Features of RA associated with positive RF
- More severe joint involvement - Radiographic progression - Extra articular features: Rheumatoid nodules, ILD, vasculitis
31
Two causes apart from RA for very high RF titre
1. Cryoglobulinemia | 2. Primary Sjogren's
32
6 Poor prognostic markers for RA
1. Early erosions on imaging (worst marker) 2. Sustained high levels of inflammation 3. RhF and/or Anti CCP titre 4. Smoking 5. HLA=DRB1*04 homozygosity (shared epitope) 6. Extraarticular features
33
Treatment of choice for Palindromic Rheumatism
HCQ | -May reduce risk of progression to RA
34
What is the cause of erosions in RA
Osteoclast activation via RANK L leads to erosions
35
Side effects of MTX
Nausea, oral ulcers, hair loss, hepatotoxicity, pneumonitis/ILD
36
Side effects of SSZ
GI symptoms, Uncommon: -agranulocytosis, aplastic anaemia, haemolytic anaemia
37
Side effects of Leflunomide
Diarrhea, Peripheral neuropathy, hepatotoxicity
38
Management for patient planning for pregnancy on Leflunomide
Give Cholesytramine to enhance excretion of LEF as it is teratogenic and has extensive enterohepatic recirculation (long half life)
39
Side effects of HCQ
Rash,GI symptoms, skin pigmentation, maculopathy
40
TNF inhibitor Safety Concerns/Adverse effects
- Serious infection - Latent TB activation - Risk of Skin Cancers - Demyelinating disease (Avoid in MS) - Precipitation of CCF in patients with known CCF NYHA Class II-III - Lupus flare - Psoriasis
41
What is the risk of infection with abetacept compared to TNF inhibitors?
Abetacept has a lower risk of serious infection than TNFi. Preferred agent for RA patients with high risk of serious infections
42
Rituximab Safety Concerns/Adverse effects
- Infusion reactions ++ - Serious infection (PJP, Hep B activation) - PML
43
Tocilizumab side effects
- LFT derrangement - Neutropenia - Hyperlipidaemia (CVS risk not increased) - Intestinal perforation (Avoid in diverticulosis)
44
Tofacitinib/Baracitinib side effects
- Shingles++ - Thrombosis (Higher risk with baracitinib - JAK2 specific) - LFT derrangement - Neutropenia - Hyperlipidaemia - Intestinal perforation
45
Preferred biologic for RA in patient with history of Lymphoma
Rituximab
46
Preferred Biologic for RA in pregnant patients
TNFi | Particularly Certolizumab does not cross placenta
47
Preferred biologic for RA in patient's with Hx of treated malignancy (not lymphoma)
TNFi
48
Duration needed off of a biologic DMARD prior to receiving a live vaccine
4 weeks | -Then wait 4 weeks post vaccine to resume biologic
49
Management of MTX perioperatively
W/H for one week prior to surgery (risk of toxicity if patient has AKI post op)
50
Management of biologic DMARDS perioperatively
W/H for one treatment cycle and resume 2 weeks post op
51
RA -DMARDs that are not safe in pregnancy
MTX LEF - ensure washout Unknown risk, so avoid: - Non TNF biologics - JAK inhibitors
52
When should TNFi be ceased during the course of pregnancy
30-32 weeks -To avoid increased passage of drugs across placenta (Only Certolizumab is safe to continue - peglyated and does not have Fc portion, so does not cross placenta)
53
What needs to be avoided in infants exposed to TNF inhibitors in utero?
-Need to avoid live vaccines for first 6 months
54
Top 3 Neuropsychiatric disorders in SLE (in order)
1. Cognitive dysfunction 2. Headache 3. Mood disorder
55
Frequency of eye examinations whilst on HCQ
Baseline examination within first year of commencing HCQ and then 5 yearly - earlier if high risk
56
Indications for Renal Bx in SLE
1. Increased Creatinine without alternative cause 2. Proteinuria >/= 1.0 g/24hr 3. Two tests showing either Proteinuira >/= 0.5g/24hr and haematuria or cellular casts
57
Target Level of proteinuria in SLE
Improved long term outcome with <0.7-0.8g/day
58
Risk factors for SLE flare during pregnancy
- Active disease in 6 months prior to conception - Hx of lupus nephritis - Discontinuation of HCQ
59
Name the two pathophysiology pathways in GCA and the role for steroids in them
IL-17/Th17 T cell pathway (steroid responsive) INF-y/Th1 T cell pathway (Less responsive to steroids)
60
GCA Histo
Panarteritis - lymphocytes, histiocytes, and plasma cells Giant cell granulomas (not always present) Disruption of internal elastic lamina Patchy and skip lesions
61
Colour doppler USS findings for GCA
Hypoechoic wall thickening (Halo sign)
62
MOA and indication for milnacipran
Dual 5HT and NA reuptake inhibitor | -Only drug TGA approved for fibromyalgia in Australia
63
Histology for dermatomyositis
Perifasicular mononuclear cells and perifasicular atrophy
64
Histology for polymyositis
Lymphocytes invade a myofibre
65
Histology for Inclusion body myositis
Vacuoles rimmed with basophilic granules
66
Histology for immune mediated necrotising myositis
muscle fibre necrosis with sparse inflammatory infiltrate
67
Upadacitinib
Selective JAK1 inhibitor for RA
68
Which biologic is superior to MTX
Tocilizumab is superior to MTX | TNFs are not superior to MTX alone

Basic Physician's Training Monash (16 decks)

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