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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
Q

MOA of uricase and indication

A

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

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26
Q

Indications to commence urate lowering therapy

A

Hyperuricemia + Gouty arthritis plus:

  • Tophi
  • Erosions on XR
  • > 2 attacks/year
  • urate nephropathy or renal insufficiency
  • Urate calculi
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27
Q

Features of Sacro-iliitis on MRI

A
  • Bone marrow oedema (active inflammation)
  • Erosions (can be detected earlier than XR)
  • Synovitis, enthesitis
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28
Q

HLA Gene associated with RA

A

HLA DRB1*0404

-Associated with production of anti-CCP antibodies

29
Q

Felty’s Syndrome Triad

A

Chronic arthritis + neutropenia + splenomegaly

30
Q

Features of RA associated with positive RF

A
  • More severe joint involvement
  • Radiographic progression
  • Extra articular features: Rheumatoid nodules, ILD, vasculitis
31
Q

Two causes apart from RA for very high RF titre

A
  1. Cryoglobulinemia

2. Primary Sjogren’s

32
Q

6 Poor prognostic markers for RA

A
  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
Q

Treatment of choice for Palindromic Rheumatism

A

HCQ

-May reduce risk of progression to RA

34
Q

What is the cause of erosions in RA

A

Osteoclast activation via RANK L leads to erosions

35
Q

Side effects of MTX

A

Nausea, oral ulcers, hair loss, hepatotoxicity, pneumonitis/ILD

36
Q

Side effects of SSZ

A

GI symptoms,
Uncommon:
-agranulocytosis, aplastic anaemia, haemolytic anaemia

37
Q

Side effects of Leflunomide

A

Diarrhea, Peripheral neuropathy, hepatotoxicity

38
Q

Management for patient planning for pregnancy on Leflunomide

A

Give Cholesytramine to enhance excretion of LEF as it is teratogenic and has extensive enterohepatic recirculation (long half life)

39
Q

Side effects of HCQ

A

Rash,GI symptoms, skin pigmentation, maculopathy

40
Q

TNF inhibitor Safety Concerns/Adverse effects

A
  • 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
Q

What is the risk of infection with abetacept compared to TNF inhibitors?

A

Abetacept has a lower risk of serious infection than TNFi. Preferred agent for RA patients with high risk of serious infections

42
Q

Rituximab Safety Concerns/Adverse effects

A
  • Infusion reactions ++
  • Serious infection (PJP, Hep B activation)
  • PML
43
Q

Tocilizumab side effects

A
  • LFT derrangement
  • Neutropenia
  • Hyperlipidaemia (CVS risk not increased)
  • Intestinal perforation (Avoid in diverticulosis)
44
Q

Tofacitinib/Baracitinib side effects

A
  • Shingles++
  • Thrombosis (Higher risk with baracitinib - JAK2 specific)
  • LFT derrangement
  • Neutropenia
  • Hyperlipidaemia
  • Intestinal perforation
45
Q

Preferred biologic for RA in patient with history of Lymphoma

A

Rituximab

46
Q

Preferred Biologic for RA in pregnant patients

A

TNFi

Particularly Certolizumab does not cross placenta

47
Q

Preferred biologic for RA in patient’s with Hx of treated malignancy (not lymphoma)

A

TNFi

48
Q

Duration needed off of a biologic DMARD prior to receiving a live vaccine

A

4 weeks

-Then wait 4 weeks post vaccine to resume biologic

49
Q

Management of MTX perioperatively

A

W/H for one week prior to surgery (risk of toxicity if patient has AKI post op)

50
Q

Management of biologic DMARDS perioperatively

A

W/H for one treatment cycle and resume 2 weeks post op

51
Q

RA -DMARDs that are not safe in pregnancy

A

MTX
LEF - ensure washout

Unknown risk, so avoid:

  • Non TNF biologics
  • JAK inhibitors
52
Q

When should TNFi be ceased during the course of pregnancy

A

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
Q

What needs to be avoided in infants exposed to TNF inhibitors in utero?

A

-Need to avoid live vaccines for first 6 months

54
Q

Top 3 Neuropsychiatric disorders in SLE (in order)

A
  1. Cognitive dysfunction
  2. Headache
  3. Mood disorder
55
Q

Frequency of eye examinations whilst on HCQ

A

Baseline examination within first year of commencing HCQ and then 5 yearly - earlier if high risk

56
Q

Indications for Renal Bx in SLE

A
  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
Q

Target Level of proteinuria in SLE

A

Improved long term outcome with <0.7-0.8g/day

58
Q

Risk factors for SLE flare during pregnancy

A
  • Active disease in 6 months prior to conception
  • Hx of lupus nephritis
  • Discontinuation of HCQ
59
Q

Name the two pathophysiology pathways in GCA and the role for steroids in them

A

IL-17/Th17 T cell pathway (steroid responsive)

INF-y/Th1 T cell pathway (Less responsive to steroids)

60
Q

GCA Histo

A

Panarteritis - lymphocytes, histiocytes, and plasma cells
Giant cell granulomas (not always present)
Disruption of internal elastic lamina
Patchy and skip lesions

61
Q

Colour doppler USS findings for GCA

A

Hypoechoic wall thickening (Halo sign)

62
Q

MOA and indication for milnacipran

A

Dual 5HT and NA reuptake inhibitor

-Only drug TGA approved for fibromyalgia in Australia

63
Q

Histology for dermatomyositis

A

Perifasicular mononuclear cells and perifasicular atrophy

64
Q

Histology for polymyositis

A

Lymphocytes invade a myofibre

65
Q

Histology for Inclusion body myositis

A

Vacuoles rimmed with basophilic granules

66
Q

Histology for immune mediated necrotising myositis

A

muscle fibre necrosis with sparse inflammatory infiltrate

67
Q

Upadacitinib

A

Selective JAK1 inhibitor for RA

68
Q

Which biologic is superior to MTX

A

Tocilizumab is superior to MTX

TNFs are not superior to MTX alone

Basic Physician's Training Monash (16 decks)

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