Rheumatology Flashcards
Name four lung manifestations of rheumatoid arthritis.
ILD (NSIP pattern), pleural effusion, pulmonary nodules, bronchiolitis obliterans.
What are two seronegative RA diseases and how do you treat?
- RA of the elderly (PMR with synovitis): treat as RA.
- Remitting seronegative symmetrical synovitis with pitting edema (men, swollen hands): low dose steroids, NSAIDs, hydroxychloroquine.
How long should you treat latent TB before starting biologic therapy?
At least 1 month.
Which vaccines are recommended with methotrexate?
Influenza (can hold methotrexate for two weeks after vaccine to improve immunogenicity), pneumococcal, hepB, herpes zoster.
Six populations where biologics are controversial.
NYHA 3+ CHF, active hepatitis (treat first), prior LPL (rituximab), prior solid cancer, prior skin cancer (DMARDs), prior serious infection (tocilizumab)
Which medications do you discontinue before pregnancy?
Methotrexate - 3 months, leflunamide - 2 years
What is the time frame for reactive arthritis?
days to 4 weeks post GI/GU infection
How do you treat reactive arthritis?
NSAIDs, intra-articular steroids, DMARDs for recurrent/ chronic disease. Rarely TNFa and never antibiotics.
What are the indications for urate lowering therapy?
> 2 attacks per year, tophi, gouty arthropathy, CKD 3+, nephrolithiasis.
What were the results of the CARES trial?
Increased cardxiovascular and all-cause mortality with febuxostat compared to allopurinol.
What are the components of ENA?
Anti-smith (lupus 30-40%), anti-histone (lupus 50-70%, DIL), anti-RNP (lupus 30-40%, MCTD), anti-Ro (Sjogren’s, congenital heart block), anti-la (Sjogren’s).
What are the major treatments for class III/IV lupus nephritis flare and maintenance who should get which?
Flare: Pulse steroids and Cyclophosphamide or MMF (better results for African-American and Hispanic patients) or azathioprine for pregnant.
Maintenance: MMF or azathioprine.
Which APLA antibodies are safe to take on anticoagulants?
Anticardiolipin and anti-B2 glycoprotein. Lupus anticoagulant can be taken on warfarin or DOAC.
Which drugs cause drug-induced lupus?
Hydralazine, procainamide, TNFa, isoniazid.
How do you treat Libman-Sacks endocarditis?
Steroids and anticoagulation.
What are some associations with diffuse scleroderma?
Positive anti-Scl/topoisomerase I, distal and proximal extremities with face and trunk, ILD, scleroderma renal crisis (10-20%, early disease, increases with prednisone), gastric antral vascular ectasia
What are some associations with limited cutaneous scleroderma?
CREST syndrome, distal to elbows and knees with face involved, anti-centromere (60%), pulmonary hypertension (5%)
What are myositis-specific antibodies?
- Anti-synthetase syndrome (anti-Jo1 positive) with acute onset, constitutional symptoms, ILD, mechanics hands, skin ulcers, arthritis, Reynaud’s, negatively associated with malignancy.
- Anti-Mi2 carries favourable prognosis.
- Anti-NXP2 and anti-TIF1-gamma associated with malignancy.
Name two non-classic inflammatory myositides.
Inclusion body (men, distal, dypsphagia), necrotising autoimmune (severe, high CK, positive HMG CoA reductase antibody, often paraneoplastic).
What are 4 xray findings of osteoarthritis.
Joint space narrowing, osteophytes, subchondral sclerosis, subchondral cysts.
How do you manage methotrexate-induced liver enzyme elevation?
AST > ULN – reduce MTX dose by 2.5 mg → repeat LFTs q2w until resolved
AST > 2x ULN – reduce MTX dose by 50% → repeat LFTs q2w until resolved
AST > 2x ULN for 2 consecutive measurements – hold MTX → repeat LFTs q2w until resolved
Liver Biopsy if 5/9 or 6/12 ↑ AST, persistent ↓ albumin, >1.5g of MTX or risk of liver damage
