Rheumatology

Question 1

Name four lung manifestations of rheumatoid arthritis.

Answer 1

ILD (NSIP pattern), pleural effusion, pulmonary nodules, bronchiolitis obliterans.

Question 2

What are two seronegative RA diseases and how do you treat?

Answer 2

1. RA of the elderly (PMR with synovitis): treat as RA.
2. Remitting seronegative symmetrical synovitis with pitting edema (men, swollen hands): low dose steroids, NSAIDs, hydroxychloroquine.

Question 3

How long should you treat latent TB before starting biologic therapy?

Answer 3

At least 1 month.

Question 4

Which vaccines are recommended with methotrexate?

Answer 4

Influenza (can hold methotrexate for two weeks after vaccine to improve immunogenicity), pneumococcal, hepB, herpes zoster.

Question 5

Six populations where biologics are controversial.

Answer 5

NYHA 3+ CHF, active hepatitis (treat first), prior LPL (rituximab), prior solid cancer, prior skin cancer (DMARDs), prior serious infection (tocilizumab)

Question 6

Which medications do you discontinue before pregnancy?

Answer 6

Methotrexate - 3 months, leflunamide - 2 years

Question 7

What is the time frame for reactive arthritis?

Answer 7

days to 4 weeks post GI/GU infection

Question 8

How do you treat reactive arthritis?

Answer 8

NSAIDs, intra-articular steroids, DMARDs for recurrent/ chronic disease. Rarely TNFa and never antibiotics.

Question 9

What are the indications for urate lowering therapy?

Answer 9

> 2 attacks per year, tophi, gouty arthropathy, CKD 3+, nephrolithiasis.

Question 10

What were the results of the CARES trial?

Answer 10

Increased cardxiovascular and all-cause mortality with febuxostat compared to allopurinol.

Question 11

What are the components of ENA?

Answer 11

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).

Question 12

What are the major treatments for class III/IV lupus nephritis flare and maintenance who should get which?

Answer 12

Flare: Pulse steroids and Cyclophosphamide or MMF (better results for African-American and Hispanic patients) or azathioprine for pregnant.
Maintenance: MMF or azathioprine.

Question 13

Which APLA antibodies are safe to take on anticoagulants?

Answer 13

Anticardiolipin and anti-B2 glycoprotein. Lupus anticoagulant can be taken on warfarin or DOAC.

Question 14

Which drugs cause drug-induced lupus?

Answer 14

Hydralazine, procainamide, TNFa, isoniazid.

Question 15

How do you treat Libman-Sacks endocarditis?

Answer 15

Steroids and anticoagulation.

Question 16

What are some associations with diffuse scleroderma?

Answer 16

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

Question 17

What are some associations with limited cutaneous scleroderma?

Answer 17

CREST syndrome, distal to elbows and knees with face involved, anti-centromere (60%), pulmonary hypertension (5%)

Question 18

What are myositis-specific antibodies?

Answer 18

1. Anti-synthetase syndrome (anti-Jo1 positive) with acute onset, constitutional symptoms, ILD, mechanics hands, skin ulcers, arthritis, Reynaud’s, negatively associated with malignancy.
2. Anti-Mi2 carries favourable prognosis.
3. Anti-NXP2 and anti-TIF1-gamma associated with malignancy.

Question 19

Name two non-classic inflammatory myositides.

Answer 19

Inclusion body (men, distal, dypsphagia), necrotising autoimmune (severe, high CK, positive HMG CoA reductase antibody, often paraneoplastic).

Question 20

What are 4 xray findings of osteoarthritis.

Answer 20

Joint space narrowing, osteophytes, subchondral sclerosis, subchondral cysts.

Question 21

How do you manage methotrexate-induced liver enzyme elevation?

Answer 21

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