Rheumatology Flashcards
What are some drugs responsible for drug induced lupus?
Most common:
- Procainamide
- Hydralazine
Less common causes
- Isoniazid
- Minocycline
- Phenytoin
- Chlorpromazine
Disease remits once offending drug is stopped.
Antibody associated with drug induced lupus?
Anti-histone antibodies (80-90%)
What is the BNF advice regarding methotrexate and pregnancy?
Patients using methotrexate require effective contraception during and for at least 6 months after stopping treatment in men or women
- Avoid prescribing trimethoprim or co-trimoxazole concurrently - increases risk of marrow aplasia
Antibody associated with rheumatoid arthritis?
Anti-cyclic citrullinated peptide (anti-CCP) antibody are highly specific for rheumatoid arthritis (98%)
Antibody associated with antiphospholipid sydrome?
Anti-Cardiolipin antibody
What is Felty’s syndrome?
Felty’s syndrome is a condition characterized by a triad of splenomegaly and neutropenia in a patient with rheumatoid arthritis. Hypersplenism results in destruction of blood cells which classically results in neutropenia but can also cause pancytopenia.
(RA + Splenomegaly + neutropenia)
Perinuclear antineutrophil cytoplasmic antibodies (pANCA) are most strongly associated with which condition?
pANCA - Churg-Strauss syndrome and primary sclerosing cholangitis
Cytoplasmic antineutrophil cytoplasmic antibodies (cANCA) are most strongly associated with which condition?
cANCA - Granulomatosis with polyangiitis (Wegener’s granulomatosis)
How is Schober’s test performed?
Schober’s test <5cm is suggestive of ankylosing spondylitis. This is an indication of reduced lumbar flexion.
Schober’s test is performed by identifying L5, and then marking 10cm above and 5cm below this point whilst the patient is stood upright. The patient is then asked to bend forwards to touch their toes whilst keeping their knees straight. If the distance between the points does not increase by 5cm (or the distance between the points originally marked is not more than 20cm in total), then it can be said that there is reduced flexion of the lumbar spine, which is a sign of ankylosing spondylitis.
Features of polymyalgia rheumatica?
PMR is a relatively common condition seen in older people characterised by muscle stiffness and raised inflammatory markers. Frequently occur with temporal arteritis.
- typically patient > 60 years old
- usually rapid onset (e.g. < 1 month)
- Aching, tenderness, morning stiffness in shoulder, hips and proximal limb muscles (arms and thighs)
Weakness is not considered a symptom of polymyalgia rheumatica! Muscle strength is normal! - also mild polyarthralgia, lethargy, depression, low-grade fever, anorexia, night sweats
raised inflammatory markers e.g. ESR > 40 mm/hr
note creatine kinase and EMG normal
Tx: Prednisolone e.g. 15mg/od
patients typically respond dramatically to steroids, failure to do so should prompt consideration of an alternative diagnosis
What are the clinical uses of bisphosphonates?
- Prevention and treatment of osteoporosis
- Hypercalcaemia
- Paget’s disease
- Pain from bone metatases
What would you advice patients on how to take bisphosphonates?
Tablets should be swallowed whole with plenty of water while sitting or standing; to be given on an empty stomach at least 30 minutes before breakfast (or another oral medication); patient should stand or sit upright for at least 30 minutes after taking tablet.
Plenty of water is to minimize the risk of the tablet getting stuck in the oesophagus. The reason for taking the medication while fasting and waiting one half-hour until eating or drinking is that bioavailability may be seriously impaired by ingestion with liquids other than plain water, such as mineral water, coffee, or juice; by retained gastric contents, as with insufficient fasting time or gastroparesis; or by eating or drinking too soon afterwards.
Patients should remain upright (sitting or standing) for at least 30 minutes after administration to minimize the risk of reflux.
What are the adverse effects of bisphosphonates?
- Oesophageal reactions: oesophagitis, oesophageal ulcers (especially alendronate)
- Osteonecrosis of the jaw
- Iincreased risk of atypical stress fractures of the proximal femoral shaft in patients taking alendronate
- Acute phase response: fever, myalgia and arthralgia may occur following administration
- Hypocalcaemia: due to reduced calcium efflux from bone. Usually clinically unimportant
What will you see in joint aspiration in pseudogout (calcium pyrophosphate deposition)?
Weakly-positively birefringent rhomboid-shaped crystals
What are the features of osteomalacia?
Osteomalacia is a disease characterized by the softening of the bones caused by impaired bone metabolism most commonly due to Vitamin D deficiency or calcium, phosphate deficiency. The impairment of bone metabolism causes inadequate bone mineralization.
- Osteomalacia in children is known as rickets
- Vitamin D deficiency e.g. malabsorption, lack of sunlight, diet
- renal failure
- drug induced e.g. anticonvulsants
- liver disease, e.g. cirrhosis
Sx: bone pain, fractures, muscle tenderness, proximal myopathy
Ix:
low 25 (OH) vitamin D
raised alkaline phosphatase
low calcium, phosphate
Tx: Calcium with vitamin D supplementation
Allergic contact dermatitis is an example of which hypersensitivity?
Type IV hypersensitivity reaction (Delayed)
First line pharmacological management of Raynaud’s disease?
Calcium channel blockers e.g. nifedipine
Which antibody is most specific for diffuse cutaneous systemic sclerosis?
Anti-Scl-70 (anti-topoisomerase) antibodies are the most specific test for diffuse cutaneous systemic sclerosis
Findings on osteoarthritis x-ray?
Loss of joint space
Osteophytes
Subarticular sclerosis
Subchondral cysts
Findings on rheumatoid arthritis x-ray?
Loss of joint space
Erosions (joint deformity)
Soft bones (osteopenia)
Soft tissue swelling
Symptoms of Behcet’s syndrome?
classically: 1) oral ulcers 2) genital ulcers 3) anterior uveitis
- thrombophlebitis and deep vein thrombosis
- arthritis
- neurological involvement (e.g. aseptic meningitis)
GI: abdo pain, diarrhoea, colitis - erythema nodosum
Should allopurinol be stopped during an acute attack of gout in a patient who is already established on treatment?
Patients suffering gout who are already established on allopurinol should continue this during an acute attack. Therefore stopping allopurinol is incorrect.
Colchicine is a good option in the acute treatment of gout. Oral steroids can be used if patients cannot tolerate colchicine or NSAIDs, but allopurinol should be continued.
What is the management for an acute episdoe of gout?
Acute management:
- NSAIDs or colchicine are first-line.
- The maximum dose of NSAID should be prescribed until 1-2 days after the symptoms have settled. Gastroprotection (e.g. a proton pump inhibitor) may also be indicated.
- Colchicine has a slower onset of action. The main side-effect is diarrhoea.
- Oral steroids may be considered if NSAIDs and colchicine are contraindicated. A dose of prednisolone 15mg/day is usually used.
- Another option is intra-articular steroid injection
- If the patient is already taking allopurinol it should be continued
What is the drug of choice for prophylaxis of acute attacks of gout?
Offer urate-lowering therapy to all patients after their first attack of gout.
- Allopurinol is first-line
- It has traditionally been taught that urate-lowering therapy should not be started until 2 weeks after an acute attack, as starting too early may precipitate a further attack. BSR updated their guidelines. They still support a delay in starting urate-lowering therapy because it is better for a patient to make long-term drug decisions whilst not in pain.
- Colchicine cover should be considered when starting allopurinol. NSAIDs can be used if colchicine cannot be tolerated. The BSR guidelines suggest this may need to be continued for 6 months
2. The second-line agent when allopurinol is not tolerated or ineffective is febuxostat (also a xanthine oxidase inhibitor)
