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Medicine > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

What are some drugs responsible for drug induced lupus?

A

Most common:

  • Procainamide
  • Hydralazine

Less common causes

  • Isoniazid
  • Minocycline
  • Phenytoin
  • Chlorpromazine

Disease remits once offending drug is stopped.

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2
Q

Antibody associated with drug induced lupus?

A

Anti-histone antibodies (80-90%)

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3
Q

What is the BNF advice regarding methotrexate and pregnancy?

A

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
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4
Q

Antibody associated with rheumatoid arthritis?

A

Anti-cyclic citrullinated peptide (anti-CCP) antibody are highly specific for rheumatoid arthritis (98%)

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5
Q

Antibody associated with antiphospholipid sydrome?

A

Anti-Cardiolipin antibody

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6
Q

What is Felty’s syndrome?

A

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)

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7
Q

Perinuclear antineutrophil cytoplasmic antibodies (pANCA) are most strongly associated with which condition?

A

pANCA - Churg-Strauss syndrome and primary sclerosing cholangitis

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8
Q

Cytoplasmic antineutrophil cytoplasmic antibodies (cANCA) are most strongly associated with which condition?

A

cANCA - Granulomatosis with polyangiitis (Wegener’s granulomatosis)

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9
Q

How is Schober’s test performed?

A

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.

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10
Q

Features of polymyalgia rheumatica?

A

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

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11
Q

What are the clinical uses of bisphosphonates?

A
  • Prevention and treatment of osteoporosis
  • Hypercalcaemia
  • Paget’s disease
  • Pain from bone metatases
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12
Q

What would you advice patients on how to take bisphosphonates?

A

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.

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13
Q

What are the adverse effects of bisphosphonates?

A
  • 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
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14
Q

What will you see in joint aspiration in pseudogout (calcium pyrophosphate deposition)?

A

Weakly-positively birefringent rhomboid-shaped crystals

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15
Q

What are the features of osteomalacia?

A

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

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16
Q

Allergic contact dermatitis is an example of which hypersensitivity?

A

Type IV hypersensitivity reaction (Delayed)

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17
Q

First line pharmacological management of Raynaud’s disease?

A

Calcium channel blockers e.g. nifedipine

18
Q

Which antibody is most specific for diffuse cutaneous systemic sclerosis?

A

Anti-Scl-70 (anti-topoisomerase) antibodies are the most specific test for diffuse cutaneous systemic sclerosis

19
Q

Findings on osteoarthritis x-ray?

A

Loss of joint space
Osteophytes
Subarticular sclerosis
Subchondral cysts

20
Q

Findings on rheumatoid arthritis x-ray?

A

Loss of joint space
Erosions (joint deformity)
Soft bones (osteopenia)
Soft tissue swelling

21
Q

Symptoms of Behcet’s syndrome?

A

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
22
Q

Should allopurinol be stopped during an acute attack of gout in a patient who is already established on treatment?

A

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.

23
Q

What is the management for an acute episdoe of gout?

A

Acute management:

  1. 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
24
Q

What is the drug of choice for prophylaxis of acute attacks of gout?

A

Offer urate-lowering therapy to all patients after their first attack of gout.

  1. 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)
25
Q

What are some lifestyle advice that can be offered to gout patients?

A

Lifestyle modifications:

  1. Reduce alcohol intake and avoid during an acute attack
  2. Lose weight if obese
  3. Avoid food high in purines e.g. Liver, kidneys, seafood, oily fish (mackerel, sardines) and yeast products
26
Q

What is the management for rheumatoid arthritis?

A

Initial therapy:
Recommended DMARD monotherapy +/- a short-course of bridging prednisolone. In the past dual DMARD therapy was advocated as the initial step.

Monitoring response to treatment:
NICE recommends using a combination of CRP and disease activity (using a composite score such as DAS28) to assess response to treatment.

  • Flares of RA are often managed with corticosteroids - oral or intramuscular

DMARDs:

  • Methotrexate is the most widely used DMARD. Monitoring of FBC & LFTs is essential due to the risk of myelosuppression and liver cirrhosis. Other important side-effects include pneumonitis.
  • Sulfasalazine
  • Leflunomide
  • Hydroxychloroquine
27
Q

What is the presentation for RA?

A

Typical features:

  • Swollen, painful joints in hands and feet
  • Stiffness worse in the morning
  • Gradually gets worse with larger joints becoming involved
  • Presentation usually insidiously develops over a few months
  • Positive ‘squeeze test’ - discomfort on squeezing across the metacarpal or metatarsal joints
  • Swan neck and boutonnière deformities are late features of rheumatoid arthritis and unlikely to be present in a recently diagnosed patient.
  • Acute onset with marked systemic disturbance.
28
Q

What is the management for Osteoarthritis?

A
  • All patients should be offered help with weight loss, given advice about local muscle strengthening exercises and general aerobic fitness.
  • Paracetamol and topical NSAIDs are first-line analgesics. Topical NSAIDs are indicated only for OA of the knee or hand.
  • Second-line treatment is oral NSAIDs/COX-2 inhibitors, opioids, capsaicin cream and intra-articular corticosteroids. A proton pump inhibitor should be co-prescribed with NSAIDs and COX-2 inhibitors. These drugs should be avoided if the patient takes aspirin.
  • Non-pharmacological treatment options include supports and braces, TENS and shock-absorbing insoles or shoes.
  • If conservative methods fail then refer for consideration of joint replacement.
29
Q

Autoantibody associated with Primary Sjogren’s syndrome?

A

Anti-Ro.

Primary Sjogren’s syndrome is an autoimmune disorder characterised by lymphocytic infiltration of the exocrine glands, particularly the salivary and lacrimal glands, leading to symptoms such as dry mouth (xerostomia) and dry eyes (keratoconjunctivitis sicca).

Anti-Ro (also known as SS-A) autoantibodies are found in approximately 60-70% of patients with primary Sjogren’s syndrome, making it the most associated autoantibody for this condition.

No tears RoLaing down their face (anti-Ro and anti-La).

30
Q

X-ray finding of pseudogout?

A

X-ray: Chondrocalcinosis
- In the knee this can be seen as linear calcifications of the meniscus and articular cartilage

31
Q

Side effect of Hydroxychloroquine?

A

Hydroxychloroquine is a drug not only used to prevent and treat malaria but now commonly part of treatment in conditions such as rheumatoid arthritis, SLE, and porphyria cutanea tarda.

Bull’s eye retinopathy.
baseline ophthalmological examination and annual screening is generally recommended.

Retinopathy which is associated with chronic use of hydroxychloroquine is a serious adverse effect which patients need to be aware of. The mechanism is uncertain but it can lead to visual loss which is permanent.

32
Q

What needs to be checked prior to starting Azathioprine?

A

check thiopurine methyltransferase deficiency (TPMT) before treatment.

33
Q

Mx for OA?

A
  1. Topical NSAIDs are first-line analgesics. Topical NSAIDs may be particualrly beneficial for patients with OA of the knee or hand.
  2. Second-line treatment is oral NSAIDs
    - a proton pump inhibitor should be co-prescribed with NSAIDs.
    NICE recommend we do not offer paracetamol or weak opioids, unless:
    - they are only used infrequently for short-term pain relief and
    - all other pharmacological treatments are contraindicated, not tolerated or ineffective
  • Glucosamine and strong opioids are not recommended
  • Intra-articular steroid injections may be tried if standard pharmacological treatment is ineffective
  • Patients should be aware that they only provide short-term relief (2-10 weeks)
  • If conservative methods fail then refer for consideration of joint replacement
34
Q

Features of anti-phospholipid syndrome?

A
  • Venous/arterial thrombosis
  • Recurrent miscarriages
  • Livedo reticularis
  • Other features: pre-eclampsia, pulmonary hypertension

Clots - veno/ arterial thrombus
L - livido reticularis
O - obstetric miscarriage
T - thrombocytopenia

-Anticardiolipin antibodies
- Lupus anticoagulant
- Thrombocytopenia
- Prolonged APTT

35
Q

Anti-Centromere antibodies?

A

Limited cutaneous systemic sclerosis (CREST Syndrome)

36
Q

Anti-Scl70 antibody?

A

Diffuse systemic sclerosis.

37
Q

Drug causes of gout?

A
  • Thiazide diuretics
  • Furosemide
  • Ciclosporin
  • Alcohol
  • Pyrazinamide
38
Q

Blood results for osteomalacia?

A
  • Low vitamin D levels
  • Low calcium,
  • Low phosphate
  • Raised ALP
  • Raised PTH
39
Q

Which medication patients are allergic to aspirin also cannot take?

A

Sulfasalazine.

Aminosalicylic acid compounds (e.g. mesalazine and sulfasalazine) are a cornerstone of treating ulcerative colitis. However, patients who are allergic to aspirin may also react to 5-aminosalicylic acid compounds as they share structural similarity.

40
Q

Mx for Raynaud’s?

A

First-line: calcium channel blockers e.g. Nifedipine

IV prostacyclin (epoprostenol) infusions: effects may last several weeks/months

41
Q
A

Medicine (21 decks)

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