Rheumatology Flashcards
How will you monitor this person on a biologic DMARD?
My considerations for patients on bDMARDS are
- infusion reactions
- increased risk of infection
- malignancy
- can cause demyelination / autoimmune phenomena
To monitor:
- will need to continue regular review of disease activity to monitor therapeutic effect
- ensure vaccinations are UTD and avoid live vaccines
- routine biochemical monitoring with FBE/UEC/LFT
- keep UTD with malignancy screening and skin checks
- if requiring a surgical procedure, will need to be withheld several weeks prior in conjunction with Rheum team
How will you monitor this person on Methotrexate?
Concerns are myelosuppression, hepatotoxicity and lung toxicity
- FBE / UEC / LFT every 3 months
- monitor for symptoms of above (SOB / infections)
How will you monitor this person on Leflunomide?
Concerns are GI upset, hepatotoxicity, HTN, ILD
Monitoring same as methotrexate =
- FBE / UEC / LFT every 3 months
- monitor for symptoms of above (SOB / infections / HTN)
How will you monitor this person on Azathioprine?
Concerns are GI upset, myelosuppression, infection, skin cancers
- FBE, skin checks
How will you monitor this person on Hydroxychloroquine?
Opthal review for retinal toxicity at baseline and then 5 year mark
How will you determine activity of SLE?
Clinically
- fatigue
- severity of current symptoms
- development of symptoms suggesting new organ manifestation
Biochemically
- low complement
- elevated dsDNA
- active urinary sediment
- cytopaenias
How will you manage this person previously on cyclophosphamide?
Concerns:
- Infertility -> counselling
- Bladder -> annual urinalysis + cytology indefinitely
Also causes increased risk of haem malignancies
Whilst on it -> high risk of infection / myelosuppression
How will you assess the activity of their inflammatory arthritis?
Clinically
- degree of morning stiffness / fatigue / change in functional capacity
- number of tender and swollen joints
- active synovitis
- development of extra-articular manifestations
Biochemically
- CRP / ESR
- albumin / plts
Radiologically
- XR to look for disease progression
What are main extra-articular manifestations of RA?
- Eyes-> epislceritis/uveitis/keratitis
- Sicca symptoms
- ILD
- Serositis
- Haematological -> cytopaenias / splenomegaly
- Cutaneous vasculitis + neuropathy
- Nodules
What would your approach to treating a flare of RA be?
In an acute flare:
- if one / few joints involved -> could consider local steroid injection
- if widespread -> initiating/increasing level of systemic steroid, to then wean when flare resolved
- if recurrent flares, then background DMARD therapy needs to be escalated in conjunction with Rheum
- > dose increase
- > decrease interval of dosing
What is a myositis ab panel?
CK U1RNP SRP Jo-1 MI-2 (can also do lupus / Sjogren's ab)
What are poor prognostic factors in RA?
Clinical = - high number of joints affected - extra-articular features - significant functional limitations Biochemical = - seropositivity - early erosions - high inflam markers
What is difference between AL / AA amyloidosis?
AL -> refers to ‘primary’ amyloidosis.
A complication of plasma cell dyscrasia with deposition of light chain fragments in organs
AA -> ‘secondary’, complicates chronic inflammatory diseases. It is fragments of an acute phase reactant serum amyloid A protein that is deposited
Can also have organ-specific amyloid, or dialysis-related
What are manifestations to ask about in AL amyloidosis?
- Mucocutaneous
- Renal -> nephrotic syndrome
- Neuro -> neuropathy
- Cardiac infiltration
- GIT -> haemorrhage / malabsorption
What are the main manifestations of sarcoidosis to ask about?
- Lung -> diffuse ILD, can have pulm HTN
- Eyes -> uveitis / plaques
- Cardiac
- Neuro -> nerve palsies
- Renal -> - Hypercalcaemia / hypercalciuria
- Skin -> erythema nodosum, rash, plaques
- Arthritis
- Endocrine infiltration
What are main manifestations of SSc?
- skin (sclerosis / Raynaud’s, calcinosis, telangectasias)
- sicca symptoms
- renal crisis (triggered by pred use)
- cardiac -> restrictive CM
- GIT -> oesohageal dysmotility, constipation, GI bleeding
- Lung -> ILD, pulm HTN
- MSK -> arthralgias, myositis
- Neuro -> neuropathy
How to differentiate between diffuse and limited SSc?
- Skin sclerosis does not extend beyond elbows in limited, not on trunk
- anti-centromere ANA pattern in limited
What are the features of MCTD?
Clinical
- overlap of SLE, SSc and PM
- swollen hands, arthritis
- Raynaud’s
- myositis
- pulm HTN
Biochemical
- Anti-U1RNP
How will you differentiate between RA and OA?
Pattern of stiffness -> morning / later
DIP involvement / Heberden’s nodes in OA
Type of swelling -> bony vs boggy
Ix -> XRs showing erosions/cysts; and elevated inflam markers in RA
What are extra-articular manifestations of spondyloarthropathies?
Eyes - uveitis
Skin - psoriasis, dactylitis
Enthesitis
Bowel - IBD
Gout Management Spiel
My approach to management will be
- rapid identification and Rx of flares
- Prevention of future attacks to avoid complications (e.g. renal, joint)
Prevention
- Lifestyle: addressing CVRFs, reducing triggers e.g. thiazides, substitute losartan, minimise ETOH and purine-rich foods
- Pharm:
-> utilising urate-lowering therapy with treat to target approach, with flare prophylaxis
1st line = allopurinol, then can add probenacid
2nd line = febuxostat (not in CVD)
I will ensure regular monitoring of uric acid levels and progress
