Rheumatology Flashcards by Nicole Herberger

When is the peak incidence of rheumatoid arthritis and is it more common in males or females?

Within fourth and fifth decades

2.5 times more common in females than males

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How long must symptoms be present to diagnose RA?

At least 6 weeks

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Key features of RA?

Inflammatory synovitis
Symmetrical and polyarticular
Nodules

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This is palpable/touchable synovial swelling and morning stiffness over an hour with fatigue.

Inflammatory synovitis

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RA typically affects what joints?

Wrists, MCP, and PIP joints

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What joints does RA typically spare?

DIPs, thoracolumbar spine, and IPs of the toes

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These are subcutaneous or periosteal at pressure points (especially along where people lean on their arms)

Nodules

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What serological markers are sent for RA?

Rheumatoid factor

Anti-cyclic citrullinated peptide antibody (anti-CCP)

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What serological marker is more specific for RA?

Anti-CCP

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If both RF and anti-CCP are positive then:

There is a higher correlation with erosive disease in RA.

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What in x-ray is also a positive sign of RA?

Marginal erosions and joint space narrowing

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Pathogenesis of RA?

Synovial fluid is overproduced and can cause pain/inflammation (like oil in a car).

Pannus: old, thickened synovial fluid that eats away at cartilage.

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Early erosion in RA leads to:

More advanced disease

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Possible systemic manifestations of RA?

Fatigue
Raynaud’s phenomenon (cold hands due to thinning blood vessels)
Dry eyes, dry mouth ( secondary Sjögren’s syndrome to RA)
Interstitial lung disease
Pleuritis or pericarditis
Vasculitis

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RA treatment principles:

Diagnose and refer to rheumatology ASAP
When damage begins early- start aggressive treatment early
Monitor for adverse effects at least every 2 months

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What medication is the gold standard in RA treatment?

Methotrexate

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Main concerns with methotrexate?

Hepatotoxic it and marrow suppression

-checkup at least every 8 weeks, but every 2 to 3 weeks at first

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Tumor necrosis factor inhibitors are used in RA for patients:

With inadequate response to methotrexate.

Before starting this try plaquenil, azathioprine, or sulfasalazine in combo with methotrexate.

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If patient has bone erosion in RA what medication is needed?

TNF inhibitors due to significant reduction in radiographic progression compared to placebo/methotrexate.

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Psoriatic arthritis clinical presentation:

Sausage digits and tenosynovitis 
Asymmetric oligoarthritis, especially DIPs 
Symmetric poly arthritis 
Spondylitis 
Arthritis mutilans 
Seronegative 
15-30 percent of psoriasis 
Associated with nail pitting and extensive skin disease

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Pharm management in psoriatic arthritis:

NSAIDs, steroid injections
Methotrexate (helps skin and joints)
Anti-TNF agents

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Polymyalgia rheumatica clinical features:

Age at least 50 usually over 70
Acute onset of pain lasting weeks in two or more axial areas including neck, shoulders, and pelvic girdle
Morning stiffness for an hour or more
Rapid response to low dose corticosteroids
Absence of another explanation of symptoms
ESR of 40 mm/hr or higher

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PMR is associated with what condition?

Giant cell arteritis

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This can cause visual changes, jaw pain, and scalp tenderness and is considered an emergency. Immediate high-dose steroids are required to prevent blindness.

Giant cell arteritis

PMR management:

Low-dose prednisone tapered to lowest dose for at least a year. Example: Begin with 20mg for 2 months Decrease by 5 mg every month until patient reaches 5 mg/day and then continue with 5 mg/day for remainder of a full year. Then decrease by 1mg every month until complete

When to use methotrexate with PMR?

Use if patient fails 2 attempts to taper prednisone. | Increase prednisone to the lowest effective dose and then add methotrexate.

This is a multi system disease that affects many organs. It has a constellation of diverse signs and symptoms that change over time.

Systemic lupus erythematous (SLE)

Constitutional symptoms of SLE:

Fatigue, fever, and weight loss

Demographic characteristics of SLE?

Overwhelming female predominance Typical onset during reproductive years Strong minority representation

SLE triggers?

``` Recent sun exposure Emotional stress Infection Certain drugs (sulfonamides, hydralazine) Surgery ```

SLE criteria?

Must meet 4: Mucocutaneous- Malar rash, discoid lesions, photosensitivity, oral ulcers Symptomatic organs: arthritis, serositis, neuropsychiatric, renal Labs: ANA, hematologic (lymphopenia, leukopenia, hemolytic anemia, thrombocytopenia), immunologic (anti-ds-DNA, anti-smith, antiphospholipid antibodies), nephrtitis (RBC casts, proteinuria)

What system is most commonly affected in SLE?

Cutaneous system

3 most common types of skin lesions in SLE?

Acute Subacute Discoid (chronic)

These types of lesions with SLE present as a butterfly rash, are erythematous and edematous, and are seen on chin and forehead, not nasolabial folds.

Acute lesions

Which type of lesions are strongly associated with active systemic lupus?

Acute

These types of lesions in SLE primarily affect Caucasian females and are symmetric, widespread, superficial, non scarring, and typically seen on sun exposed skin.

Subacute lesions

These types of lesions of SLE are seen typically on face, scalp, pinnae, behind the ears, and neck. They are seen in non-sun-exposed areas, can be exist as part of systemic disease or in isolation, and present with central atrophic scarring with active indurated erythema at periphery.

Discoid (chronic)

Mucocutaneous manifestations of lupus?

Alopecia, mucosal lesions, and vasculitis.

Important areas to inspect with SLE?

``` Scalp Pinnae Behind ears Palate Finger tips Palms ```

Musculoskeletal symptoms of SLE?

Painful joints with synovitis, erythema, or decreased ROM. Is generally symmetrical unlike RA can be brief or persistent.

What organ is the signature organ affected by SLE?

Kidneys

Lupus nephritis has been shown to:

Lead to a bad outcome

What lead to a diagnosis of renal disease in SLE?

Proteinuria | *urinalysis is key

Nervous system symptoms of SLE?

Psychiatric- mood disorders, anxiety, psychosis Cognitive- attention deficit, lack of concentration, impaired memory Neurological- acute confusional state, seizures, headaches Neuro deficits- visual defects, ptosis, nystagmus, vertigo, and peripheral neuropathy

What is the most frequent cardiac complication of SLE?

Pericarditis- substernal or pericardial pain aggravated by inspiration, coughing, swallowing lasting hours to days

Pulmonary complications of SLE?

Pneumonitis, pulmonary hemorrhage, pulmonary HTN, shrinking lung syndrome. Acute lupus pneumonitis- pleuritic chest pain, cough with hemoptysis and dyspnea

SLE treatment:

``` Sunblock NSAIDs Plaquenil- used for skin and joint manifestations Corticosteroids Immunosuppressants ```

What is the first fda approved treatment for lupus in 50 years?

Benlysta (benlimumad)- B-lymphocyte stimulator inhibitor

Presence of this antibody almost always indicates lupus?

Antibody to SM

What are complements?

Proteins that fortify immune system.

Inflammation from lupus severely ___ the amount of complements.

Reduces

Lupus may be active if C3 and C4 numbers are ___?

Low

Unlike RA, OA is:

Generally not considered an inflammatory disease and it affects individual joints without systemic effects.

What is the most common form of arthritis?

Risk factors of OA?

``` Age (75 % of people over 75 have OA) Female Obesity Hereditary Trauma Neuromuscular dysfunction Metabolic disorders ```

Symptoms and signs of OA?

``` Pain related to use Pain worsens throughout the day Minimal morning stiffness Decreased ROM Joint instability Bony enlargement Restricted movement Crepitus Variable swelling and/or instability ```

Joints commonly affected by OA?

``` Hands Feet Hips Knees Spine ```

Treatment of OA:

``` Routine exercise (essential) Patient education (essential) Weight loss PT Tylenol- 1st line up to 3g/day NSAIDs if no liver issues Intra-articular steroid injections Hyaluronate injection- viscous solution that helps relieve knee pain in some Surgical procedures- is all conventional therapies have been utilized ```