Rheumatology/autoimmune/arthritis/vasculitis/connective tissue Flashcards
Advice about imaging in diagnosing Knee OA?
(3)
Imaging is unnecessary with strong clinical suspicion
Can be ordered as part of an orthopaedic work up if planning surgical management
Radiographic changes for OA do no correlate well with severity of knee pain
Non pharmacological management of Osteoarthritis?
(8)
weight loss of 5-10%
Referral to a physiotherapist/EP for lower limb strength training
attend CBT for dealing with knee pain
Use of ice/heat packs
Manual therapy or massage
Participate in aquatherapy or hydrotherapy
can use taichi
consider referral to physio for a mobility aid
topical analgesic options for joint pain?
- NSAID like diclofenac 2% gel, applied over affected joint, up to 4 times a day as needed
- capsaicin 0.025% cream applied directly to the painful area, 3 to 4 times daily.
What is the diagnostic criteria for a GCA?
(5)
When three of the following are met
- Age > 50
- New onset localised headache
- Temporal artery tenderness or reduced temporal artery pulse
- ESR> 50
- Postive Temporal Artery Biopsy
What are the 2 key management steps for GCA?
- Urgent referral to an ophthalmologist for management to prevent blindness
- Commence Prednisolone 40-60mg, orally, daily usually for a minimum of 4 weeks
How do you confirm the diagnosis of Gout?
While you might suspect it clinically, an aspiration of joint fluid, tophi or bursa is technically required for diagnosis.
First line acute treatment for Gout?
(3)
Local steroid injection
Prednisolone 15-30mg daily for 3-5 days, taken orally
Higher dosing of NSAIDs, orally, until symptoms resolve.
Second line treatment for acute gout?
Colchicine 1mg orally, immediately, then 500micrograms 1 hour later, orally.
What are risk factors for gout that you can address in management?
(4)
- Diet. Lower purine rich foods are better. Also lower fructose. Search Gout diet.
- Lowering alcohol intake
- Smoking cessation
- Regular exercises 150minutes moderate intensity exercise a week.
What is the recommended gout prophylaxis and how do you adjust the dosing?
Allopurinol started at 50mg daily for 4 weeks, taken orally. And increase by 50mg every 2 weeks to achieve target urate level.
Target urate level is under 0.36 for non tophaceous gout and under 0.3 for tophaceous gout
Maximum dose is 900mg a day
Consider flare prophylaxis for up to 6 months
First line: colchicine 500micrograms, orally once or twice a day
Second line: NSAIDs
Third line: Prednisolone, 5mg orally, daily
What are early signs and symptoms of Rheumatoid arthritis?
(3)
early morning stiffness usually > 1 hour
symmetrical joint involvement
arthritis in the MCPs and PIPs
Initial investigations to order for RA?
(4)
FBC
Anti-CCP
RF
XRAYs of both hands to look for erosions
What is the most important step in management for RA, that a GP should do?
Refer to a rheumatologist to start DMARDs, or similar specialist
Reason is so that the inflammatory process can be aggressively targeted and can reduce long term disability and joint damage
What is the single most important lifestyle factor to address with RA?
What are other recommendations?
(3)
- STOP SMOKING
- Exercise- regular exercise. Low impact exercises like swimming or cycling if joints are sore. Partake in strength exercises to prevent muscle and bone density loss
- Diet- mediterranean diets
What are analgesic options for rheumatoid arthritis?
(4+1)
- paracetamol
- NAIDs
- Fish oil at least 2.7g of omega three, orally, daily. But can take 3 months to work
- Corticosteroids when other options fail
- Severe pain- for rheumatology to deal with
Non pharmacological pain management in RA?
(7)
TENS
Mindfulness, meditiation, relaxation
thermotherapy
CBT
Rest
splints/orthoses
Psychotherapy
3 psych related options
2 application related options
2 rest options
What are extra articular complications of RA?
(6 areas)
Cardiovascular - MI, Congestive heart failure
Pulmonary - ILD, bronchiectasis, bronchiolitis
GIT - hepatomegaly, cirrhosis, pancreatitis, amyloidosis, oesophageal dysmotility
Renal- Glomerulonephritis
Cancers- hodgkins and non-hodgkins lymphomas, lung cancer
Neurological- meningitis, anxiety, depression
Consumption of what products can increase the risk of gout developing in susceptible individuals?
(3)
Meat including seafood
Alcohol (beer and spirits)
Fructose sweetened drinks
Aspiration of an affected joint, bursa or tophi is the gold standard for Gout diagnosis. What other tests should you order?
(2)
- EUC for renal function as this is both a cause and consequence of Gout
- Serum uric acid to help titrate management- lifestyle and medication
Options for treatment of gout?
First line:
NSAIDs or Local Steroid injection or Prednisolone
Second: Colchicine
What dosing instructions of Prednisolone do you use in Gout versus PMR vs GCA?
Gout: 15-30mg, orally, daily for 3 - 5 days
PMR: prednisolone 15 mg orally, daily for 4 weeks; then reduce daily dose by 2.5 mg every 4 weeks to 10 mg daily; then reduce daily dose by 1 mg every 4 to 8 weeks to stop. Course should be over 12-18 months. Do not taper too quickly
GCA: prednis(ol)one 40 to 60 mg orally, daily (in two divided doses if necessary for symptom control) for a minimum of 4 weeks
What management would you implement to someone after their acute gout flare has settled?
- Regular Exercise
- Follow a Gout diet (low in purine foods)
- Advice about lowering alcohol
- Stop smoking
- Address other cardiovascular risk factors
What is flare prophylaxis in the context of treating gout?
What can you use?
For some reason when starting or uptitrating prophylactic medication to treat gout it increases the risk of a gout flare up.
When starting allopurinol
Also start
first line: colchicine 500microg, PO, twice a day
or second line: NSAIDs at normal doses
May need to use flare prophylaxis for 6 months.
What medication can you initiate for gout prophylaxis? How do you judge the effectiveness?
allopurinol 50 mg orally, daily for 4 weeks; then increase the daily dose by 50 mg every 2 to 4 weeks or by 100 mg every 4 weeks to achieve the target serum uric acid concentration, up to a maximum maintenance dose of 900 mg daily.
start slowly and increase due to hypersensitivity.
And don’t forget about flare prophylaxis
Measure urate levels to assess appropriate dosing
Non tophaceous Gout:
Target Urate < 0.36mmol/L
Tophaceous gout
Target Urate <0.3mmol/L
What are the 4 spondyloarthropathies? And what makes them so?
- Psoriatic Arthritis
- Ankylosing spondylitis
- Reactive arthritis
- Enteropathic arthritis
HLA-B27 mutation is common amongst these
What extra arthritis features are common in psoriatic arthritis?
(4)
- Psoriasis rash. 67% get the rash before the arthritis.
- Nail Psoriasis/disease. occurs in 90% of those with psoriatic arthritis. can get onycholysis or splinter haemorrhages.
- Dactylitis
- Enthesitis.
For ankylosing spondylitis what should you measure on examination, and how?
- Spinal mobility
- Modified Schober’s test , lateral side flexion, chest expansion (<5cm is abnormal), occiput to wall (should be zero)
What does management for Ank Spond entail
(5)
- Consistent Exercise to keep joints mobile and functionality
- Stop smoking- worsens disease prognosis
- NSAID for analgesia
- Local steroid injections
- bDMARDS. by specialist.
How to treat GCA without evolving visual loss?
(3)
- Specialist referral
- Prednisolone 40-60mg at once orally, daily for \ 4 weeks
- Aspirin 100mg daily to prevent ischemic events like ophthalmic vascular thrombosis
nb
evolving visual loss needs IV steroids and admission to hospital for such
What is the criteria for diagnosis of PMR?
(6)
Pretty much all of the following
Age ≥50 years with new bilateral shoulder pain
New hip involvement (pain, tenderness, limited movement)
Morning stiffness for >45 min
Elevated C-reactive protein and/or ESR
In the absence of peripheral synovitis or of positive RA serology (RF and anti-CCP negative)
Ultrasound findings of bilateral shoulder abnormalities (subacromial bursitis, bicipital tenosynovitis, glenohumeral effusion) or abnormalities in one shoulder and hip (hip effusion, trochanteric bursitis)
What is the recommended course of treatment for PMR?
prednis(ol)one 15 mg orally, daily for 4 weeks; then reduce daily dose by 2.5 mg every 4 weeks to 10 mg daily; then reduce daily dose by 1 mg every 4 to 8 weeks to stop
what do you need to know about treatment for GCA?
(4)
Don’t reduce the dose if there is still active disease.
Do not taper too quickly. Full course should last 12-18 months. Though over 18 months may warrant a referral.
May need to get regular bloods to check disease activity.
Advise not to cease the medication abruptly incase of adrenal insufficienc/crisis
What options exist to treat fibromyalgia?
- CBT
- Stress reduction and relaxation techniques
- Mindfulness
- Exercise. usually hydrotherapy is a good place to start
- TCAs or Duloxetine
- Gabapentin or pregabalin
What are features of fibromyalgia?
(6)
Multiple and various and fluctuating symptoms
Diffuse soft tissue pain,
Sore lateral epicondyles,
Associated with fatigue, sleep dysfunction
Allodynia
Extensive pain history
What conditions can you group under Inflammatory connective tissue diseases?
- SLE
- Sjogren Syndrome
- Systemic sclerosis aka slceroderma
- Mixed connective tissue disease
- Immune mediated myopathies : juvenille dermatomyositis and dermatomyositis.
What are common features that need management with an inflammatory connective tissue disease?
(4)
- Arthralgia , myalgia , arthritis
- Fatigue
- Raynauds
- Sicca symptoms
Three options for managing pain related to arthritis/arthraliga/myalgia in connective tissue disease
(3)
- paracetamol
- NSAIDs
- Fish oil (2.7mg of omega 3 daily, oral) - can take 3 months to work
Refer to specialist if this doesn’t work. for MTX+folic acid, or prednisolone or csDMARD (conventional synthetic disease modifying anti rheumatic drugs)
Options for managing Rayanuds phenomenon:
- Avoid cold exposure.
Wear gloves - Stop smoking if relevant
- Avoid use of beta blockers
- Can use a CCB like amlodipine 5-10mg, PO, daily
- GTN patches or ointment, ACEi, SSRIs, PDE5i, alpha blockers.
What is sicca?
drying of mucosal membranes mainly eyes and mouth
Mucosal membranes such as the mouth, eyes and vagina can become dry with SLE or other connective tissue disorders. What can be done to treat this?
- Avoid heated dry air
- Wear sunglasses that completely cover the eye/orbit
- Avoid cigarette smoker
- avoid anti-cholinergic drugs
- Various lubricant preparations for eyes, mouth or vagina.
- Good and regular dental hygiene.
What tests do you need to diagnosis SLE?
Trick question
It is primarily clinical. However there are a set of clinical and investigative criteria that can be used to diagnose it. 4 of the 11 set of criteria need to be met. So you can diagnose it alone if the person has 4 clinical signs/symptoms.
Tests include ANA positivity, dsDNA, anti-Smith or anti-phospholipid, renal features of proteinuria or casts, as one; (haemolytic anaemia, leucopenia, thrombocytopenia).
what are the two variants of systemic sclerosis (scleroderma)?
- Diffuse cutaneous disease
- Limited cutaneous disease
What does CREST stand for when evaluating symptoms of a connective tissue disease? And which disease are we referring to?
Calcinosis
Raynouds
oEsophageal dysmolitiy
sclerodactyly
Telengectasia
In reference to limited cutaneous disease of systemic sclerosis
What are some features indicative of Ankylosing spondylitis?
(6)
- BACK pain
- Stiffness, but related to the back NOT hips (as in PMR)
- Usually younger individuals (40s)
- Usually more men than women
- Onset over about 3 months
- Arthritis is usually asymmetric, unlike RA
What are features of fibromyalgia?
(7)
- Multiple and various symptoms
- Fluctuating symptoms
- Diffuse soft tissue pain
- Sore lateral epicondyles
- Associated with sleep dysfunction or fatigue
- Allodynia (pain experienced from non painful stimuli)
- Extensive pain history
What are the three main ways to classify a vasculitis?
Small
Medium
Large
What is the pathophysiological mechanism that vasculitis cause damage?
- Auto immune antibodies attack the endothelium
- Sometimes the autoimmune dysfunction is against cells near the endothelium (e.g WBC). The inflammatory process releases cytokines etc and this then affects the endothelium.
This can cause weaker vessel walls and lead to aneurysms
Or thicker vessel walls from fibrin deposition that lead to stiffer arteries/vessels
Name the two main types of large vessel vasculitities?
Giant Cell arteritis
Takayasu - affects the aortic arch. Mainly in asian women aged under 40.
Name the three medium vessel vasculitities?
Think fast food
burger, hotdog and arancini
Kawasaki Disease - mainly kids
Buergers disease - mainly men 20-40 that use tobacco
Polyarteritis Nodosa
What type of vasculiitis do you suspect p-ANCAs vs. c-ANCAs?
Only in small vessel vasculitities.
p-ANCAS is microscopic polyangitis
c-ANCAs in Granulomatosis with polyangitis
can also get p-ANCAs in a third small vessel vaculitis called Churrg-Straus
What are the four small vessel vasculitities?
Churrg-Straus
Microscopic polyangitis
Granulomatosis with polyangitis
Henoch-Schonlien Purpura
What disease is this rash commonly seen?
Henoch Schonlien Purpura
What two initial things should you do for HSP?
Blood pressure
Urinalaysis
If a child with HSP isn’t unwell and has normal BP and urinalysis, what is the recommended plan?
No need for hospital admission
Follow up with weekly urinalysis and blood pressure for the first month
If there is any issue with Blood pressure or urinalysis or even macroscopic haematuria then consult renal physician.
When should you consider admission with HSP?
(5)
Serious abdominal complications
Severe debilitating pain
Severe renal involvement (see UPCR values below)
Neurological or pulmonary involvement
If treatment with prednisolone is considered
Key signs when assessing for Kawasaki Disease?
COREL
Conjunctivitis
Oral: strawberry tongue
Rash; erythematous polymorphous rash
Extremity change: swelling/oedema
Lymphadenopathy. usually unilateral and one LN > 1.5cm
Traditionally you need 2 of the 4 signs on exam plus how many days of fever to diagnose Kawasaki Disease?
5 days
But if there are signs and you’re suspicious, theres no need to wait 5 days before admission
Differentials for Kawasaki disease like presentations?
(7)
Group A infections: tonsillitis, scarlet fever, acute rheumatic fever
Viral infections
Systemic Juvenile Idiopathic Arthritis
Sepsis
Toxic shock syndrome
Steven-Johnsons syndrome
Drug reaction
Malignancy
