Rheumatology Guidelines Flashcards
schobers test and ank spond
<5cm is postiive
most useful 1st test for ank spond gold standard Ix
Xray sacroiliacs MRI is gold standard
ESR and CRP in ank spond
both up
1st line ank spond
NSAIDs and exercise
DMARD in ank spond
only if peripheral involvemtn (mor ein woman)
When do you do biologic in ank spond
if failed 2 NSAIDs
antiphospholipid syndrome aPTT
paradoxically up
antiphospholipid Mx
warfarin - first VTE = 6m at 2-3 - recurrent VTE if second one during warfarin = lifelong at 3-4 - arterial thrombosis = lifelong 2-3
behcets Ix
pathergy test
CFS 1st line
CBT
dermatomyositis definitive ix
muscle biopsy
CK in dermatomyositis
up
EMG in dermatomyositis
fibrillations
1st line dermatmyositisi
steroids
diagnosis of fibromyalgia
need t be tender at 11+ out of 18 points
best evidence Tx for firbomyalgia
aerobic exercise
gout acute 1st line
NSAIDs (max dose for 1-2d after Sx stop) or colchicine
when can you not use NSAIDs in gout
any CKD
when can you not use colchicine in gout and what do you then use
ESKD, use prednisolone
serum urate aim for when on allopuronol
less than 300
2nd line urate lowering drug
febuxostat
diet for gout?
increase vit C
diuretics for gout?
stop thiazides. ARB help
xray findgins in rickets
cupped ragged metaphysis
adults osteomalacia xray finding
pseudofracture/loosers zone
skull problem in pagets
frontal bossing osteoporosis circumscipta (patches of osteoporosis)
polyarteritis nodosa association
man with hep B
PAN definitive biopsy (2)
renal or mesenteric angiogram biopsy with microaneursysm
PAN Mx
control BP steroids a cyclophosphamide
PAN blood test - crp, esr, wcc, hb
crp esr wcc up anaemia
PMR Ix - esr, ck, alp, emg
esr up alp up ck and EMG
PMR Mx
prednisolone (methylpred if eye involvement)
pseudogout Mx
NSAIDs or steroids
psoriatic arthroapthy : systemic steroids?
makes rash worse
joint aspirate in reactive arthtis
negative
Mx for reactive arthtiris
4w to start 4m to leave self limiting so don’t have to do anytihgn, can use MTX is lasting more than 6m
how do you detect RF
rose waaler test - sheep red cell agglutination less specific Latex aggluniation test
how do you diagnose RA
need 6/10 score of American thingy: - abnormal ESR + CRP, >6w, joints involved (more joints= more points), serology (RF + ACPA)
1st line RA Tx in flare first time
single DMARD (methotrexate) +/- short course of bridging pred
disease monitoring in RA
DAS28 + CRP
TNFa-i indication in RA
failed 2 DMARDS including MTX
definitive test for sjogrens
biopsy shows lymphocytic infiltration
other weird blood test for sjogrens
IgG high and C4 low
Mx for sjogrens
articificla tears and saliva pilocarpine may stimulate excretions DMARDs- hydroxychoroquine
SLE diagnsitic critera
Need 4 or more of: dicoid rash, malar rash, photosensitivity, oral ulcer, arthritis, serositis, renal disorder, CNS disorder, haem disorder, immunological disrde, ANA
SLE blood during flare - CRP/ESR - complemenyts?
Crp normal but ESR raised low C3 and C4
disease monitoing for SLE
dsDNA
severe flare SLE Mx
IV cyclophosphamide + high dose pred
signs on X-ray for osteoarthritis
LOSS loss of joint space osteophytes subchondral sclerosis subchondral cyst
risk factors for osteoarthritis
most common place is knee then hip risk factors: - increasing age - female - obesity - developmental dysplasia of hip
is RA/OA pain relived by rest or exercise
RA pain relieved by exercise OA pain relieved by rest
first line investigation for OA
X-ray clinical diagnosis can be made if features typical
Mx of OA
analgesia: - first line: paracetamol and topical NSAIDs second line: oral NSAIDs/ COX2 inhibitors, opioids, intra-articular corticosteroids PPI co-prescribed with NSAIDs and COX-2 inhibitors joint replacement - definitive treatment
reasons for revision of total hip replacement
- aseptic loosening (most common reason) - pain - dislocation - infection
anticoagulation after hip operation
LMWH for 4 wks after hip replacement
what is a bakers cyst
popliteal cyst (back of knee) swelling in popliteal fossa if underlying pathology no treatment needed if underling cause - treat
Mx for flare of RA
corticosteroids - oral or intramuscular
monitoring for methotrexate
monitoring of FBC and LFTs - risk of myelosuppression and liver cirrhosis
what type of vasculitis is temporal arteritis
giant cell arteritis
main treatment for vaculitides
immunosuppression
most likely vasculitis in young male smokers
Buergers disease helped by smoking cessation
what population is polyarteritis nodosa most common in
in populations with high prevalence of hep B
head pain in temporal region jaw claudication vision problems diagnosis
temporal arteritis
what condition is giant cell arteritis linked to
polymyalgia rheumatica
risk factors for osteoporosis
corticosteroid use smoking alcohol low BMI FHx
first line Mx for osteoporosis
alendronate post menopausal women to be offered Vit D and calcium supplements
administration of bisphosphonates
tablets swallowed with plenty of water while sitting or standing on empty stomach for at least 30mins before breakfast sit stand for at least 30mins after tablet to reduce chances of oesophageal ulcers
assessing risk of osteoporosis
all women >65 + all men >75 assessed + people with risk factors FRAX score- 10yr risk of fragility fracture (patients 40-90) DEXA scan if FRAX intermediate result
when should you straight DEXA someone
- before starting treatment affecting bone density (sex hormone deprivation for breast/prostate cancer) - <40yrs with major risk factors
management according to FRAX score
FRAX low risk: reassure + lifestyle advice intermediate risk: offer BMD (DEXA) high risk: offer bone protection treatment
T score interpretation for DEXA scan
>-1.0 = normal -1.0 to -2.5 = osteopenia
rheumatoid arthritis xray changes
early findings: - loss of joint space - junta-articular osteoporosis - soft-tissue swelling late x-ray findings: - periarticular erosions - subluxation
epidemiology of SLE
- females - afro-caribbeans and asians - onset 20-40yrs -
SLE HLA?
HLA B8, DR2, DR3
what crystals are in pseudo gout
deposition of calcium pyrophosphate dehydrate crystals in synovial
what distinguishes gout from pseudogout on XR
pseudogout has chonedrocalcinosis on XR (can bee seen in knee as calcification of meniscus and articular cartilage)
Mx of pseudogout
knee, wrist, shoulders most commonly affected MX: - aspiration of joint to exclude septic arthritis NSAIDs or intra-articular or intra-muscular or oral steroids as for gout
what type of immune reaction is SLE
type 3 hypersensitivity reaction
dermatomyositis features
skin lesions and proximal muscle weakness - violet periorbital rash - red papules over back of fingers (gottrons papules) (by joints)
management for chronic gout to prevent recurrent attacks
allopurinol
chemotherapy increases the risk of gout due to what?
increased urate production
weeks after infection can’t pee can’t see can’t climb a tree diagnosis
reactive arthritis GI: salmonella GUS: chlamydia UTI conjunctivitis joint pain and swelling
gout Vs pseudogout on joint aspirate
crystals: - gout: negative needles, urate crystals - pseudogout: positive rhomboid, calcium pyrophosphate crystals
turbid grey coloured joint aspirate
septic joint
symptoms of antiphospholipid syndrome
CLOT symptoms: - Clot - Lived reticular - Obstetrics - recurrent miscarriages - Thrombocytopaenia
limited systemic sclerosis (scleroderma) symptoms
CREST symptoms: - Calcinosis - Raynauds phenomenon (may be first sign) - Esophageal dysmotility - Sclerodactylyl (stiff fingers) - Telangiectasia
osteomalacia what is it Mx
low calcium and phosphate high ALP treat with Calcium (cholecalciferol) with Vit D tablets
Pagets levels in blood
calcium and phosphate normal ALP high
Kocher’s criteria
septic arthritis asses prob of SA in children non-weight bearing - 1 point Fever > 38.5 - 1 point WCC > 12 - 1 point ESR > 40 - 1 point 1= 3% 2= 40% 3= 93% 4= 99%
bacteria causing septic arthritis in young sexually active adults
neisseria gonorrhoea
Mx of septic arthritis
- Synovial fluid obtained before starting treatment - IV Abx – flucloxacillin 6-12 weeks or clindamycin if penicillin allergic - Needle aspiration - Arthroscopic lavage may be required
presentation of juvenile idiopathic arthritis
occurs in <16yrs lasts > 6 wks polyarticular presentation (multiple joints) systemic features: - fever - rash ANA +ve RF -ve
sjogrens presentation
‘D’ factor: - dry eyes - dry mouth - dry cough - dysphagia - dry vagina - dyspareunia (pain during sex) generalised arthralgia and fatigue
tests for sjogrens
Schirmers test: - filter paper in eyes - <5mm of moister over 5 mins = positive schimers Lissamine green test and rose bengal staining (ocular surface staining to look for damage)
blue sclera
osteogenesis imperfecta
Marfans disorder
connective tissue disorder tall stature high arched palate pacts excavatum scoliosis aortic dissection and cardiac problems Mx: - echo monitoring - BB/ ACEi
which antibodies for myositis
anti-Jo antibodies
how long after finishing methotrexate should you continue contraception
contraception 6months after stopping methotrexate
what is co-prescribed with methotrexate
folic acid both taken once weekly
treatment for methotrexate toxicity
folinic acid
most common cause of hip pain in children
transient synovitis acute hip pain associated with viral infection well or mild fever 2-10yrs
nail changed + skin changes + arthritis
psoriatic arthropathy
marker for most likely position of gout
marker E - first metatarsophalangeal joint
what should patients be put on after first attack of gout
allopurinol - started 2 weeks after attack
colchicine should be considered when starting allopurinol
what should be done to allopurinol during gout attack
remain on it if already on it
rheumatoid arthritis + splenomegaly + low WCC
Felty’s syndrome
most common type of anaemia in inflammatory conditions
microcytic anaemia - due to iron deficiency
can be due to NSAID and lack of iron intake
what type of anaemia can be caused by methotrexate
macrocystic anaemia - due to folic acid deficiency
need to take folate when taking methotrexate
prognostic indicator of RA
RF
if they have rheumatoid arthritis, more likely to have extra-articular features
anti JO-1 in SLE patient
indicates the person is more likely to develop interstitial lung disease
need high resolution CT of lungs
serum uric acid level during gout attack
low during acute attack
once attack has gone then its high
level up from methotrexate if not working
sulfasalazine
then anti-TNF
how do you deliver steroids in acute attack of RA
IM steriods into buttock
first two treatments for ank spond
first line: physiotherapy
NSAIDs for 3 months
if not working then different NSAIDs
if not then biologics
dont give DMARDs unless peripheral involvement
mx for acute flare of ank spond
steroids + NSAIDs
side effect of colchicine
diarrhoea
if giving allopurinol during acute attack what should yu give in addition
give NSAIDs to stop gout attack from the allopurinol
treatment for fibromyalgia
due to trauma
focus on sleep, fatigue, anxiety/depression, unresolved psychological issues
