Rheumatology LC

Question 1

First line therapy for Raynaud’s?
Second line therapy?
Exacerbating factors other than cold?

Answer 1

1. Dihydropyrine ca channel blockers - amlodipine, nifedipine
2. PDE5 inhibitors (i.e. sildenafil), topical nitrates (i.e. nitroglycerin ointment), some evidence for ARBs and fluoxetine
3. Smoking, vasoconstricting drugs (i.e. tryptans, beta blockers)

Question 2

Indicators of more severe disease in RA

Answer 2

Anti-CCP positive
Rheumatoid nodules
Later age of onset (>60)
Smoking
Early radiologic involvement
>20 involved joints
Persistently elevated inflammatory markers (CRP, ESR)

Question 3

Features of RA on x-ray

Answer 3

Periarticular soft tissue swelling
Joint space erosions
Joint space narrowing
Periarticular osteopenia
Ulnar deviation at MCPs
DIP sparing
Deformities in advanced disease

Question 4

Extra-articular complications of RA

Answer 4

Haem

• Feltys syndrome
• anemia

Eyes
- scleritis

Neuro

• carpal tunnel syndrome
• cervical cord
• mononeuritis multiplex

Renal

• mesangioproliferative/membranous GN
• vasculitis

Lung

• pulmonary fibrosis/caplans syndrome
• pulmonary nodules

Cardiac

• pericarditis/myocarditis
• Afib
• atherosclerosis (IHD)

Skin

• raynayds
• erythema nodosum

Question 5

Indications for osteoperosis screening

Answer 5

Minimal trauma fracture
Males >70yo, female >65yo
Premature menopause/hypogonadism
Major risk factors
- medications (steroids >3 months, anti-androgens)
- disorder (CKD, RA, hyperparathyroidism, chronic liver disease, celiac)
- cumulative risk factors

Question 6

Indications for treatment of osteoperosis

Answer 6

Anyone with BMD ≤ 2.5 SD
Minimal trauma fracture in post menopausal woman or man >50yo
3-5 times more likely to have a further fracture
Absolute fracture risk >3% (hip) or >20% (any site)
Asymptomatic vertebral trauma
Osteopenia in postmenopausal women or men >50yo + chronic corticosteroid if high FRAX risk OR if on >7.5mg pred for >3 months

Question 7

Features of SLE

Answer 7

SOAP BRAIN MD

Serositis
Oral/nasal ulcers ulcers
Arthritis in >2 joints (non erosive)
Photosensitivity
Bleeding disorders (APLS and miscarriages)
Renal involvement
ANA positive
Immumologic (DsDNA, amyloidosis) 
Neurologic sx
Malar rash
Discoid rash

Question 8

PBS indications for teriparetide

Answer 8

T score: severe established osteoporosis (T score -3.0 or loss)

AND

Fracture: continued high risk of fracture + 2 or more fractures due to minimal trauma,

AND

Previous treatments: at least 1 fracture after min 12 months continuous therapy with an anti-resorptive AND cannot have used Romosozumab prev (or be intolerant after 6/12 treatment)

Max 18 months