Rheumatology Longs Flashcards
RA
- Dx
- Presentation
- Ix
- Mx
- Pregnancy
Dx: Joint involvement (4-10 small joints, +/- large joint), RF / anti-CCP, CRP / ESR, >6/52
Presentation:
1. Fatigue
2. Morning stiffness
3. Weight loss
4. Functional limitations
5. Joint involvement
Ix:
Hb - normochromic anaemia
Hand XR: soft tissue swelling, symmetrical joint space narrowing, marginal joint erosions and juxta-articular OP
Mx:
Non-pharm- education, PT (exercise, splint for deformity), OT, smoking cessation, joint rest
Pharm-
- antiinflammatory. Nsaid (GI/Renal- AIN, CVD risk)
- Steroid. Bridge to onset of DMARD, vasculitis, elderly needing chronic low dose, local steroid injections for acute flare.
- DMARD.
1. Methotrexate (monitor LFT, WCC/neut- leukopenia, plt - thrombocytopenia, increased RA nodules, folate supplement - mouth ulcers, ILD, warning- G6PD) +/- sulfasalazine OR hydroxychloroquine (opthalmology rv)
2. leflunomide (mtx alternative, pyramiding antagonist- inhibits T-cell proliferation)
3. cyclosporine, azathioprine, penicillamine, gold (po/iv).
-Biological.
FAILURE= 6/12 DMARD + includes MTX +/- HCQ, leflunomide, SZN
SE: local site, infusion reaction (antihistamine- nausea, headache, flush, palpitations), delayed infusion reaction (steroid- fatigue, rash, arthralgia, myalgia), increased risk serious infection (avoid undercooked eggs, meat ie listeria, salmonella / TB reactivation / Hep B/C), non-melanoma skin cancer
Contraindicated: on immunosuppression, live vaccines, pregnancy.
- TNF inhibitors (infliximab-IV, others SC- adalimumab, certolizumab, etanercept, golimumab)
- Non-TNF inhibitors (abatacept- T-cell costimulation inhibitor, anakinra- IL1 receptor antagonist, rituximab- CD20 ab with risk of serious infection and PML, tocilizumab- IL6i, tofacitinib- JAK inhibitor with risk of herpes, liver dysfunction)
- Surgery. Replacement, arthroplasty, relief of contractures.
Pregnancy: stop MTX 3/12 pre-conception and breastfeeding, men stop SZN 3/12 pre-conception (oligospermia).
Safe in breast feeding but aspirin / NSAIDs interfere with implantation and labour + premature PDA closure, steroids increase maternal diabetes and cleft palate.
SLE
Dx
R
P- systems review
I
M
C
O
P
Dx.
Rash-
- malar
- discoid
- photosensitivity
Oral ulcers
Non-erosive arthritis 2+ joints
Serositis (pleurisy or pericarditis)
Renal: proteinuria >0.5g/d or cellular casts
Neuro: seizures, psychosis
Haem: haemolytic anaemia, leukopenia, lymphopenia, thrombocytopenia
Immuno: anti-DNA ab, anti-Sm, + anti-phospholipid ab
ANA > 1:160
R- F>M, 20-40s, HLA DR2/3, meds (procainamide, hydralazine, isoniazid, methyldopa, penicillamine, chlorpromazine, phenytoin and anti-TNF with anti-histone ab)
P- systems review (aphthous ulcer, serositis, raynauds, alopecia, photosensitivity rash, dry eyes and mouth, thrombosis, miscarriage, nephritis)
Cushingoid, weight, mental status
Vasculitis, rash, symmetrical polyarthropathy (arthritis), nail fold infarcts, Raynauds
Livedo reticularis, purpura, proximal myopathy
Alopecia, scleritis, mouth ulcers
CN lesion, cervical adenopathy
Cardiac- endocarditis
Resp- pleural eff, pulmonary fibrosis, infection / pleurisy
Abdo- hepatosplenomegaly
Hips- aseptic necrosis
Feet- small joint synovitis, cerebellar ataxia, neuropathy, mononeuritis multiplex, transverse myelitis
Renal: urine, BP
I- ANA, anti Ro (SSA/SSB), antidsDNA, anti-Sm, anti-U1RNP (MCTD), antihistone, antiphospholipid, complement (low CH50, normal C3)
Renal bx (mesangial proliferation, focal glomerulonephritis, diffuse proliferation- high dose steroid + cyclophosphamide, membranous proliferation).
M- contraception, Sun protection
NSAID + rest for arthralgia, myalgia, fever
Hydroxychloroquine, pregnancy ✅
CCB for Raynauds.
Steroids for CNS, pericarditis, myocarditis, pleurisy, severe haemolytic anaemia and thrombocytopenia.
Thrombosis and antiphospholipid - warfarin, INR 2.5-3.5
Renal disease transplant, high risk graft failure.
- mycophenalate less toxic than CYC
Osteoporosis- Ca2+ / vit D
AZA (steroid sparing) or MTX
RTX
Pregnancy.
HCQ
APL- heparin + low dose aspirin to prevent spont abortion.
Steroids except dex.
Anti-Ro (SSB/SSA) CHB, transient erythematous rash.
Cervical dysplasia - HPV vaccine.
Complications.
CAD
Lymphoma
Systemic sclerosis
D
R
P
C
O
P
DcSSc- anti-Scl70 (ILD- topoisomerase 1 ab, serositis, acute renal failure).
LcSSc- anti-centromere ab (PAH)
- CREST = calcinosis, Raynauds, esophageal, sclerodactyly, telangiectasia.
Ddx- GVHD, polyvinyl chloride, L-tryptophan and drugs (bleomycin), nephrologenic systemic fibrosis + gadolinium MRI exposure, diabetic cheiroarthropathy, eosinophilia fasciitis, morphea, scleroderma.
R- F>M, FHx
P.
Skin- Raynauds (bb makes it worse).
Arthritis- RA distribution, carpal tunnel
GI- esophagitis, malabsorption
Resp- ILD, pulmonary HTN
Cardiac- pericarditis, arrhythmia, dilated cardiomyopathy.
Other- erectile dysfunction.
I- ESR. Hb (anaemia, iron def, folate / b12 def, MAHA 2o renal crisis).
Hypergammaglobulinaemia (IgG).
RF, ANA,
CXR, gastroscopy, esophageal manometry
RFT, HRCT, echo -> if ?PAH then R heart Cath.
Mx.
Avoid vasospasm (smoking, weather, bb).
PPI for reflux, prevent stricture.
Raynauds- nifedipine, phenoxybenzamine, prazosin or methyldopa, iloprost (prostacyclin analogue), bosentan (endothelin antagonist for digital ischemia)
Morphea (UV light).
Dry eyes- artificial tears
Joint sx - NSAIDs
Malabsorption- SIBO (abx),
D-penicillamine (skin, improved survival): glomerulonephritis and nephrotic syndrome, MG, thrombocytopenia, leukopenia, aplastic anaemia. Other- altered taste, rash, fever, nausea, anorexia.
CYC (9/12) lung disease.
Steroids - pericarditis, inflammatory myopathy, early ILD.
PAH Tx
1. Endothelin receptor antagonists. Bosentan. Ambrisentan.
2. Phosphodiesterase inhibitors. Sildenafil and tadalafil.
3. Prostanoids. IV epoprostanol, inhaled iloprost.
HTN Mx to prevent CKD - ACEi, monitor for renal crisis.
C
Outcome. Impact on home, work, finances.
Prognosis.
Worse in men, renal or late dx.
DMARDS
TNFi-
-adalimumab
-certolizumab (pregnancy)
-etanercept
-golimumab (if injections inconvenient)
-infliximab
CTLA4: abatacept (useful if TNFI doesn’t work).
IL6: Tocilizumab can be IV / SC
Suppressed CRP response.
JAKI: tofacitinib (increased DVT).
Psoriasis
Deforming small joint arthropathy with DIP involvement
-swelling
-sausage
-dactylitis
Spondyloarthropathy
Skin plaques
Nail changes: pitting, ridging, onycholysis
HLA-B27
Mx:
Non-pharm: education, exercise, physical therapy, rehab, associations, self-help groups
Pharm: NSAIDs (reduce pain, disease activity, improves function and spine mobility).
- peripheral joints: local steroids, DMARDs (SZN, MTX)
-BOTH: 1o = NSAIDs, 2o= TNF-a blocker or IL-17 (secukinumab), additional= analgesia, surgery
