General Flashcards
(47 cards)
Rx non-renal SLE
Mild/moderate
Hydroxychloroquine +/- pred
Moderate
Azathioprine or MTX
- Azathioprine in childbearing age/pregnancy. Otherwise MTX is probably a bit better.
Severe
Mycophenolate (more for renal SLE) - very potent
Rituximab
Cyclophophsmiade
Anti-dsDNA in SLE
very specific, can correlate with disease activity, high result suggests renal disease
Anti-SM positive in SLE
Very specific
Main differences between SpA and DISH
SpA
- Younger people before age 45
- History of psoriasis, IBD, uveitis, dactylitis
- FHx
- Inflammatory back pain or stiffness
- Postural abnormalities
- Response to NSAIDs
- Xray:
DISH
- Asymptomatic
- Found on xray - continuous bulky calcificat of the anterior longitudinal ligaments
- Cervical and thoracic spine
What is Livedo racemosa?
Similar to livedo reticularis
Lace is contained in livedo racemosa but broken in reticularis
What is polyarteritis nodosa?
Raised inflammatory markers
Renal impairment
CT small vessel aneurysms
Livedo racemosa
No available autoantibody screening test
Febuxostat vs allopurinol
Both xanthine oxidase inhibitors
Febuxostat
- Can cause LFT derangement
- Drops uric acid very quickly (more likely to have flares) so important to have people on prophylaxis colchicine 500microg BD (eGFR >60). If renal function is bad, may need pred.
- ?Higher CV events
Uric acid targets for tophi and non-tophi gout
Tophi: <300micromol/L
Non-tophi: <360micromol/L
When to start febuxostat?
Better for renal impairment
Not tolerating uptitration of allopurinol
Allopurinol hypersensitivity syndrome
How to start allopurinol?
Uptitrate allopurinol up to 900mg first - increase 100mg each month if renal function normal until uric acid level is at target
Start prophylaxis (colchicine) at the same time. Continue until you reach target for 6 months.
When to avoid colchicine?
eGFR <30: don’t use colchicine. Use pred instead.
eGFR 30-60: daily dosing instead of BD
When can you start allopurinol after a flare?
Can start during the acute attack
Bad flare and on prednisolone/NSAIDs - wait for flare to turn around and start allopurinol after 3-4 days (100mg if no renal impairment; dose reduce if renal impairment)
Rx acute gout flare
Prednisolone and NSAIDs work equally well
Can hit them harder with prednisolone (up to 50mg for polyarticular gout)
Need to be careful with NSAIDs in kidney impairment
Can you get total resolution of tophi with good serum uric acid control?
Yes
Can take several years
Can also have surgical management but this must be done after good serum uric acid control. If not it will come back quickly.
Dual energy CT for gout
When is it used?
Not that helpful
Can’t rely on it diagnostically
Poor sensitivity, specificity
Can quantify the amount of uric acid in a joint e.g. 20ml
GCA is pretty rare under age …
50
Few case reports around the world!
What’s a specific sign of GCA?
Jaw claudication
Why should we do bilateral temporal artery biopsies for GCA?
Biopsy of the contralateral temporal artery can increase the yield by 15%
What might you see on ultrasound of temporal artery suggesting GCA?
Halo sign
But US is generally not useful cause its not done often
Does steroids influence temporal artery biopsy outcome?
TAB should be performed ASAP after steroid treatment (Within 14 days)
But it can be positive even after weeks of steroids
How big should the temporal artery biopsy be?
2.5cm or more
High suspicion for GCA but negative temporal artery biopsy
What do you do?
Start
PET - large vessel vasculitis but no cranial nerve involvement
Should we screen GCA patients with aortic aneurysm?
No
This is controversial some rheumatologists do
Why do we use aspirin in GCA?
Secondary prevention
Pred increases hypertension, cholesterol, BSLs
Continue until pred is finished (or continue if there are risk factors)
