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Lecture 9: Arthritis Part 1 Flashcards

1
Q

MC form of joint disease

A

OSTEOarthritis

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2
Q

90% of all patients will have radiographic evidence of arthritis in weight bearing joints by age….

A

40

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3
Q

Who is OA of the hands and knees MC in?

A

Females

But men complain more

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4
Q

Why do osteophytes develop in articular margins?

A

It is where they try to repair it

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5
Q

Is OA relieved by rest?

A

Yes

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6
Q

What does OA typically reduce?

A

Range of motion

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7
Q

What are bony enlargements of the DIP and PIP called?

A
  • DIP: Herberden nodes
  • PIP: Bouchard nodes

Peanut Butter, Dip in Herbs

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8
Q

Does OA cause elevations in ESR?

A

No

Also does not show inflammatory synovial fluid

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9
Q

Diagnostic modality of choice for OA?

A

XR

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10
Q

What is typically seen on XR for OA?

A
  • Narrowing of joint space
  • Osteophyte formation
  • Lipping of marginal bone
  • Thickened, subchondral bone
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11
Q

First line therapy for mild OA

A

3-4g of acetaminophen daily

Caution in liver dz and heavy alcohol

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12
Q

What is the issue with NSAIDs vs acetaminophen for OA?

A

NSAIDs have more SEs

OA does not seem inflammatory, so tylenol > NSAIDs

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13
Q

Which NSAID has low systemic absorption but is good for pain?

A

Voltaren gel

Diclofenac gel

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14
Q

Which PO NSAIDs are safe to use with coumadin?

A

Celebrex?

Selective COX-2 inhibitor

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15
Q

When might we administer PPI with NSAIDs?

A

For High risk OA patients

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16
Q

What can we inject into joints for OA?

A
  1. Intra-articular steroids
  2. Hyaluronic acid (last resort, symptomatic relief)
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17
Q

Where is natural hyaluronic acid from?

A
  • Rooster Combs
  • Cow
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18
Q

When is surgery indicated for OA?

A
  • Pain at rest
  • Restricted walking

Total replacements

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19
Q

How does gout typically present?

A

MONOarticular buildup of gout

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20
Q

Who is primary gout MC in?

A

Men older than 30y

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21
Q

What serum uric acid is considered hyperuricemia?

A

> 6.8

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22
Q

MC joint affected in gout

A

MTP of big toe

Looks like a bunion

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23
Q

What is the characteristic lesion of gouty arthritis?

A

Tophus

Monosodium urate crystal deposit + Foreign body rxn

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24
Q

What is podagra?

A

A tophus of the MTP joint of the big toe

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25
Where does gouty arthritis rarely affect?
* Hips * Shoulders
26
How does a gout attack present?
* Sudden * Nocturnal * Asymmetric * Swelling * **fever sometimes** | I guess you just wake up with a swollen toe
27
What diagnostic study confirms gouty arthritis?
**Joint fluid analysis** showing sodium urate crystals (needle-like and **negatively birefringent** with light microscopy)
28
What is a "rat bite" on XR?
Punched out erosions with overhanging rim or cortical bone (**seen in gouty arthritis**)
29
When do you treat hyperuricemia?
**Only if symptomatic**, otherwise diet modifications!
30
What is the main diet modification for gout?
Avoiding purine-rich foods | Also drink water, avoid alcohol
31
What is first-line tx for management of pain in gouty arthritis?
* Naproxen BID * Indomethacin Q8h
32
MC SEs of colchicine?
GI effects | Usually a loading dose then maintenance
33
When are corticosteroids primarily used for acute gout?
* People who can't take NSAIDs * For dramatic attacks
34
Which corticosteroid is used primarily for joint injection during acute gout?
Triamcinolone | If mono-articular
35
Between Triamcinolone and Methylpredinosolone, which is more likely to lead to bursitis?
Triamcinolone per kevin
36
When is colchicine best used for gout?
Prophylaxis
37
What common drug classes can lead to hyperuricemia?
* Thiazides * Loop diuretics * Niacin
38
When is urate lowering therapy indicated and what is the goal?
* Frequent arthritis (> 2 attacks annually) * Tophaceous deposits * CKD stage 2 or worse * **Goal: < 6**
39
First-line therapy for urate lowering therapy?
Xanthine oxidase inhibitors: Allopurinol & Uloric
40
What is the main HSR that occurs with allopurinol?
**Rash progressing to TEN** associated w/ vasculitis & hepatitis
41
What is the main concern with Uloric?
CV outcomes | Xanthine oxidase inhibitor, first-line gout tx?
42
What does probenecid do?
Increase uric acid excretion by kidney | Indicated when xanthine oxidase inhibitor fails or not good enough ## Footnote Cannot use if CrCl < 50
43
For chronic tophaceous arthritis, how do we get the body to resorb the urate crystals?
Keep serum uric acid < 6
44
What distinguishes pseudogout from gout?
Pseudo has **Positive birefringent rhomboid-shaped crystals** on synovial fluid analysis.
45
How does rheumatoid arthritis (RA) differ from gouty?
RA is synovitis of MULTIPLE joints, and is symmetrical
46
Who is RA MC in?
Women, also tends to occur early at 40-50 | Male is typically 60+
47
What are the pathologic findings in the joint associated with RA?
Formation of a pannus | Roux is in a Pan
48
How long and when is stiffness prominent in RA?
* Most prominent in the **AM** * Lasts **GREATER THAN 30 mins, up to hours** | Morning symmetrical stiffness
49
Image of late RA
50
Where do RA nodules typically occur over?
Bony prominences
51
What does presence of RA nodules correlate with?
Serum rheumatoid factor | More RF = more nodules
52
Besides joint stuff, what else does RA present with?
* Dryness of eyes, mouth, mucous membranes * ILD * Pericarditis or pleural dz * Felty syndrome (splenomegaly + neutropenia) * Small vessel vasculitis
53
What is the most specific blood test for RA?
Anti-CCP antibodies | Chinese communist party, republic army
54
What confirms the inflammatory nature of RA?
Joint fluid analysis | R/o superimosed septic arthritis
55
What kind of imaging is specific for RA?
Radiograph changes (stocking-glove distribution) | After 6 months
56
In later RA, what occurs to joint spaces?
Uniform narrowing of joint spaces
57
Primary tx for RA
DMARDs | Once diagnosed with RA
58
What is the role of corticosteroids in RA?
Bridging to DMARDs
59
What is the max # of injections of triamcinolone we want to give for RA?
4 a year
60
What is the initial DMARD of choice for RA?
Methotrexate | Takes 4-6 weeks
61
What do you need to monitor/educate about with methotrexate use?
* Teratogenic * Gastric irritation/stomatitis * Avoid alcohol * Folic acid 1mg daily
62
What is the 2nd line therapy for RA?
Sulfasalazine
63
Main SEs of sulfasalazine
* Neutropenia * Thrombocytopenia * Hemolysis in G6PD | CI in someone with an ASA allergy ## Footnote Need CBC Q2-4wks for 3 months, then every 3 months
64
When are TNF inhibitors used for RA?
Inadequate response to MTX | Usual combo is TNF + MTX for RA

MSK (17 decks)

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