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Fdnts 3 exam 4 > RHEUM > Flashcards

RHEUM Flashcards

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1
Q

osteoporosis is characterized by

A

low bone mass, microarchitectural disruption, increased skeletal fragility

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2
Q

who gets osteoporosis?

A

POSTMENOPAUSAL & premenopausal women

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3
Q

RF’s for osteoporosis?

A

advancing age, hormone deficiency or excess, alcohol, smoking, immobilization, IBS, long-term medication use, fam h/o osteoporosis or hip fx, LBW

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4
Q

what long-term med use are considered risk factors for osteoporosis?

A 
Aromatase inhibitors
Heparin
Pioglitazone
SSRIs
SGLT2 inhibitors
Vitamin A excess
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5
Q

MC presentation for osteoporosis?

A

asymptomatic!!!

fracture (vertebral, hip pelvic) or loss of ht.

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6
Q

who should be screened for osteoporosis according to USPSTF?

A

65y/o and older (grade B)

<65y/o, when fx risk >65y/o white woman w/no additional RF’s (grade B)

men insufficient evidence

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7
Q

what tool helps calculate 10yr risk in women <65 y/o

A

FRAX tool

baseline risk = 65y/o w/no other RF’s

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8
Q

What are indicators of fx risk?

A

age, sex, wt/ht, parent fx’d hip, smoker, glucocorticoids, RA, 2ndary osteoporosis, alcohol 3 or more units/day, femoral neck BMD

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9
Q

what is the gold standard dx for osteoporosis?

A

DEXA = determines bone density of lumbar spine and hips

T score < -2.5

*use z-score if under 65y/o

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10
Q

what are other diagnostic tests used to dx osteoporosis?

A

Fragility fx of spine, hip, wrist, humerus, rib, or pelvis

quant u/s of the calcaneus

labs: chem panel, 25-hydroxyvitamin D, CBC

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11
Q

non-pharm tx management for osteoporosis?

A

diet, avoid corticosteroids, tobacco cessation, EXERCISE (wt bearing and resistance), fall prevention, excessive alcohol

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12
Q

pharmacologic tx options for osteoporosis?

A

vit D and Ca, bisphosphonates, monoclonal antibody bone modifying agents, parathyroid hormone analog (teriparatide), SERM’s, sex hormone replacement

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13
Q

recommended vitamin D and Ca intake?

A

daily vit D = 600-800U/day
– oral Vit D3 gieven at 800-2000U/day to achieve a 25-hydroxvitamin D level of >20

Ca intake = 1000mg/d or if postmenopausal women or men over 70y/o then 1200

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14
Q

MOA of biphosphonates

A

inhibit osteoclast induced bone resorption

long half life = 10yrs

CI w/ CKD

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15
Q

indications for biphosphonates

A

Pathologic spine fx or low-impact hip fx

Osteoporosis or Osteopenia

FRAX-determined 10-yr hip fx risk > 3% or major osteoporotic fx risk > 20%

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16
Q

rare complications for biphosphonates

A

osteonecrosis of the jaw, atypical low-impact fx’s of femoral shaft

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17
Q

who is oral biphosphonates not indicated in?

A

patients with esophageal disorders, inability to follow dosing instructions, or s/p Roux-en-Y gastric bypass

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18
Q

AE’s of oral biphosphonates?

A

N, CP, hoarseness, erosive esophagus

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19
Q

what are some oral biphosphonates?

A

alendronate (once wkly)

risedronate, ibandronate sodium (x1 monthly)

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20
Q

what is an IV biphosphonate and how often is it given?

A

Zoledronate (Reclast), IV administration over 15-30 minutes, annually

Educate patients about acute phase response

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21
Q

indications for denosumab (prolia)?

A

Osteoporosis, major fragility fx’s, osteopenia w/high FRAX score in both men/women, pt’s w/ high fracture risk receiving sex hormone suppression therapy

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22
Q

MOA for denosumab?

A

Monoclonal antibody that inhibits the proliferation and maturation of preosteoclasts into mature osteoclast bone-resorbing cells

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23
Q

MOA for teriparatide?

A

stimulates production of new collagenous bone matrix that must be mineralized

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24
Q

contraindications for teriparatide?

A

Patients with increased risk of osteosarcoma

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25
what are AE's for teriparatide?
injection site reactions, orthostatic hypotension, arthralgia, muscle cramps, depression, pna, hypercalcemia (N, constipation, asthenia, muscle weakness)
26
What are some SERM's and what does it reduce the risk of?
Raloxifene, Tamoxifen reduce vertebral fx's, invasive breast CA
27
AE's of SERMs
increase risk of thromboembolic events, hot flashes
28
Calcitonin use?
analgesia for pain of acute osteoporotic vertebral compression fractures for up to 3 months
29
AE's for calcitonin?
rhinitis, epistaxis, flu-like sx, allergy, arthralgias, back pain, HA Long term use increases risk of liver cancer
30
long-term use of calcitonin reduces the risk of...
breast CA
31
how often should you monitor osteoporosis using a DEXA scan
repeat DEXA scan T score -1.0 to -1.5: q 5 yrs T score -1.5 to -2.0: q 3-5 yrs T score < -2.0: q 1-2 yrs If there is response to therapy, can decrease frequency
32
complications for osteoporosis
MC = vertebral fx (2/3 asx. and ht. loss if sx) other fx's hip and distal radius (colles fx)
33
osteoporosis related fx's prognosis
``` Premature mortality Loss of function and independence Reduced quality of life Chronic pain Disability Costs ```
34
6 recommendations for osteoporosis?
1. Rx alendronate, risedronate, zoledronic acid or denosumab to reduce risk of hip/vertebral fx in women with known osteoporosis 2. Tx osteoporotic women w/ Rx x5 yrs 3. Offer Rx bisphosphonate to reduce vertebral fx risk in men w/ clinically recognized osteoporosis 4. No bone density monitoring during the 5yr Rx period for women 5. No HRT or raloxifene for osteoporosis tx in women 6. Decide whether to tx osteopenia in women > 65 y/o w/high fx risk based on discussion of pt preferences, fx risk profile, and benefits, harms, and costs of medicine
35
what is fibromyalgia?
soft tissue pain syndrome w/chronic sx and MC in women 20-50y/o
36
clinical presentation for fibromyalgia?
Chronic wide spread musculoskeletal pain (out of proportion), fatigue, cognitive disturbance, psych sx, multiple somatic sx
37
PE for fibromyalgia?
primarily noncontributory, trigger points of pain
38
red flags for fibromyalgia?
fam hx of myopathy, personal hx of CA, unexplained wt. loss or fevers, joint inflammation, neurologic abnormalities
39
dx for fibromyalgia?
hx: chronic wide spread pain in all 4 quadrants of body and axial skeleton, assess sleep and mood PE: 11 out of 18 tender points (joint exam) Labs: CBC, ESR, CRP, TSH, CK
40
nonpharm tx options for fibromyalgia
pt education, sleep hygiene, CBT, trigger point injections, massage therapy, chiropractic manipulation, acupuncture/pressure, EXERCISE
41
pharmacologic tx options for fibromyalgia?
TCA's (amitriptyline), SSRI/SNRI's (fluoxetine, duloxetine, milnacipran), anticonvulsants (pregabalin, gabapentin) do NOT use opioids!!
42
what is vasculides??
RARE inflammatory process w/in walls of affected blood vessels systemic or constitutional sxs w/evidence of organ dysfx
43
what are some vasculitis assoc. dz's?
large = giant cell arteritis medium = polyarteritis nodosa, kawasaki dz small = Wegners, churg-strauss, IgA vasculitis variable = Behcet's
44
manifestations of large vessel?
[function: life or limb] limb claudication, asymmetric BP's, absence of pulses, bruits, aortic dilation
45
manifestations of medium vessel?
cutaneous nodules, ulcers, livedo reticularis, digital gangrene, mononeuritis multiplex, microaneurysms
46
small vessel manifestations?
[skin] purpura, vesiculobullous lesions, urticaria, cutaneous extravascular, splinter hemorrhages [eyes] necrotizing granulomas, uveitis, episcleritis, scleritis [kidney] glomerulonephritis [lungs] alveolar hemorrhage
47
Polymyalgia Rheumatica (PMR): up to half of pt's w/ ____ have PMR?
giant cell arteritis (temporal arteritis)
48
who gets PMR?
50+y/o's, W>M
49
clinical presentation of polymyalgia rheumatica?
Stiffness, aching, pain in muscles of neck, shoulder and pelvic girdle (Shoulders, hips, lower back) Difficulty combing hair, putting on a coat, rising from chair Fever, malaise, wt loss
50
Dx for polymalgia rheumatica
clinical -- based on pain and stiffness anemia elevated acute phase reactants
51
tx for polymalgia rheumatica
Prednisone 10-20 mg/day (low dose), expect dramatic response in 72hrs, slow taper after 2-4 weeks, monitor for GCA
52
Polyarteritis nodosa
Necrotizing inflammation of medium-sized vessels and small arteries Neutrophilic infiltrate Some assoc. w/ hepatitis B
53
Polyarteritis nodosa presentation
Pain in the extremities – arthralgias, myalgias or neuropathy Skin – livedo reticularis, subcutaneous nodules, skin ulcers, distal gangrene Peripheral nerves – mononeuritis multiplex – foot drop Mesenteric vessels - intestinal angina Kidneys – renal insufficiency and HTN assoc. w/fever, malaise, wt. loss
54
Labs for polyarteritis nodosa?
Anemia, leukocytosis, elevated ESR, ANCA-negative | Test for active hepatitis B (HBsAg, HBeAg)
55
diagnosis for polyarteritis nodosa?
Tissue bx of involved organ Angiogram finding of aneurysmal dilations in renal, mesenteric, or hepatic arteries
56
tx for polyarteritis nodosa
High dose corticosteroids Cyclophosphamide in refractory dz --- Prophylaxis against Pneumocystis jiroveci
57
prognosis for polyarteritis nodosa??
poor w/out tx rarely relapses w/appropriate tx good prognosis (60-90%) Poor prognostic factors: CKD, proteinuria, GI ischemia, CNS dz, cardiac involvement
58
what is kawasaki dz??
``` Mucocutaneous LN syndrome Affects children < 5yo, peak 2 yrs M > F Etiology: Probably infectious in origin Fever and skin findings Cardiac abnormalities ```
59
clinical findings in kawasaki dz?
fever (>38.5F), conjunctivitis (b/l), mucositis (strawberry tongue), rash, lymphadenopathy, extremity changes (indurated edema dorsum of hands/feet)
60
labs for kawasaki disease?
``` Leukocytosis with left shift Normochromic, normocytic anemia Elevated acute phase reactants Elevated ALT/AST Thrombocytosis Pyuria ``` EKG and ECHO
61
tx for kawasaki dz?
ER/Cardiac Complications Rapid treatment Untx'd, risk of aneurysms increases 2 g/kg of IVIG administered over 10–12 hrs 80–100 mg/kg/d of aspirin in 4 divided doses
62
f/u for kawasaki dz?
ECHO
63
s/s of granulomatosis w/polyangiitis (wegner's)?
common: nasal congestion, sinusitis, OM, mastoiditis, gingivitis, stridor systemic: cough, dyspnea, hemoptysis, fever, malaise, wt. loss [joints] migratory oligoarthritis; large [eyes] scleritis, anterior uveitis [skin] purpura, dysesthesia
64
PE findings in granulomatosis w/polyangiitis?
``` Congestion Crusting Ulceration Bleeding Perforation of the nasal septum ``` CT scan!!!!
65
UA for pt w/granulomatosis w/polyangiitis?
proteinuria, RBC's, red blood cast
66
lab tests for granulomatosis w/polyangiitis?
usual: CBC, CMP, ESR, UA ANCA (+) consistent w/dx
67
tx for granulomatosis w/polyangiitis?
Pt. edu & support, early tx referral, prevent end-organ failure, preserve life, remission, cyclophosphamide plus corticosteroids OR Rituximab plus corticosteroids +/- plasma exchange PO QD > IV OC’s Methotrexate PCP prophylaxis
68
prognosis of granulomatosis w/polyangiitis?
fatal w/out tx
69
Eosinophilic Granulomatosis with Polyangiitis(Churg-Strauss syndrome) characteristics?
chronic rhinosinusitis, *asthma, peripheral blood eosinophilia, peripheral neuropathy, skin involvemnt (palpable purpura, subQ nodules), cardiac (heart failure, pericarditis)
70
dx for Eosinophilic Granulomatosis with Polyangiitis??
ANCA in 30-60% Consolidations, nodules or ground glass opacification on chest CT Lung bx (gold standard) or other affected tissue Other: ESR/CRP, UA, Sr Cr, Sr troponin
71
tx for Eosinophilic Granulomatosis with Polyangiitis
Systemic glucocorticoids | Advanced or refractory disease: immunosuppressive agents (cyclophosphamide)
72
prognosis of Eosinophilic Granulomatosis with Polyangiitis
70-90% 5-year survival with tx, deaths from vasculitic phase complications (MI, GI bleeding, renal failure), w/out tx 50% mortality w/in 3 mo's of onset
73
what is the MC systemic vasculitis in children??
IgA vasculitis, <13y/o, IgA
74
Clinical presentation IgA vasculitis
Acute onset fever, palpable purpura on LE and buttocks Tetrad: Purpura, Arthritis, Glomerulonephritis, Abd pain
75
Labs IgA vasculitis?
``` Urinalysis Skin Biopsy CBC CMP CRP ESR Elevated serum IgA levels Direct immunofluorescence ```
76
tx for IgA vasculitis
pt. edu, support, analgesics, , low-dose steroids | usu. self limiting
77
Behcet's syndrome?
Involves vessels of all sizes, both arterial and venous “Silk Road Disease” 20-40 y/o Usu. sporadic, familial clustering possible M:F 1:1
78
clinical presentation for behcet's syndrome?
Recurrent, painful mucocutaneous ulcers Skin lesions Ocular
79
Tx
``` Aphthous ulcers – topical or intralesional steroids Prednisone Colchicine Thalidomide MTX Azathioprine Cyclosporine TNF-alpha inhibitors ```

Fdnts 3 exam 4 (3 decks)

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