Rheumatology

Question 1

what is the recommended dosage for GCA steroid therapy w/ no visual loss?

Answer 1

60 mg oral prednisone for 2 weeks, then taper to 2 weeks of 50 mg

Question 2

what is the recommended dosage for GCA steroid therapy for high risk patients or those w/ visual loss?

Answer 2

high dose steroids for 3 days (500-1000 mg methylprednisone) followed by 60 mg prednisone for 2 weeks, then taper to 50 mg prednisone for 2 weeks

Question 3

GPA is diagnosed by…

Answer 3

tissue biopsy

Question 4

pathology w/ drug induced vasculitis is caused by…

Answer 4

molecular mimicry (so would expect to see lots of different random antibodies to be (+) so would see c-ANCA and p-ANCA (+) for example)

Question 5

SLE criteria is >*** for ANA to meet criteria

Answer 5

40

Question 6

vasculitis stroke pattern looks like…

Answer 6

more scattered pattern

Question 7

inflammatory monoarthritis etiologies tend to be either:

Answer 7

crystal-induced or infectious etiologies

Question 8

acute inflammatory oligoarthritis may be caused by either…

Answer 8

gonorrhea or rheumatic fever

Question 9

chronic non-inflammatory oligoarthritis is usually caused by…

Answer 9

osteoarthritis

Question 10

how much involvement does genetics have in the etiology of RA?

Answer 10

60% risk

Question 11

the most important genetic risk factor for RA is:

Answer 11

class II HLA group, especially HLA-D alleles (codes for specific protein that binds CCP)

Question 12

one of more specific markers for RA

Answer 12

anti-CCP

Question 13

most important environmental risk factor for RA

Answer 13

smoking (can lead to lung inflammation and activation of PADI, which promotes local protein citrullination)

Question 14

important infectious risk etiology for RA development

Answer 14

periodontal dx (porphyromonas gingivalis) (others include mycoplasma species, EBV and parvo B19)

Question 15

are hormones related to development of RA?

Answer 15

yes, but incompletely understood. there are estrogen receptors on synovial fibroblasts that may drive cartilage destruction

Question 16

classic presentation of RA includes pain in the ** (morning/evening) that lasts at least ** minutes

Answer 16

morning, lasting at least 30-45 minutes (stiffness is worse following rest)

Question 17

RA mostly affects which joints?

Answer 17

MCPs and MTPs, and proximal interphalangeal joints of the hands and feet, but spares the distal interphalangeal joints. RA tends to affects joints symmetrically as well (but severity can be asymmetric)

Question 18

what is RF?

Answer 18

it is a Ig (usually IgM) that targets the Fc portion of IgG. it occurs in 70% of RA patients (so it is not a great marker for RA, cause it has the same sensitivity as anti-CCP and is very non-specific, it is present in other inflammatory dx)

Question 19

*** is most predictive of erosive dx in patients already diagnosed w/ RA

Answer 19

anti-CCP

Question 20

typical radiographic changes in patients w/ RA

Answer 20

peri-articular osteopenia, marginal erosions and joint space narrowing (remember to get radiography of the cervical spine as well if C1-C2 subluxation is suspected)

Question 21

extra-articular manifestations and complications of RA include…

Answer 21

rheumatoid nodules, dry eye and scleritis, ILD, pleural effusions, and anemia of inflammation

Question 22

*** is the first line DMARD in RA

Answer 22

MTX (15 mg weekly but can be titrated up to 25 mg)

Question 23

what supplement should always be given w/ MTX?

Answer 23

folic acid

Question 24

*** is another DMARD option if patient is not able to tolerate MTX

Answer 24

leflunomide

Question 25

when do you use biologic DMARDs for RA?

Answer 25

when there is high dx activity despite being on MTX (always try MTX first). TNF-a inhibitors are most common and have evidence of synergy w/ MTX

Question 26

NSAID use in RA..

Answer 26

only use when waiting for DMARDs to kick in (they are NOT disease modifying and do NOT prevent joint damage)

Question 27

when to use glucocorticoids in RA

Answer 27

low dose (5-15 mg) prednisone can be used to improve RA sx while bridging to a DMARD, and can be used short term for dx flares

Question 28

important adverse effects of glucocorticoids to keep in mind

Answer 28

osteoporosis w/ long term use, diabetes mellitus, and infection

Question 29

most important modifiable risk factor for OA

Answer 29

obesity (specifically OA of the knee)

Question 30

osteoarthritis is a chronic progressive disorder characterized by...

Answer 30

cartilage and meniscal degradation, subchondral bone changes, osteophyte formation, and low-grade synovitis

Question 31

Erosive OA is a subset of primary hand OA and typically affects which joints?

Answer 31

DIP and PIP

Question 32

*** is a non-inflammatory condition characterized by calcification and ossification of the spinal ligaments (especially the anterior longitudinal ligament) and entheses (tendon and ligament attachments to bone)

Answer 32

diffuse idiopathic skeletal hyperostosis (DISH)

Question 33

typical description of pain pattern w/ OA

Answer 33

insidious onset of sx, joint pain is exacerbated by activity and relieved by rest, can have morning stiffness lasting less than 30 minutes (as opposed to RA, which is >30 min)

Question 34

radiographic findings in OA include...

Answer 34

asymmetric joint space narrowing, subchondral sclerosis, osteophytes, bone cysts (remember, radiographic findings are NOT necessary to diagnose OA)

Question 35

when are pharmacologic agents for OA considered?

Answer 35

when non-pharmacologic therapy does not work (since there are no DMARDs specifically for OA). drug options include NSAIDs, acetaminophen, duloxetine, and tramadol (try topical NSAIDs first, or capsaicin especially in older patients)

Question 36

*** is recommended pharmacologic therapy for hip and knee osteoarthritis when conservative measures have failed, acetaminophen is suggested as an add-on therapy

Answer 36

NSAIDs and duloxetine

Question 37

fibromyalgia pathophys

Answer 37

not well understood, but thought to be related to central sensitization, so there is abnormal processing and pain perception, and amplification of pain signaling in the central nervous system

Question 38

what tests are specific to the dx of fibromyalgia?

Answer 38

none

Question 39

initial management of fibromyalgia

Answer 39

reassurance that sx are real, and pain will not lead to tissue injury. aerobic exercise can improve pain. patients should also be assessed for psych stressors and psych illness.

Question 40

pharmacologic options for fibromyalgia (remember: no studies have directly compared efficacy of medication therapy for fibromyalgia)

Answer 40

gabapentin and pregabalin (short term), low dose amitriptyline is an option, SNRIs (evidence does NOT support use of NSAIDs for fibromyalgia)

Question 41

genetic association w/ ankylosing spondylitis

Answer 41

HLA-B27

Question 42

spondyloarthritis is a blanket term that includes...

Answer 42

ankylosing spondylitis, psoriatic arthritis, reactive arthritis, and enteropathic arthritis

Question 43

*** is a chronic inflammatory disease affecting the axial skeleton (including sacroiliac joints), entheses, and peripheral joints

Answer 43

ankylosing spondylitis