Rheumatology 3 Flashcards
(42 cards)
Fibromyalgia: Give the general overview
Characterized by WIDESPREAD chronic musculoskeletal pain with multiple tender points, cause is unknown
Pain and stiffness is diffuse, but predominates in the neck, shoulders, low back, and hips
Affects 3-10% of the general population, most common in women 20-50 years old
Fibromyalgia: Describe the clinical manifestations
1) Characterized by a NORMAL physical exam, except for “trigger points” in various areas of the trapezius, medial fat pad of the knee and lateral epicondyle of the elbow
2) This may be accompanied by other somatic symptoms, particularly fatigue and sleep disturbances, as well as cognitive and psychiatric disturbances
3) These symptoms occur in the absence of abnormal lab findings and negative imaging studies
How do you Dx fibromyalgia?
CRP/ESR will be normal, no specific autoantibodies noted
Radiographs will not show joint destruction, narrowing, or effusions
This is a DIAGNOSIS OF EXCLUSION
You must rule out other causes of symptoms first
Fibromyalgia:
1) What are the diagnostic criteria?
2) What must you rule out?
1) Multiple tender points (trigger points) that have been present for 3 months, and all lab tests and imaging studies are normal
2) You rule out other causes and other endocrine or rheumatological conditions (hypothyroidism, PMR, other seronegative rheumatoid diseases)
What meds show modest efficacy for fibromyalgia?
Amitriptyline (PANCE considers this treatment of choice)
Fluoxetine
Duloxetine
Gabapentin
Pregabalin
Cyclobenzaprine
Naltrexone
What is often helpful for fibromyalgia?
Mindfulness, meditation, CBT, exercise are often helpful
What is the prognosis for fibromyalgia?
All patients have chronic symptoms, but this is not a progressive disease, and objective findings do not develop
Patients may find comfort in earning a diagnosis since the road to it can be frustrating and long
Gout:
1) What is it characterized by?
2) What is the main lab finding?
3) Who is it seen in?
4) What causes most cases?
1) Characterized by recurring acute monoarticular arthritis that can develop into chronic deforming arthritis
2) Manifested by hyperuricemia (>6.8 mg/dL) or rapid fluctuations in serum urate levels
3) 90% of cases of primary gout are in males over 30 years old. In women onset is typically postmenopausal
4) Most cases caused by eating too much processed meats, fructose, alcohol, medications
What are the clinical manifestations of gout? Explain
1) Sudden onset of red, hot, swollen joint
-Podagra: large, erythematous, warm MTP joint of big toe, which is the most susceptible joint
2) Feet, ankles, knees can also be affected
3) Rapid onset, frequently nocturnal, exquisitely painful, fever common
4) Local desquamation and pruritus during recovery phase
5) Can have tophi formation: nodular deposits of urate crystals in soft tissue or joints that develop from elevated uric acid levels for prolonged periods of time
-Can lead to pain and ulcerations
What are the lab findings in gout?
Serum uric acid level may be elevated. It is better to do serial measurements since a single level can be normal in 12-43% of gout cases
A normal serum acid level does not EXCLUDE gout
May have neutrophilic leukocytosis, elevated ESR or CRP during flares
How is gout diagnosed? Explain
Establishes the diagnosis of gout
Aspirate shows negatively birefringent crystals that are “needle shaped” (this distinguishes from pseudogout which we will talk about next)
Culture-negative
Joint aspiration will rule out septic arthritis. If aspirate has WBC >50k, negative for crystals and starts growing something funky …it’s not gout
Describe gout on XR
X-rays are usually normal early in the disease
Later, they may show “punched out” erosions surrounding the joint, sometimes called “rat-bite” lesions
What are the 3 main ways to reduce inflammation during gout flareups? Explain each
1) NSAIDs (indomethacin or naproxen)
-Beware of NSAIDs contraindications: PUD, CKD, allergy
2) Colchicine (if symptoms have been present for less than 36 hours)
-Loading dose of 1.2mg, then 0.6mg one hour later
-Then 0.6mg BID until resolution of symptoms
-Do not use if there is kidney or liver impairment
3) Steroids (to be used as a last resort)
-May be given systemically, especially if other medicines are not an option
-Can be given as an intra-articular injection, but must r/o septic arthritis
How do you manage gout between attacks?
Goal is to minimize urate deposition in tissues and to reduce frequency and severity of attacks
1) Lifestyle changes: Change diet, decrease high purine intake (meats, high fructose, shellfish), reduce alcohol
2) Medication changes: Stop thiazide diuretics, loop diuretics, and niacin (these can precipitate a gout attack due to increasing uric acid levels)
If attacks keep occurring with lifestyle and medication changes, check uric acid when not having a flare, if elevated, then this indicates the cause
How do you manage a pt between attacks if they have >2 attacks/ yr or uric acid levels high even when not in a flair?
1) Target uric acid with allopurinol to prevent flares
Sometimes initiation of urate-lowering therapy can precipitate flares, likely due to an acute fall in levels. May need colchicine treatment for 3-6 months
Goal of allopurinol is to maintain serum uric acid levels less than 6 mg/dL.
Do not start during an acute flare. Treat flare first.
If flare starts after initiation, treat flare and continue allopurinol
2) Other medications:
Probenecid-uricosuric drug. Treatment of choice if patient has a good diet and 24-hour uric acid level is normal. This means their issue is underexcretion
Pegloticase- porcine-like uricase that is used in patients with severe, refractory gout. Given IV every 2 weeks
Pseudogout:
1) Who is it seen in?
2) What joints is it found in?
3) What can it mimic Sx of?
1) Prevalence increases with age, often seen in people over 60
2) Typically involves the larger joints, knee and wrist are most common. Can also affect shoulders, ankles, feet, elbows, etc.
3) PMR
What is the main test for pseudogout? Explain
Joint Aspiration + Fluid Analysis
-Since patient will present with sudden onset of a red, hot, swollen joint, it’s ideal to aspirate to get a good idea of what you are working with
-Aspirate will show positively birefringent crystals with rhomboid shape
-And remember, you will need to r/o septic arthritis
How do you Tx pseudogout?
1) NSAIDs are the most helpful in acute attacks.
2) Colchicine 1-2 times daily works better for prophylaxis than for treatment of acute flares
3) Intra-articular steroid injections work well for symptomatic relief, depending on the joint
4) Systemic steroids are the last resort
How common is osteoporosis?
Causes 1.5 million fractures annually in the U.S.
List some other Fxs that may be seen in osteoporosis
Hip fractures (15% of women and 5% of men by 80 years old)
Distal radius (Colles’ fracture)
Pelvic fractures
Besides being found incidentally, when else may you see this present?
Sometimes a patient will come in with or without back pain and complaining that they are getting shorter as they get older
What are some common causes of osteoporosis?
Aging
Ethnicity
Sex
Hormone deficiency
Alcohol use
Cigarette smoking
Long term PPI therapy
High dose and/or chronic steroid use
Laboratory testing is required to screen for secondary causes of osteoporosis; list and describe these tests
1) If low T-score, it’s recommended to obtain: BUN, creatinine, albumin, serum calcium, phosphate, alkaline phosphatase, and 25-hydroxyvitamin D
-2) If serum calcium is abnormal, need to obtain serum PTH
-3) CBC is usually normal. If anemia present, screen for plasma cell myeloma and intestinal malabsorption
-4) Test for thyrotoxicosis, hypogonadism, celiac disease if clinically indicated
How can you prevent osteoporosis?
1) Diet should be adequate in protein, total calories, calcium, and vitamin D
2) Steroids should be d/c or reduced if possible
3) Smoking cessation is key
4) Avoid excessive alcohol intake
5) Exercise is recommended to increase both bone density and overall strength
-Reduces the risk of fractures due to frailty falls
-Both aerobic and resistance training
-Weight bearing exercises are best
