Rheumatology Flashcards
(21 cards)
Name four lung manifestations of rheumatoid arthritis.
ILD (NSIP pattern), pleural effusion, pulmonary nodules, bronchiolitis obliterans.
What are two seronegative RA diseases and how do you treat?
- RA of the elderly (PMR with synovitis): treat as RA.
- Remitting seronegative symmetrical synovitis with pitting edema (men, swollen hands): low dose steroids, NSAIDs, hydroxychloroquine.
How long should you treat latent TB before starting biologic therapy?
At least 1 month.
Which vaccines are recommended with methotrexate?
Influenza (can hold methotrexate for two weeks after vaccine to improve immunogenicity), pneumococcal, hepB, herpes zoster.
Six populations where biologics are controversial.
NYHA 3+ CHF, active hepatitis (treat first), prior LPL (rituximab), prior solid cancer, prior skin cancer (DMARDs), prior serious infection (tocilizumab)
Which medications do you discontinue before pregnancy?
Methotrexate - 3 months, leflunamide - 2 years
What is the time frame for reactive arthritis?
days to 4 weeks post GI/GU infection
How do you treat reactive arthritis?
NSAIDs, intra-articular steroids, DMARDs for recurrent/ chronic disease. Rarely TNFa and never antibiotics.
What are the indications for urate lowering therapy?
> 2 attacks per year, tophi, gouty arthropathy, CKD 3+, nephrolithiasis.
What were the results of the CARES trial?
Increased cardxiovascular and all-cause mortality with febuxostat compared to allopurinol.
What are the components of ENA?
Anti-smith (lupus 30-40%), anti-histone (lupus 50-70%, DIL), anti-RNP (lupus 30-40%, MCTD), anti-Ro (Sjogren’s, congenital heart block), anti-la (Sjogren’s).
What are the major treatments for class III/IV lupus nephritis flare and maintenance who should get which?
Flare: Pulse steroids and Cyclophosphamide or MMF (better results for African-American and Hispanic patients) or azathioprine for pregnant.
Maintenance: MMF or azathioprine.
Which APLA antibodies are safe to take on anticoagulants?
Anticardiolipin and anti-B2 glycoprotein. Lupus anticoagulant can be taken on warfarin or DOAC.
Which drugs cause drug-induced lupus?
Hydralazine, procainamide, TNFa, isoniazid.
How do you treat Libman-Sacks endocarditis?
Steroids and anticoagulation.
What are some associations with diffuse scleroderma?
Positive anti-Scl/topoisomerase I, distal and proximal extremities with face and trunk, ILD, scleroderma renal crisis (10-20%, early disease, increases with prednisone), gastric antral vascular ectasia
What are some associations with limited cutaneous scleroderma?
CREST syndrome, distal to elbows and knees with face involved, anti-centromere (60%), pulmonary hypertension (5%)
What are myositis-specific antibodies?
- Anti-synthetase syndrome (anti-Jo1 positive) with acute onset, constitutional symptoms, ILD, mechanics hands, skin ulcers, arthritis, Reynaud’s, negatively associated with malignancy.
- Anti-Mi2 carries favourable prognosis.
- Anti-NXP2 and anti-TIF1-gamma associated with malignancy.
Name two non-classic inflammatory myositides.
Inclusion body (men, distal, dypsphagia), necrotising autoimmune (severe, high CK, positive HMG CoA reductase antibody, often paraneoplastic).
What are 4 xray findings of osteoarthritis.
Joint space narrowing, osteophytes, subchondral sclerosis, subchondral cysts.
How do you manage methotrexate-induced liver enzyme elevation?
AST > ULN – reduce MTX dose by 2.5 mg → repeat LFTs q2w until resolved
AST > 2x ULN – reduce MTX dose by 50% → repeat LFTs q2w until resolved
AST > 2x ULN for 2 consecutive measurements – hold MTX → repeat LFTs q2w until resolved
Liver Biopsy if 5/9 or 6/12 ↑ AST, persistent ↓ albumin, >1.5g of MTX or risk of liver damage