Rheumatology Investigations and Management

Question 1

What is the criteria for diagnosing RA?

Answer 1

ACR/EULAR classification criteria

Question 2

RA investigations

Answer 2

Blood testing (anaemia, raised platelets)
Inflammatory markers
Autoantibodies (anti-CCP)
Imaging (x-ray, US, MRI)

Question 3

RA management

Answer 3

DMARD (1st methotrexate, 2nd sulfasalazine, 3rd hydroxychloroquine)
Steroids (for exacerbations)
Biologics (if DAS28 greater than 5.1 on 2 occasions 4 weeks apart)

Question 4

Lupus diagnostic investigations

Answer 4

ANA
Anti-dsDNA
Anti-Sm
Antiphospholipid ab
Low complement
Direct coombs test (haemolytic anaemia)

Question 5

Lupus organ involvement investigations (depend on symptoms)

Answer 5

CXR
Pulmonary function tests
CT chest
Urine protein quantification
Renal biopsy
Echocardiogram
Nerve conduction studies
MRI brain

Question 6

SLE management

Answer 6

NSAIDs and simple analgesia
Hydroxychloroquine (may reduce systemic complications)
Steroids (varying dose for complications)
DMARDs
Biologics

Question 7

Raynauds management

Answer 7

Calcium channel blockers or PDE5 inhibitors (sildefanil)

If digital ulcers - prostacyclin analogues (iloprost), botox injections, endothelin receptor antagonists (bosentan)

Question 8

Systemic sclerosis management

Answer 8

Yearly ECHO and PFTs
Treat raynauds
Treat reflux (PPI)
Treat pulmonary fibrosis (immunosuppression)
Treat pulmonary hypertension (prostacyclin analogues, endothelin receptor antigonists, PDE5 inhibitors)
Tight blood pressure control (ACEI)

Question 9

Sjogrens investigations

Answer 9

Antibodies (anti-ro and anti-la, ANA)
Salivary gland ultrasound and biopsy (if antibodies negative)
Inflammatory markers (high ESR/PV)
Raised IgG
Cytopaenia

Question 10

Sjogrens management

Answer 10

Lubricants
Strong fluoride toothpaste
Hydroxychloroquine (if fatigue and arthralgia)
Immunosuppression for major organ involvement

Question 11

Antiphospholipid investigations

Answer 11

Autoantibodies (anti-cardiolipin, lupus anticoagulant, beta 2 glycoprotein)
Thrombocytopenia

Question 12

Anti-phospholipid management

Answer 12

Lifelong anti-coagulation IF THROMBOSIS

Question 13

General principles of CTD management

Answer 13

Assess disease severity
Urinalysis
CXR, PFT, ECHO
Manage cardiovascular risk factors
If major organ involvement - immunosuppression
If not - hydroxychloroquine, symptomatic management

Question 14

Poly/dermatomyositis investigations

Answer 14

Blood tests (CK, inflammatory markers, U&E, PTH, TSH)
Autoantibodies (ANA, anti-Jo-1)
Electromyography
Muscle biopsy (definitive test)
MRI

Question 15

Poly/dermatomyositis management

Answer 15

Steroids (prednisolone)

Immunosuppressants (steroid sparing)

Question 16

Temporal arteritis/polymyalgia rheumatica investigations

Answer 16

Inflammatory markers (raised)
Temporal artery biopsy

Question 17

Temporal arteritis/polymyalgia rheumatica management

Answer 17

Low dose steroids in just polymyalgia rheumatica
Higher dose in temporal arteritis
Gradual reduction in dose around 18 months to 2 years

Question 18

Fibromyalgia management

Answer 18

Supportive/holistic therapy (including graded exercise therapy)
Antidepressants
Analgesia
Gabapentin/pregabalin

Question 19

What is the radiographic grading scale for OA?

Answer 19

Kellgren-lawrence

Question 20

OA management

Answer 20

Physiotherapy
Lifestyle advice
Analgesia
NSAIDs
Atypical pain killers
Intra-articular steroids
Surgery

Question 21

Gout investigations

Answer 21

Inflammatory markers (raised)
Serum uric acid (may be raised or normal)
Synovial fluid polarised microscopy (diagnostic)
X-rays

Question 22

Gout management

Answer 22

Acute: NSAID (colchicine second line)
Steroid

Prophylaxis: allopurinol or febuxostat (2-4 weeks after acute attack)
Need to take NSAID or colchicine as well.

Question 23

Pseudogout management

Answer 23

NSAIDs
Colchicine
Steroids
Rehydration

Question 24

Milkwaukee shoulder management

Answer 24

NSAIDs
Intra-articular steroid
Physiotherapy
Partial or total arthroplasty

Question 25

Score for hypermobility name

Answer 25

Modified beighton score

Question 26

Criteria for ank spon name

Answer 26

ASAS classification criteria

Question 27

Ank spon investigations

Answer 27

Inflammatory markers HLA B27 X-ray

Question 28

Ank spon management

Answer 28

Physio/occupational therapy NSAID DMARDs if peripheral joint involvement Anti-TNF/anti-IL17 if severe

Question 29

Psoriatic arthritis investigations

Answer 29

Inflammatory markers (raised) Negative RF X-rays (pencil in cup, enthesitis)

Question 30

Psoriatic arthritis management

Answer 30

``` NSAIDs Steroid IA DMARDs Anti-TNF (if unresponsive to DMARDs) Anti-IL17 ```

Question 31

Reactive arthritis

Answer 31

Inflammatory markers FBC/U&Es HLA B27 (rarely necessary) Cultures Joint fluid analysis (rule out septic arthritis) X-ray Ophthalmology opinion (for eye involvement)

Question 32

Reactive arthritis management

Answer 32

NSAIDs Corticosteroids (IA, oral, eye drops) Antibiotics for underlying infection DMARDs if resistant or chronic

Question 33

Enteropathic arthritis management

Answer 33

``` Treat inflammatory bowel disease (controls arthritis) NO NSAID Normal analgesia Steroids DMARDs Anti-TNF ```

Question 34

Small vessel vasculitis investigations

Answer 34

ANCA, PR3, MPO (varies with disease activity) | C3/4

Question 35

Anca associated vasculitis management

Answer 35

Localised/early systemic - methotrexate and steroids Generalised/systemic - cyclophosphamide and steroids Refractory - IV immunoglobulins, rituximab

Question 36

HSP investigation and management

Answer 36

Self-limiting | Urinalysis to screen for renal involvement