Rheumatological Disorders and Treatment of RA, SLE, and Gout
What is the treatment for rhabdomyolysis?
-Aggressive IVF (4-6L/day), mannitol, urine alkalization (prevent precipitation of myoglobin in the renal tubules)
What are the side effects for leflunomide in treating RA?
-Hepatotoxicity, nausea, diarrhea, HTN, rash, abdominal pain
In what groups of people is gout prophylaxis possibly considered for?
-Previous, but infrequent flares (> 2/year) -First flare and CKD Stage 3+, uric acid > 9, or urolithiasis
What is the most common cause of mortality in older patients with SLE?
Atherosclerosis; much higher risk of CV death
What lab value is specific to scleroderma?
anti-SCL 70 -Other labs values: (+)ANA, anemia, anticentromere Ab
What are the most commonly affected joints in gout?
#1 is 1st MTP joint (Podagra) -Feet, ankles, knees -Usually monoarticular; polyarticular is long-standing disease.
What medications are used to treat fibromyalgia?
#1- Gabapentin and Pregabalin, TCA -Muscle Relaxants -Non pharm: Exercise, sleep hygiene, cognitive therapy
What things should be avoided when taking methotrexate?
-Alcohol, echinacea, loop diuretics, PPIs, sulfonamide drugs, vaccines (especially live).
What types of foods/supplements should be avoided in those with SLE?
-Alfalfa sprouts, garlic (mostly large amounts like in supplements), echinacea -Sulfa drugs should be monitored.
What foods should be avoided with gout?
-Animal Purines (shell fish, sardines, herring, turkey, veal, etc) -Organ Meat -Alcohol (Beer) -Fructose
What are the DDI of leflunomide in treating RA?
-Bile acid sequestrants, echinacea, estradiol, norethindrone, grazoprevir, Tysabri, Nurtec.
What are the components of CREST for limited scleroderma?
-Calcinosis of Skin -Raynaud's Phenomenon -Esophageal Dysmotility -Sclerodactyly thickening -Elongated Fingers with Ulceration and Calcification -Telangiectasias ***Due to diffuse fibrosis of the skin.
Aquifer Summary of RA
-Can develop at a broad range of ages. -Can have associated subcutaneous nodules that are firm, nontender, and located at pressure points. -Joint stiffness for more than 30 minutes in the morning is common. -Typically bilateral joint pain, involving three or more joints (in particular the hands or feet).
Aquifer Summary for Psoriatic Arthritis
-Common clinical manifestations may include peripheral arthritis, nail and skin disease, dactylitis, enthesitis and axial disease. -Clinical pattern is variable, and arthritis may precede skin changes. -Skin findings precede joint symptoms in up to 75% of patients. Can be difficult to distinguish from RA if skin changes are not present, though less common.
Which SLE medications are safe to use in pregnancy?
-Corticosteroids -Hydroxychloroquine -Azathioprine
What type of medications are used to treat lupus dermatitis?
-Face: Fluocinolone or hydrocortisone -Trunk: Triamcinolone or betamethasone -Scalp/Soles/Palms: Clobetasol -Topical Calcineurin Inhibitors: Tacrolimus or pimecrolimus -Systemic steroids and hydroxychloroquine also help
NSAIDS should be avoided in what groups of people?
-Hx of gastropathy, especially ulcers/GI bleeds -Renal Insufficiency (eGFR < 30 or eGFR < 60 with increased risk of AKI) -Heart Failure -Uncontrolled HTN -> 65 y/o
What are the most common drugs causing drug induced lupus?
-Hydralazine, TB medications, minocycline, TNF- alpha inhibitors, procainamide, quinidine, methyldopa, chlorpromazine -Symptoms: Fever, myalgias, arthralgias, serositis. No renal or neurologic issues. Tx: Stop the offending agent and will improve within months to a year.
What are other systemic symptoms of RA?
-Inflammatory nodules over shins/extensor surfaces -Small vessel vasculitis: Small hemorrhages of the nailfolds/finger pulps Ocular: dryness, scleritis, episcleritis Other: Interstitial lung disease, pericarditis, pleuritis, small vessel vasculitis, aortitis, Felty Syndrome, Palmar Erythema
What is the treatment for APLA?
-Life-long: Anticoagulants (Warfarin) -Pregnancy: Heparin and ASA (warfarin is teratogenic)
What is the first line therapy for preventing disease progression for RA?
-Methotrexate
What are the types of non biologic DMARDS used to treat RA?
-Methotrexate -Leflunomide -Hydroxychloroquine -Sulfasalazine ***Should be used before trying biologic DMARDS.
What are the types of immunomodulators used to treat SLE?
-Methotrexate: Avoid in pregnancy! -Azathioprine: Safe in pregnancy! -Mycophenolate motefil (Cellcept): Used for cyclophosphamide refractory disease. Avoid in pregnancy!! -Cyclophosphamide -Rituxumab
In African American/Hispanic patients with lupus nephritis, which immunomodulating medications are most effective?
-Mycophenolate motefil -Rituxumab
Aquifer Summary of Gout
-Occurs in recurrent episodes of acute unilateral pain and swelling lasting days to weeks. -Most common joint is the first metatarsophalangeal joint, though other joints, such as the knees, are commonly affected. -Can be associated with tophi, which are visible or palpable nodules often located on the ears or in the soft tissue. Tophi can also form in the bones, joints, and cartilage. They are typically not painful and take years to develop.
What are the AE for methotrexate in treating RA?
-Photosensitivity, GI toxicity, N/V/D, GI ulcers, bone marrow depression, anemia, SJS/TEN, hepatotoxicity, fatal infection, nephrotoxicity, neurotoxicity, headache, pulmonary toxicity, dizziness, decreased libido.
What are the contraindications for methotrexate in treating RA?
-Pregnancy, lactation, men trying to father children due to fertility issues, alcoholism, alcohol liver disease, other chronic liver disease, immunodeficiency syndromes, pre-existing blood conditions. ***Must be on birth control while taking this
What are the AE of hydroxychloroquine?
-Retinopathy (main AE), alopecia, weight loss, N/V/D, anemia, acute hepatic failure.
What is the symptom criteria for SLE? (SOAP BRAIN MD)
-Serositis: Pleuritis, pericarditis, endocarditis, restrictive lung disease, effusions, pneumonitis -Oral or Nasopharyngeal ulcers -Arthritis: Non erosive of 2+ peripheral joints -Photosensitivity: Skin Rashes from UV light -Blood Disorders -Renal Involvement: Proteinuria >0.5/day or 3+ urine dipsticks. Cellular casts on UA -(+)Anti-nuclear antibodies -Immunologic Phenomenon: (+)anti-DNA, Anti-Sm, (+)Antiphospholipid antibodies -Neurologic Disorder: Seizures, psychosis, cognitive defects, CVA, myelitis, neuropathy -Malar Rash: Spreads across the bridge of the nose -Discoid Rash: Erythematous raised patches with kerotic scaling/follicular plugging. ***Must meet 4/11 of the symptoms (not necessarily all at once) to be diagnosed with SLE!!!!! -Other common symptoms not included in criteria: Alopecia, Reynaud's Phenomenon, splinter nail hemorrhages, fever, anorexia, fatigue, weight loss, conjunctivitis, photophobia.
What medications are known to cause hyperuricemia?
-Thiazide and loop diuretics -Niacin -ASA
What are the types of JAK inhibitors used to treat RA?
-Tofacitinib (Xeljanz)- Risk of serious infection and malignancy -Baricitinib (Olumiant)- Risk of VTE, URI, Shingles -Upadacitinib (Rinvoq)- Risk of serious infection, VTA, malignancy
Aquifer Summary of Septic Arthritis
-Typically presents with a single painful joint. -Exam is usually remarkable for swelling and warmth. -Patients are typically febrile, though sometimes elderly patients will be afebrile with this diagnosis. -Risk factors include diabetes, rheumatoid arthritis, prosthetic joints, recent surgery, preceding skin infection or trauma, and being over the age of 80. -Often resembles gout or pseudogout, but can be differentiated from these by joint aspiration. In septic arthritis, the fluid appears very turbid (opaque) and has an abundance of inflammatory cells (white blood cell count 15,000 to > 200,000; the lower part of this range (< 35,000) may be associated with infections caused by low virulence or partially treated organisms, and the synovial white blood cell count may be elevated in inflammatory causes of arthritis, though usually not as markedly as in septic arthritis.) In gout or pseudogout, the fluid is usually slightly turbid with a moderate amount of white blood cells (3,000 to 50,000), and the presence of crystals (calcium pyrophosphate or monosodium urate) is diagnostic.
In what groups of people is gout prophylaxis strongly recommended against?
-Uncomplicated first flare -Asymptomatic hyperuricemia
Aquifer Summary of OA
-Usually the large joints are asymmetrically involved. -Can be monoarticular in young adults if due to trauma or a congenital defect, but more commonly presents as polyarticular or generalized arthritis. -Joint stiffness, if present, is typically worse after effort.
What are systemic symptoms of Sjorgren's Syndrome?
-Vasculitis, pleuritis, obstructive lung disease, neuropsychiatric symptoms, pancreatitis, renal tubular acidosis, interstitial nephritis.
Fibromyalgia affects which population of patients?
20-50 y/o female ***If over 50 y/o, or have fever, weight loss, should do further work-up for other causes of symptoms
How long is prophylaxis treatment for gout?
3-6 months -Can also be indefinitely to maintain SUA <6.
Above what dosage will you see the best results when using allopurinol for gout prophylaxis?
> 300 mg/day; no more than 800 mg/day -Start low to prevent hypersensitivity syndrome; titrate every 2-5 weeks as needed and based on renal function. -Allopurinol is safe to use in CKD!
Above what uric acid level is hyperuricemia?
> 6-8 mg/dL
In what groups of people is gout prophylaxis strongly recommended for?
>/= 1 Tophi -Evidence of radiographic damage -Frequent gout flares (>/= 2 per year)
What lab value is highly sensitive for SLE, but not necessarily specific?
ANA (Anti Nuclear Antibody) (-)ANA= most likely not lupus (+)ANA= could be lupus, but can be other autoimmune conditions as well.
What is the first line biologic DMARD for treating RA?
Adalimumab (Humira)- TNF alpha inhibitor AE: headache, rash, positive ANA titer, antibody development, infection, injection site reaction, HTN
Patient is a 34 y/o female who is presenting in labor at 29 weeks due to pre-eclampsia. G:7 P:2 A:4 (spontaneous). She had pre-eclampsia during both of her other pregnancies (live birth) as well. She reports four first trimester miscarriages as well due to vascular issues with her placenta. She is also on daily ASA due to history of frequent DVT. What lab values are used to diagnose the suspected condition?
Anti-Phospholipid Syndrome Labs: - (+)Anti-cardiolipin Ab - (+)Beta-2 glycoprotein -(+)Lupus Anticoagulant- Also indicated by prolonged PTT -Thrombocytopenia ***Must have above lab values AND symptoms (hx of early labor due to pre-eclampsia, 3+ miscarriages; placental issues, thrombotic events at a younger age (?)) -positive lab values doesn't always indicate the disorder! *** If making an isolated diagnosis, cannot have any other symptoms of lupus (SOAP BRAIN MD), otherwise it is lupus.
During an acute attack, in which allopurinol is given, what other medication MUST be given with it?
Anti-inflammatory: NSAID, Colchicine, Corticosteroid -Because sudden shift in UA mobilization from allopurinol can exacerbate a flare.
Why is it important that patients taking cyclophosphamide stay hydrated?
Can lead to hemorrhagic cystitis -Need aggressive fluids (before, during, after treatment)
A patient, who recently began strenuous exercise to prepare for a triathlon, presents with mild diffuse myalgias and tea colored urine. What lab value(s) are likely to be elevated in this patient?
Cause: Breakdown/necrosis of skeletal muscles leads to release of contents (such as myoglobin) Labs: -Myoglobinuria -Markedly CK (5-10x above normal) -Myoglobulin (UA is (+)for blood, but no RBC in sediment) -Elevated AST/ALT released from the muscles
What are the common symptoms of fibromyalgia?
Chronic pain, stiffness of the entire body (especially in neck, shoulders, low back, and hips) for greater than 3 months. -Insomnia, HA, IBS symptoms. ***Diagnosis of exclusion
Other than an NSAID, what is another treatment of choice for oligo-articular gout?
Colchicine -Do not use if Cr Cl < 30 ml/min
What is the BBW for febuxostat?
Increased risk of CV death in those with hx of CVD.
What is the BBW for adalimumab (Humira)?
Increased risk of lymphoproliferative cancers and active tuberculosis. ***Must get a PPD prior to treatment
What is the most common cause of mortality in younger patients with SLE?
Infection, renal or CNS disease
Where are the tender trigger points of fibromyalgia?
Must meet 11/18 tender points, along with unremarkable PE and work up, to meet criteria for diagnosis.
What is the first line treatment for oligo-articular gout?
NSAID (any NSAID) -Most commonly used are indomethacin (Indocin), Naproxen (Naprosyn) and Sulindac. -Most effective when given within 24 hours of an episode
What are the first line therapies in treating mild disease of SLE (fever, arthritis, and serositis)?
NSAIDS -Any NSAID, with consideration to specific side effects
What are the side effects of colchicine?
Nausea, abdominal pain, diarrhea -Rare: myopathies, bone marrow suppression
Are NSAIDS capable of preventing disease progression in RA?
No! Only used as bridge therapy for symptom relief until DMARDS start working. -Recommended to d/c NSAIDS once DMARDS start to work in order to prevent unwanted side effects.
Patient is a 36 y/o female who is presenting with discoloration of the bilateral fingers, onset 5 months. Patient states she notices her fingers turn cold and pale when she is under a lot of stress. After a while, the her fingers turn very red, warm, and tingly/burning. She also notes that symptoms are worse during the winter months. She denies any ulcerations or injuries to the fingers. She is also a current smoker. No further complaints reported. PE: Unremarkable All lab work was unremarkable.
Raynaud's Phenomenon -Paroxysmal Digital ischemia (vasoconstriction to vasodilation), usually brought on by cold and emotional stress. Treatment: Use gloves/mittens, stay warm, avoid hand injuries, no smoking, avoid certain drugs (vasoconstrictive), -Running digits under warm water -Use CCB for refractory disease -Sympathectomy (digital or cervical)
What supplement should be taken along with methotrexate in treating RA?
Folic Acid since methotrexate blocks the synthesis. -Take 1 mg 6x days a week (other than the day you take methotrexate) or take 5 mg the day after you take methotrexate.
When taking Colchicine with a CYP-34A inhibitor (verapamil, ritonavir, cyclosporine, etc), how should the dose of colchicine be adjusted?
It should be reduced, especially in those with renal/hepatic disease. -CRP-34A inhibitor prevents colchicine from fully binding to target enzyme; leads to accumulation of colchicine in the blood, which increases risk of systemic side effects.
What population groups are more likely to experience Allopurinol Hyper Sensitivity Syndrome?
Korean, Han Chinese, Thai descent -Must check for HLA B*5801 testing. -Monitor for progressive rash during first few months of treatment!
What is the second line treatment in preventing disease progression in RA?
Leflunomide (Arava) -Taken as a monotherapy or in combination with MTX.
What are various systemic symptoms for diffuse scleroderma?
GI: Dysphagia, reflux, hypomotility, malabsorption, pseudo-obstruction Pulmonary: Restrictive lung disease, pulmonary fibrosis, pulmonary hypertension Cardiac: Pericarditis, heart block, Cor pulmonale Renal: Proliferation of small renal arteries, leading to severe HTN ***Leading cause of death from scleroderma is due to lung disease, CHF, and renal disease
Patient is a 62 y/o male who is presenting with acute onset of pain, redness, and swelling of the R 1st MTP joint. He states that he woke up with the pain yesterday and has been progressively worsening. Pain is so severe that he cannot even put his sock on or wear shoes. He denies any recent trauma/injuries. He also reports intermittent low grade fevers since last night as well. He reports a history of these symptoms, but is unsure of what it was called. He denies any recent dietary changes, but he does reports eating too much BBQ and drinking too much beer over the weekend prior to symptoms. PE: R 1st MTP joint is erythematous, edematous, and warm; no evidence of inflammation of other joints. Pt has limited ROM due to pain and is unable to bear weight. Labs: -CBC: Leukocytosis -ESR elevated -Joint Fluid Analysis: (-)birefringent crystal, Hyperuricemia XR: Punched out erosions (Rat Bites) with overhanging bone.
Gout -Etiology: Due to overproduction or underexcretion of urate crystals; collects in synovial joints of fluids and leads to destruction. -Can be hereditary (primary) or secondary (acquired) due to certain medications (thiazide/ASA/fructose/chemo drugs/ TB drugs), red meat, alcohol -Mostly in men! Clinical Presentation: Acute attacks of inflammation and exquisite pain of a joint, mostly commonly in the big toe. -Possible low grade fevers and mild leukocytosis. Labs: (-)Birefringent crystals, (+)Hyperuricemia of joint analysis. -May need serial uric acid levels
What is the recommended agent in preventing disease progression in RA if patient is pregnant or breast feeding?
Hydroxychloroquine (Plaquenil) -Sulfasalazine (Azulfidine) is also an option. Both are not as effective as MTX and leflunomide, but are safer. -Both must be given at least for 6 months due to longer time to effect (8-24 weeks)
What medication should all patients with SLE be placed on to control disease progression?
Hydroxychloroquine (Plaquenil) AE: headaches, rash, dermatitis, insomnia, N/V
What are the two types of IL-6 Receptor Antagonists medications used to treat RA?
Tocilizumab (Actemra)- BBW: Risk of serious infection Serilumab (Kevzara)- BBW: Risk of serious infection
Chronic accumulation of urate crystals can lead to palpable deformities known as?
Tophi
What is the treatment of choice for urate lowering/gout prophylaxis?
Xanthine Oxidase Inhibitors- (#1)Allopurinol (Zyloprime) and Febuxostat (Uloric)
Are glucocorticoids capable of preventing disease progression in RA?
Yes! -But, mostly used as bridge therapy (low doses for < 3 months) for symptom control due to side effects. AE: Cushing's syndrome, PUD, HTN, weight gain, infection, mood changes, cataracts, dyslipidemia, hyperglycemia, osteoporosis
Is Adalimumab safe to use in pregnancy?
Yes! (likely safe)
What lab values are highly specific for SLE, but not necessarily sensitive?
anti-ds DNA (Gold Standard) and anti-Sm
Which of the types of scleroderma involves systemic symptoms that extend beyond the skin?
Diffuse -Most Common -Skin changes in trunk and proximal -Renal and pulmonary are major problems. -Diffuse fibrosis of the internal organs and skin
What are the palpable nodules of OA?
Heberden (DIP) and Bouchard (PIP)
What are the contraindications for leflunomide in treating RA?
Hepatic impairment, pregnancy, lactation ***must be on birth control, but avoid estradiol due to DDI
What is the first line treatment for treating lupus nephritis?
Cyclophosphamide -Also used to treat severe organ involvement/life threatening SLE -Avoid in pregnancy!!! -Not as effective in African Americans and Hispanics
Why is the max dose of hydroxychloroquine at 5 mg/kg?
Due to risk of macular damage and visual changes -Need to have fundoscopic and visual field exam at baseline, after 5 years, and then yearly.
What is the second line therapy for patients who do not tolerate Allopurinol?
Febuxostat- Also an XO inhibitor -Not recommended in those with CrCl < 30 ml/min!!!!! -Must also monitor LFT because it can lead to transient elevations of transaminases.
What is the most common demographic for Systemic Lupus Erythematosus?
Females; mostly in African Americans and Hispanics/Latinos
What medications are used to control flares of: lupus nephritis, CNS disease, pneumonitis, vasculitis, and thrombocytopenia in SLE?
Corticosteroids -Can start with IV methylprednisolone for induction therapy, then start on lower dose prednisone for maintenance.
If a patient, who has gout, is unable to take an NSAID or colchicine, what is the next line of therapy?
Corticosteroids -Usually Prednisone or Prednisolone -Methylprednisolone is an alternative option
If a patient has an poly-articular attack of gout, what is the treatment of choice?
Corticosteroids -Usually Prednisone or Prednisolone -Methylprednisolone is an alternative option -Can still use corticosterioids in oligo-articular gout in combination with NSAID or colchicine.
What is the most commonly seen ocular finding for SLE?
Cotton Wool Exudates on retina due to degeneration of nerve fibers
What are the various causes of rhabdomyolysis?
Crush injuries, prolonged immobility, drug overdose, exposure hypothermia, extreme heat, certain medications (statins, CYP450 medications, niacin, fibrates).
Patient is a 70 y/o female who is presenting with arthralgias that have been progressively worsening over the past several months. She reports pain mostly in her hips, lower back, and knees, but also has pain at the joints of her finger tips. She states that she is usually fine in the morning, but pain begins later in the evening and is usually worse with activity. She denies any fevers, chills, redness or warmth at the site of pain. She thinks that the joint pain is caused by her longtime work as a cleaning lady and gardener. PE: Limited ROM at the hips, knees, and DIP/PIP joints and thumb secondary to pain. ROM is intact at all other joints, including wrist and MCP. -Asymmetric distribution of hard and bony nodules present at the DIP and PIP joints. -No edema, erythema, warmth, or signs of inflammation at the joints. Labs: ESR and CRP are normal. XR: Asymmetric joint space narrowing, osteophytes, thickened subchondral bone, cysts
Osteoarthritis (DJD) -Most common joint disorder and mostly a disease of aging. -Etiology: Cartilage degeneration and bony hypertrophy at articular margins (bone on bone); inflammation is minimal. Primary: Weight bearing joints (hip, knee, C/L spine), DIP, PIP and thumb Secondary: Sites of old injury Clinical Presentation: Develops later in the evening; worse with activity and better at rest. No signs of inflammation. (Should not be confused with RA; opposite signs) Labs: No evidence of inflammation!
Probenecid should not be used in uric acid overproducers or under excreters?
Over Producers -Also with history of urolithiasis. -Maintain adequate hydration to prevent stone formation!
Patient is a 55 y/o African American female who is presenting with gradual weakness of the upper extremities and discoloration of skin. Patient states that she has been unable to keep up with daily activities (such as climbing stairs, getting out of a chair, brushing her teeth, combing her hair) due to this progressive weakness. She denies any muscle pain, facial weakness, vision loss, other stroke like symptoms. She also reports odd dark discoloration around her bilateral eyes and across her bilateral knuckles. PE: 2/5 strength of the upper and lower extremities. Facial motor and sensations are intact. PERRLA and EOMI. -Hyperpigmentation and edema of the periorbital regions BL. Scaly rash over the dorsal MCP and PIP joints BL. Diffuse erythematous rash of the neck, shoulders, upper chest, and back. Labs: CBC: Normal CMP: Normal Iron Panel: Normal Thyroid Panel: Normal UA: Normal CK: Elevated (+)ANA Aldolase: Elevated (+)anti- Jo Ab
Polymyositis/Dermatomyositis -Mostly in women 50-60 y/o and African Americans. -Presentation: Progressive muscle weakness +/- skin changes (Heliotrope rash), Gottren's Papules over MCP and PIP joints, and shawl sign (rash across torso). Labs: Elevated CK, aldolase, and ANA. -Possible ASL elevation -anti-Jo Ab Treatments: Long term, daily steroids -MTX or azathioprine -Limit sunlight exposure -Possible hydroxychloroquine.
If a patient doesn't tolerate or cannot take XO inhibitors for gout, or have not reached target uric acid level/symptom control, what medication can be added/used?
Probenecid -Increases UA excretion -Do not use if CrCl < 50 ml/min
Patient is a 62 y/o female, with a PMHx of hyperparathyroidism, who is presenting with acute onset of pain, redness, and swelling of the R knee. she states that she woke up with the pain yesterday and it has been progressively worsening. Pain is so severe that she cannot bend her knee. She denies any recent trauma/injuries. She also reports intermittent low grade fevers since last night as well. She denies any recent dietary changes. PE: 1st MTP joint is erythematous, edematous, and warm; no evidence of inflammation of other joints. Pt has limited ROM due to pain and is unable to bear weight. Labs: -CBC: Leukocytosis -ESR elevated -Joint Fluid Analysis: (+)birefringent rhomboid shaped crystals. normal urate levels
Pseudo gout (Calcium Pyrophosphate Hydrate Deposition) Etiology: Deposition of Calcium Pyrophosphate Hydrate crystals in the joints. Chondrocalcinosis can also be asymptomatic and found incidentally on XR. -Can be familial and associated with diseases such as hemochromatosis, hyperparathyroidism, DM, Hypothyroidism, Wilson's Disease) Clinical Presentation: Mostly in women! Presents similarly as gout, but mostly affects larger joints. -Rarely chronic Labs: (+)Birefringent rhomboid shaped crystals, normal uric acid levels Treatment: NSAIDs, steroids, colchicine
Patient is a 54 y/o female who is presenting with arthralgias and swelling, redness of the joints in the BL hands, onset 1 week. She reports pain at wrist, and up the finger joints, but does not include the joint of the finger tips. She states that pain/stiffness begins in the morning and lasts about 2 hours and usually get better as she uses her hands more, but is worse when she is relaxing. She also reports dry eyes over the past week as well. PE: Erythema, edema, warmth and tenderness over the BL Wrists, MCP, and PIP joints with no involvement of the DIP joints. Limited ROM due to pain. Diffuse soft, warm, and tender nodules over the joints. Tiny vessel hemorrhages over the BL finger nailfolds. Labs: Leukocytosis and mild thrombocytopenia -Elevated ESR and CRP (+)anti CCP antibodies (+)Rheumatoid Factor
Rheumatoid Arthritis Etiology: Immune system attacks the joint spaces, leading to polyarthritis, bone erosion, cartilage/tendon/ligament destruction, and structure loss. -Mostly in women 40-50 y/o. Clinical Presentation: Develops in the morning; better with activity and worse with rest (opposite of OA). Signs of inflammation. Labs: (+)anti- CCP is the most specific test; (+)Rheumatoid factor can be false positive due to other diseases/immune disorders. XR: Usually normal initially; will see narrowing of the joint spaces in chronic diseases ***Higher risk of mortality from CV disease due to chronic systemic inflammation
What are the AE of Rituximab (Rituxan) in treating RA?
Risk of Tumor Lysis Syndrome and Serious Infections -B cell depleting agent
Lesinurad is only used as an add-on therapy to XO inhibitors; what happens if it is used as a monotherapy?
Risk of acute renal failure increases -Medication should be discharged if CrCl < 45 ml/min.
What are the AE of Abatacept (Orencia) in treating RA?
Risk of serious infection and activation of Hep B ***Get Hep B titers before treatment -T cell costimulatory blocking agent.
For patients who experience CNS issues from SLE, what is a medication that can be given?
SNRI, such as duloxetine (Cymbalta)
Which subset of Raynaud's Phenomenon (Primary vs Secondary) leads to more complications?
Secondary -Associated with scleroderma; leads to ulceration of gangrene-nailfold capillary abnormalities. -Unilateral: Digital pitting, ulceration, skin tightening, loss of extremity pulse, rash, swollen joints.
Sensitivity vs Specificity
Sensitivity: Ability to identify those with the disease Specificity: Ability to identify those without the disease
Patient is a 56 y/o female, with a PMHx of Hashimoto's thyroiditis, who is presenting with dry eyes and dry mouth over the past several months. She states that symptoms have become progressively worse. She states that she is unable to eat dry foods, such as crackers, without taking a sip of water and it feels like her mouth is "full of cotton". She also reports frequent nose bleeds. She also states that her eyes have been very dry and itchy and she is unable to put her contacts in due to discomfort. She states that she tries to stay hydrated. PE: Pt has slight slurred speech. Skin is significantly dry. Dry bilateral conjunctiva with injected sclera; dry oral mucous membranes. Dental caries present, especially at the gum line. Labs: CBC: Mildly low Hgb, leukopenia, eosinophilia CMP: Normal UA: Normal TSH: Normal (+)ANA (+)RF (+)anti-SS-A (Ro) and SS-B (La)
Sjogren's Syndrome Etiology: Autoimmune dysfunction of the lacrimal and salivary glands. Often associated with other autoimmune diseases. Clinical Presentation: Dry Mucous Membranes (mostly of mouth and eyes (keratoconjunctivitis sicca), but also in vagina, nose, throat, larynx, bronchi, skin. Will often have dysphagia, inability to tolerate contacts. Possible dental caries due to dry mouth. Labs: anti-SS A (Ro) and SS-B (La), (+)ANA, (+)RF Treatment: Artificial Tears, topical ocular cyclosporine, water, candy, pilocarpine, steroids (severe disease) -Avoid atropine drugs and decongestants because they decrease salivary secretions. -Use fluoride toothpaste to protect teeth
What is the treatment for scleroderma?
Supportive and symptomatic treatment based on affected organ system.