Rheumatology Review Update in Internal Medicine COPYRIGHT. Robert H. Shmerling, M.D. Beth Israel Deaconess Medical Center.

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1 Rheumatology Review Update in Internal Medicine Robert H. Shmerling, M.D. Beth Israel Deaconess Medical Center Boston MA

2 Case #1 True statement(s) regarding etanercept and leflunomide, for the treatment of rheumatoid arthritis, include: A. Their mechanism of action is inhibition of TNF B. Limiting toxicities include the development of autoantibodies and a lupus-like illness. C. They delay the development of joint erosions over time. D. They are safer than methotrexate in the elderly. E. All of the above.

3 Case #2 A 54 year-old man develops acute arthritis of the left 1st MTP, ankle and knee. Similar episodes have occurred at least 5 times in the past 2 years and resolved within a few days of treatment. PMHx is remarkable for hypertension for which he takes diltiazem. Physical examination confirms swelling, warmth and loss of motion of the left 1st MTP, ankle and knee. Which of the following is true? A. The most likely diagnosis is calcium pyrophosphate deposition disease (CPPD/pseudogout) B. High dose colchicine (0.6 mg, 8 doses over 6 hours) is more effective than low dose colchicine (0.6 mg, 3 doses over 1 hour) for this condition C. Urate-lowering treatment (with colchicine prophylaxis) is inappropriate because the diagnosis has not been established. D. Radiographic erosions in this condition are usually indistinguishable from those of rheumatoid arthritis. E. The starting dose of allopurinol should be 100 mg/day.

4 Case #3 A woman with newly diagnosed systemic lupus erythematosus (SLE) has been doing well without specific therapy. Which of the following is true? A. Her risk of developing cardiovascular disease is decreased compared with women without SLE. B. Antimalarial therapy (e.g., hydroxychloroquine/plaquenil) may protect her from major organ disease. C. She should be discouraged from becoming pregnant because pregnancy poses a major risk to her health and she is unlikely to deliver a healthy baby. D. If she became pregnant, it would be important to know whether she is positive for anti-rnp as this autoantibody increases the risk of neonatal lupus. E. None of the above.

5 Case #4 A 46 year-old schoolteacher has recently been diagnosed with rheumatoid arthritis after 3 weeks of polyarthritis involving the MCPs, wrists and knees. Her physician has recommended a second-line agent, methotrexate; she is unsure whether she should take this drug. Which of the following statements is true: A. She should not take methotrexate because the diagnosis is not secure B. Early therapy with disease-modifying agents, including methotrexate, is appropriate at this time to prevent expected development of erosions C. A high titer rheumatoid factor would confirm the diagnosis D. Radiographs now will probably demonstrate erosions at the MCPs and/or wrists E. A negative anti-ccp antibody would rule out rheumatoid arthritis.

6 Case #5 A 34 year-old woman complains of diffuse pain above and below the waist, both sides of the body for the last 4 months. Extensive evaluation is unrevealing. Physical examination is normal except for multiple tender points around the lateral elbows, medial knees, medial scapula, and costochondral junctions. First line or FDA-approved therapies for her condition include: A. amitriptyline (Elavil) B. duloxetine (Cymbalta) C. milnacipran (Savella) D. pregabalin (Lyrica) E. All of the above

7 Case #6 A 68 y/o woman develops the sudden onset of morning stiffness in the upper arms and thighs. She has difficulty arising from a chair due to stiffness and improves dramatically within the first 3 days of corticosteroid therapy. Which of the following is true regarding her condition? A. Physical examination is likely to demonstrate proximal muscle weakness. B. An MRI of her shoulder would likely demonstrate bursitis and tenosynovitis. C. At the time of presentation, her erythrocyte sedimentation rate (ESR) would likely be normal. D. An electromyogram (EMG) would demonstrate signs of muscle irritability, such as insertional spikes and fibrillations. E. High dose corticosteroids (e.g., prednisone, 1 mg/kg/d) is appropriate initial therapy for this condition

8 Case #7 Which of the following is true regarding rheumatoid arthritis (RA) or its treatment? A. Smoking and periodontal disease may contribute to disease development B. Active RA is associated with an increased incidence of cardiovascular (CV) disease (vs. non-ra). C. Compared with non-responders, improvement with anti- TNF therapy is associated with a reduced risk of myocardial infarction. D. Anti-malarial therapy may be associated with a reduced risk of diabetes E. All of the above

9 Case # 8 This radiograph was obtained from a 74 y/o woman who presented to the emergency room with a painful, warm and swollen wrist.

10 Case # 8 (continued) Which one of the following statements regarding this patient and her x-ray is true? A. The x-ray findings are specific for this patient s condition. B. The most likely diagnosis is septic arthritis. C. The most likely diagnosis is rheumatoid arthritis. D. Tests of calcium, iron and magnesium are appropriate for this patient. E. Colchicine is not effective for this condition.

11 Case # 9 A 32 year-old woman with rheumatoid arthritis (RA) is planning to become pregnant. Which of the following is true regarding her planned pregnancy? A. Her RA is likely to become more active during pregnancy. B. Methotrexate is the drug of choice for her RA. C. Anti-TNF therapy, such as etanercept (Enbrel), is the drug of choice for her RA. D. Hydroxychloroquine (Plaquenil) during pregnancy has an acceptable toxicity profile. E. None of the above.

12 Case #10 A 68 y/o woman with a history of chronic renal insufficiency, hypertension, and diuretic use complains of the acute onset of 1 st MTP pain and swelling over the last 24 hours. She recalls 2 similar episode in the past year that resolved after taking ibuprofen. Which of the following is true? A. Treatment with pegloticase (Krystexxa) is indicated now. B. Treatment with febuxostat (Uloric) is inappropriate now. C. Treatment with allopurinol (Zyloprim) is inappropriate now. D. A high uric acid level would secure the diagnosis. E. A low uric acid (e.g., < 5.5 mg/dl) would reduce the likelihood of gout.

13 Case # 11 A 74 year-old man complains of a new headache, jaw pain & diplopia. General physical and temporal artery examinations are normal. A recent ophthalmologic evaluation was normal. His ESR is 22 mm/hr (0-20); blood counts & chemistry studies are normal. Which of the following argues against the diagnosis of temporal arteritis? A. New headache in a 74 y/o man B. Jaw pain that worsens with chewing C. History of diplopia D. A normal slit lamp examination by an ophthalmologist E. The ESR result

14 Case #12 A 38 year-old man complains of gradually increasing left hip pain over the last 2 years. He recalls no trauma. Symptoms are worse at night or walking, but lately he has noted rest pain. He has no other significant past medical history. Treatment with NSAIDs, acetaminophen, and PT have been unhelpful. Examination reveals moderately reduced external rotation and no internal rotation in the left hip; other joints are normal as is the remainder of his exam. Radiographs of the left hip reveal loss of joint space and marked sclerosis with osteophyte formation. Each of the following would be appropriate at this point except: A. Order an anti-ccp and RF B. Review pediatric medical history C. Refer to an Orthopedic Surgeon D. Order iron studies (Fe, TIBC) E. Review history of medications taken in the past

15 Good websites for patients: Harvard Medical School s health website: National Library of Medicine: American College of Rheumatology: The Arthritis Foundation:

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