Rheumatology Week 5 Summary

Question 21

Name two antibodies that are associated with poor fetal outcomes in the offspring of women with lupus.

  • Anti-Ro (SSA) antibodies
  • Antiphospholipid antibodies

Anti-Ro antibodies in the mother are associated with a 5% risk of neonatal lupus, which consists of a rash and/or complete heart block in the offspring. About 2% of the offspring of Ro-positive women will have complete heart block. 50% of those offspring will require a permanent pacemaker.

Antiphospholipid antibodies are associated with a risk of spontaneous abortion due to placental infarction.

Question 22

Name 4 gastrointestinal conditions that are associated with inflammatory arthritis.

  • Crohn’s Disease
  • Ulcerative colitis
  • Infectious gastroenteritis
  • Celiac disease

Others include Whipple’s disease, microscopic colitis and intestinal bypass arthritis.

Question 23

Corticosteroids are often used to gain rapid control of an inflammatory process. In most situations they are eventually tapered and replaced with less toxic “steroid-sparing” agents.

List 10 adverse consequences of corticosteroid therapy. What parameters should be monitored in a patient on prednisone therapy?

Adverse consequences of corticosteroid therapy include the following:

  1. Weight gain and altered fat distribution leading to the classical Cushingoid appearance. This is characterized by truncal obesity, a dorsal fat pad, and moon facies.
  2. Hirsutism
  3. Acne
  4. Psychiatric disturbances, including depression, anxiety and rare psychoses
  5. Hypertension
  6. Hyperglycemia and insulin resistance
  7. Increased susceptibility to infection
  8. Skin changes including striae, bruising
  9. Muscle weakness
  10. Osteoporosis
  11. Osteonecrosis
  12. Cataract formation
  13. Glaucoma

Patients taking corticosteroids should have regular blood pressure monitoring. Patients on higher doses may require blood glucose testing. Chronic use necessitates baseline and follow-up bone mineral densitometry.

Question 24

List five risk factors for NSAID-induced ulceration. How can this risk be minimized?

  • Advanced age (particularly over 60)
  • Past history of GI ulceration or hemorrhage
  • Higher NSAID doses
  • Concurrent anticoagulant use
  • Concurrent corticosteroid use
  • Use of multiple NSAIDs
  • Alcohol use

To minimize the risk of NSAID-induced mucosal injury, alternative analgesics (such as acetaminophen) should be used when possible. When using NSAIDs, use the lowest effective dose.

COX-2 selective agents reduce the likelihood of gastric complications by approximately 50%, relative to non-selective agents.

Misoprostol or a PPI can be used with non-selective NSAIDs to reduce the likelihood of GI ulceration and bleeding.

Question 25

Weekly methotrexate is considered the cornerstone of therapy for rheumatoid arthritis. Methotrexate is also used as a steroid-sparing agent in a variety of other rheumatic diseases. It improves all clinical parameters of RA, including joint pain, swelling and function. It also slows the rate of radiographic progression of the disease.

What toxicities are associated with methotrexate use? How are patients monitored for methotrexate toxicity?

Side effects of methotrexate include fatigue, oral ulcers, nausea, vomiting, anorexia. Methotrexate is hepatotoxic and can cause myelosuppression. It is a teratogen. Pneumonitis and alopecia are rare complications of methotrexate use. Use of folic acid supplements reduces toxicity.

Before starting methotrexate, a baseline CBC, creatinine and liver enzymes should be performed. A chest x-ray along with hepatitis B and C serology should also be done. In women of child-bearing age, it is prudent to perform a B-HCG. Patients on methotrexate are monitored with liver enzymes and a CBC every 1 to 2 months.

What are the contraindications to methotrexate use?

Contraindications to methotrexate use include chronic liver disease and alcoholism. It can be used with caution and dose adjustment in patients with renal dysfunction. Relative contraindications include parenchymal lung disease and cytopenias.

Women of childbearing age should use effective contraception. Methotrexate should be held (in men as well as women) three months prior to attempting conception. Methotrexate is not used in nursing mothers.

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