Pharmacology Rheumatoid Arthritis & SLE

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Questions and Answers

Which of the following treatments is NOT recommended for chronic musculoskeletal pain?

Massage therapy

Opioids (correct)

Trigger point injections

NSAIDs

What is a characteristic feature of osteoarthritis pathology?

Bone collapse and wear (correct)

Excessive cartilage production

Chronic inflammation of synovial fluid

Increased joint lubrication

Which diagnostic criteria is NOT used for osteoarthritis?

Age greater than 45

Morning stiffness

Persistent joint pain in multiple joints

Evidence of inflammation in synovial fluid (correct)

What is commonly observed in the synovial fluid of a patient with osteoarthritis?

Mostly mononuclear cells Signup and view all the answers

Which of the following factors can contribute to the progression of osteoarthritis?

Sedentary lifestyle Signup and view all the answers

What is one key element that should be included during the disclosure of complications to patients and their families?

A clear statement that an error has occurred Signup and view all the answers

Which of the following should be included when disclosing complications to families?

Explanation of how the error will affect the patient’s health Signup and view all the answers

What is a potential consequence of delivering life-altering news without empathic communication skills?

Long-lasting negative emotional impacts on patients and families Signup and view all the answers

When should error disclosure ideally take place after an incident?

As soon as possible after stabilization Signup and view all the answers

Which setting is recommended for disclosing complications to minimize interruptions?

A dedicated conference room Signup and view all the answers

What is the significance of the phrase 'bad news' in patient-doctor communications?

News that may affect the patient's loved ones as well Signup and view all the answers

What is an essential moment in empathic communication?

Anticipating and imagining patient/family experiences Signup and view all the answers

What is recommended regarding the attendees present during the disclosure of an error?

Include individuals such as involved providers and administrators Signup and view all the answers

Which muscles are primarily affected in Erb-Duchenne palsy?

Infraspinatus and deltoid Signup and view all the answers

What characteristic posture of the arm is associated with Erb-Duchenne palsy?

Arm hanging at the side in medial rotation Signup and view all the answers

Which muscle group is functional in cases of Erb-Duchenne palsy?

Flexors in the forearm Signup and view all the answers

What is a common clinical finding associated with Klumpke paralysis?

Clawing of the ring and little fingers Signup and view all the answers

What signifies a poor prognosis in infants with birth-related brachial plexus injuries?

Absence of any recovery in biceps by 3 months Signup and view all the answers

What is the most reliable indicator for considering surgical intervention in cases of brachial plexus injury?

Biceps function Signup and view all the answers

When is spontaneous recovery most likely to occur in infants with upper root paralysis?

During the first 3 months Signup and view all the answers

Which imaging technique is considered promising but not yet routine for evaluating brachial plexus injuries?

Magnetic resonance imaging (MRI) Signup and view all the answers

What is a key indication for early surgical intervention in brachial plexus injury?

Absence of biceps function by 3 months Signup and view all the answers

How effective is clinical assessment compared to electrical testing for determining outcomes in brachial plexus injuries?

Clinical assessment is more reliable than electrical testing. Signup and view all the answers

What is the primary mechanism of action of methotrexate in the treatment of rheumatoid arthritis?

Blocks purine synthesis Signup and view all the answers

Which of the following adverse effects is associated with hydroxychloroquine?

Cardiomyopathy Signup and view all the answers

In the treatment of systemic lupus erythematosus, which medication is used as a combination therapy for active proliferative lupus nephritis?

Low dose IV cyclophosphamide Signup and view all the answers

What is a primary goal in the management of rheumatoid arthritis?

Control disease activity Signup and view all the answers

Which characteristic is a distinguishing feature of synovial sarcoma?

Has epithelial features Signup and view all the answers

What complication is associated with the long-term use of biologic DMARDs like TNF inhibitors?

Increased susceptibility to infections Signup and view all the answers

In the context of pediatric musculoskeletal oncology, which disease is associated with the EWS-FLI 1 mutation?

Ewing Sarcoma Signup and view all the answers

What is the expected clinical presentation for Erb-Duchenne palsy?

Arm held in the 'waiter’s tip position' Signup and view all the answers

Which of the following conditions significantly increases the risk of developing osteosarcoma?

Hereditary Retinoblastoma Signup and view all the answers

In the layered approach to anatomy, which structure is involved in dynamic stability?

Musculature crossing the joint Signup and view all the answers

What is one of the primary risk factors for developing synovial sarcoma?

Radiation exposure Signup and view all the answers

Which approach is crucial in the management of pelvic pain by a PM&R physician?

Restore or enhance function Signup and view all the answers

Which of the following components makes up the caudal part of the brachial plexus?

C8 Signup and view all the answers

What is a well-known side effect of leflunomide, an immunosuppressive agent?

Hepatotoxicity Signup and view all the answers

What does the 'N' in the NURSE mnemonic stand for?

Name the emotion Signup and view all the answers

Which of the following is a key characteristic of fibromyalgia?

Widespread musculoskeletal pain and tenderness Signup and view all the answers

What is a clinical feature of myofascial pain syndrome (MPS)?

Localized or regional deep, aching pain Signup and view all the answers

Which aspect is NOT part of the SPIKES protocol for delivering bad news?

Knowledge of specific medical jargon Signup and view all the answers

What should be prioritized in the non-pharmacological management of fibromyalgia?

Education on disease and managing expectations Signup and view all the answers

Which of the following correctly describes the treatment approach for fibromyalgia?

Combining medications that address multiple symptoms Signup and view all the answers

Which of the following is a symptom of both fibromyalgia and myofascial pain syndrome?

Trigger points Signup and view all the answers

What is the primary focus of the 'E' in the SPIKES protocol?

Ensuring patient feelings are acknowledged Signup and view all the answers

Patients with fibromyalgia often report high levels of what coexisting conditions?

Anxiety and depressive symptoms Signup and view all the answers

Which of the following statements accurately describes a treatment consideration for myofascial pain syndrome?

Trigger points are often used in diagnosis Signup and view all the answers

Which symptom differentiates fibromyalgia from myofascial pain syndrome?

Presence of tender points Signup and view all the answers

What is meant by 'central sensitization' in fibromyalgia?

Increased pain threshold and sensitivity Signup and view all the answers

In the context of treatment for fibromyalgia, what is the role of cognitive-behavioral therapy (CBT)?

Helps patients manage anxiety and expectations Signup and view all the answers

What aspect of NURSE emphasizes the necessity of good listening techniques?

Respect for the patient Signup and view all the answers

Study Notes

Pharmacology of Rheumatoid Arthritis & Systemic Lupus Erythematosus

Rheumatoid Arthritis (RA) Treatment Goals: Control disease activity, slow joint damage, minimize pain/stiffness/complications.
RA Treatment General Guidelines:
- High Disease Activity: Start with methotrexate, avoid steroids.
- Low Disease Activity: Hydroxychloroquine (HCQ), Sulfasalazine (SSZ), Methotrexate (MTX). Vaccinate before treatment.
- Symptomatic Control: Use NSAIDs or corticosteroids for flares, adjunct to DMARD therapy.
Disease-Modifying Anti-Rheumatic Drugs (DMARDs):
- Non-Biologic DMARDs:
  - Methotrexate: First-line, folic acid antagonist, blocks purine synthesis, weekly dosing. Adverse effects: stomatitis, nausea/diarrhea, alopecia, myelosuppression, hepatic/pulmonary fibrosis. Contraindications: liver/lung disease, alcohol abuse, pregnancy.
  - Hydroxychloroquine: Increases pH, inhibits immune cells, hepatic/renal excretion. Adverse effects: cardiomyopathy, ocular changes (retinal depigmentation, retinopathy, corneal deposits). Contraindications: long-term use in children.
  - Leflunomide: Inhibits pyrimidine synthesis (prodrug). Adverse effects: nausea, weight loss, alopecia, hepatotoxicity, thrombocytopenia. Contraindications: pregnancy.
  - Sulfasalazine: Mechanism uncertain, may be leukotriene/TNF inhibitor. Adverse effects: nausea, dyspepsia, headache, rash, fatal blood dyscrasias.
  - JAK Inhibitors (Tofacitinib, Baricitinib, Upadacitinib): Block immune signaling. Used as monotherapy or with other non-biologic DMARDs. Adverse effects: infection, hypertension, anemia, hepatic injury, latent TB reactivation.
- Biologic DMARDs:
  - TNF Inhibitors: Used after DMARD failure. Adverse effects: headache, infection, rash, injection site reactions, allergic reactions, demyelinating disorders, heart failure, leukemias. Contraindications: demyelinating disorders, heart failure, recent malignancy, latent TB, avoid live vaccines.
  - Anti-B Cell (Rituximab): Used if TNF inhibitors fail. Adverse effects: infection, rare fatal reactions, GI perforation, interstitial pneumonitis.
  - T-Cell Co-Stimulation Inhibitors: Blocks T-cell activation. Adverse effects: headache, nausea, infection, hypertension, leukemia, malignancies. Contraindications: immunocompromised patients.
  - IL-6 Receptor Blockers: Reduces cytokine reactions. Adverse effects: headache, diarrhea, increased liver function tests (LFTs), LDL elevation. Contraindications: hypersensitivity, demyelinating polyneuropathies, infection, TB reactivation.
Systemic Lupus Erythematosus (SLE) Treatment Goals: Remission with minimal adverse effects, prevention of comorbidities (e.g., osteoporosis).
SLE Treatment General Guidelines:
- Mild Disease: NSAIDs, low-potency immunosuppressants, HCQ.
- Organ Involvement: Prolonged steroids, potent immunosuppression (cyclosporine, mycophenolate, azathioprine). High-dose glucocorticoids + cytotoxic agents (combo therapy).
- Drug-Induced Lupus: Treat with NSAIDs, glucocorticoids (adjust dose based on affected areas).
SLE Risk Factors: Radiation, chemotherapy, genetics (retinoblastoma, Li-Fraumeni syndrome), Paget's disease.

Pediatric Musculoskeletal Oncology

Key Cancers: Ewing sarcoma, Langerhans cell histiocytosis, rhabdomyosarcoma, synovial sarcoma.
Ewing Sarcoma: Second most common childhood bone cancer. Small round blue cell tumors, arise from neural crest, commonly in diaphysis. Associated with EWS-FLI 1 mutation. Radiographic features: mixed radiolucent/radiodense, permeative destructive pattern, "onion skinning."
Langerhans Cell Histiocytosis: Proliferation of Langerhans cells. CD1a and S100 positive, Birbeck granules on electron microscopy. Lesions in skin, lymph nodes, spleen, marrow, lungs, brain.
Rhabdomyosarcoma: Most common soft tissue sarcoma. Originates from skeletal muscle, often in head/neck/GU. Risk factors: Li-Fraumeni syndrome, radiation. Histology: sheets of small round blue cells. Subtypes: embryonal (MYOD1, desmin, actin positive) and alveolar (PAX3/FKHR or PAX7/FKHR fusion gene).
Synovial Sarcoma: Spindle cell carcinoma of soft tissue, in deep extremities (knees, shoulder), slow-growing. Epithelial markers (keratins, EMA, S100) positive. Associated with SYT/SSX fusion gene.
Risk Factors for Pediatric Musculoskeletal Sarcomas: Li-Fraumeni syndrome (p53 mutation), neurofibromatosis 1 (NF1), hereditary retinoblastoma, radiation exposure.

Physiatric Approach to Non-Rheumatologic MSK Care

MSK Anatomy: Layered approach includes osteochondral, joint congruence (static stability), arthrokinematic movement, contractile (dynamic stability), neuromechanical (mechanical rhythm, neurovascular structures).
MSK History: Onset, provocation/palliation, quality, radiation, severity, time. Duration, disability, desire, patient goals, training changes.
MSK Physical Exam: Visual: skin, symmetry, posture. Palpation: pain reproduction, masses, step-offs. Range of motion (ROM): active, passive. Neuro: strength, sensation, reflexes, long track signs. Functional tests (squat, step-down, gait). Special tests (provocative).
Treatment Options: Activity modification (posture, sleep), home exercises, medications (analgesics, NSAIDs, neuropathic), orthotics, surgical interventions.
Athlete Care: Identify operative candidates (neurologic/vascular compromise, structural damage, minimal non-surgical improvement, intractable pain, malignancy/infection).

Management of the Patient with Pelvic Pain

PM&R Physician Role: Focus on physical impairments, restore/enhance function, maximize quality of life, support patients/families, coordinate interdisciplinary care, improve access to rehab.
PM&R Physician Background/Training: 1 year internship, 3 year residency. Subspecialties exist in brain injury, sport medicine, pediatric rehabilitation, spinal cord injury, hospice/palliative care, neuromuscular medicine, pain medicine, pelvic health.
Physical Therapist Role: Movement expert, improve quality of life through hands-on care, education, prescribed movement/exercise. Doctor of Physical Therapy degree, state licensure, additional fellowships/residencies.
MSK Assessment: Global screen (UE/LE joint motion, scapular motion, function squat, heel/toe walk), spinal movement screen, single-leg stance, strength tests, peripheral nerve screen, special tests, movement screens (lunge, squat, step-up, stairs), sport/work-specific screens, balance.
Collaboration: PM&R physician and PT utilize each other's expertise, referrals are common, early PT involvement improves outcomes.

Synthesis

Brachial Plexus: Formed by anterior rami of C5-T1, innervating the upper limb and shoulder.
Erb-Duchenne Palsy: Upper brachial plexus injury (C5, C6). Arm adducted, medially rotated, and elbow extended.
Klumpke Paralysis: Lower brachial plexus injury (C8, T1). Claw hand, forearm supinated, wrist extended, fingers flexed.
Brachial Plexus Injury Prognosis: Spontaneous recovery possible in early stages (first 3 months). Complete recovery is more likely with early biceps contraction and normal contraction by month 2. EMG and myelography are imprecise monitoring tools. Surgery is indicated for non-recovering infants, especially those with complete palsy after birth. Early intervention is key for better outcomes.
Ethical Disclosure: Clear, objective explanation of error/complication, sincere apology, avoidance of future incidents, minimized interruptions, family support, and presence of involved personnel.

Breaking Bad News

Bad News Definition: Serious, life-altering news impacting patient and loved-ones.
Respectful Setting/Tone: Focus on delivering news empathetically, not methodically. Establish trust for better outcomes.
Communication Skills: Anticipate and imagine patient/family experiences; notice and recognize emotions (body language, paralanguage, emotional statements); acknowledge and respond effectively (empathic responses).
SPIKES Model: S - Setting, P - Perception, I - Invitation, K - Knowledge, E - Emotion.
NURSE Model: N - Name emotions, U - Understanding, R - Respect, S - Support, E - Explore Emotions.

Fibromyalgia & Myofascial Pain

Fibromyalgia (FM) Pathophysiology: Widespread musculoskeletal pain/tenderness, genetic predisposition, central sensitization (reduced descending pain inhibition), potential peripheral pathology (reduced nerve fibers, AV shunt changes).
Myofascial Pain Syndrome (MPS) Pathophysiology: Regional soft tissue pain, acute/repetitive microtrauma or chronic strain, calcium release -> sustained muscle contraction, ischemia/inflammation/nociceptor sensitization, increased pro-nociceptive mediators and sympathetic activity.
Fibromyalgia Clinical Features: Widespread pain (3+months), diffuse/bilateral, tenderness/increased sensitivity (tender points), sleep disturbance/fatigue, anxiety/depression, cognitive complaints.
Myofascial Pain Clinical Features: Localized/regional deep pain, one/two muscles, trigger points, less systemic symptoms.
Fibromyalgia Diagnostic Workup: Symptoms 3+ months, rule out other disorders, WPI ≥ 7 & SS ≥ 5 (or WPI 3-6 & SS ≥ 9).
Myofascial Pain Diagnostic Workup: Suspect based on regional pattern, trigger points, persistent pain.
Fibromyalgia Treatment: Education, pain-independent behaviors, CBT, aerobic exercise, sleep hygiene. Medications (pregabalin, duloxetine, milnacipran).
Myofascial Pain Treatment: PT (stretching, strengthening, trigger point release), heat/cold therapy, massage, trigger point injections, NSAIDs, muscle relaxants, SNRIs, TENS.

Osteoarthritis

Osteoarthritis Pathophysiology: Chronic degenerative joint failure; loss/failure of joint protection, cartilage loss, bony sclerosis, weakness, pain, mild-moderate inflammation, dysfunction; post trauma OA, genetics, obesity (increases incidence/progression). Loss of joint protection, accelerated wear, loss of lubricant, stress/synovial inflammation (more catabolic factors than anabolic), bone collapse, joint capsule/ligament injury, muscle weakness, peripheral neuropathy.
Osteoarthritis Diagnostic Workup: May be diagnosed without investigations, but imaging may be useful to guide treatment; synovial fluid analysis (non-inflammatory, mostly mononuclear cells), ESR/CRP typically normal, tests for rheumatoid arthritis (RA). Persistent usage-related joint pain (one or few joints), age > 45, morning stiffness.

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Description

This quiz covers the pharmacological treatments for Rheumatoid Arthritis and Systemic Lupus Erythematosus. It focuses on treatment goals, guidelines for disease activity management, and the details of Disease-Modifying Anti-Rheumatic Drugs (DMARDs). Test your knowledge on essential medications and their effects.