Master the board step 3

Rheumatology
Which of the following will have the lowest glucose level on pleural effusion?
a. CHF
b. Pulmonary embolus
c. Pneumonia
d. Cancer
e. Rheumatoid arthritis
f. Tuberculosis
The sacroiliac joint is spared
in rheumatoid arthritis.
Answer: E. Rheumatoid arthritis has the lowest glucose level of all the causes of pleural
effusion described here.
Treatment
NSAIDs combined with a disease-modifying antirheumatic drug (DMARD)
is the standard of care in patients with RA. There is no therapeutic difference
among NSAIDs, and you may use ibuprofen for any of the rheumatological
diseases described. There is no point in waiting to use a DMARD in a patient
with severe RA or anyone with joint erosions. NSAIDs will not delay the progression
of the disease.
Eliminating an abnormal
x-ray as a criterion for
diagnosis allows earlier
treatment with DMARDs.
DMARDs
The best initial DMARD is methotrexate. Add others if it is not effective.
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Methotrexate: This is the best-tolerated and most widely used DMARD.
Adverse effects are bone marrow suppression, pneumonitis, and liver disease.
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Biological agents (infliximab, adalimumab, etanercept): All of these
block the activity of tumor necrosis factor (TNF). Methotrexate and these
biological agents can be used in combination. Anti-TNF agents are added if
methotrexate fails.
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Hydroxychloroquine: Use with mild disease. The patient will need a regular
eye exam to check for retinopathy. Anti-TNF agents are added if methotrexate
fails.
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Sulfasalazine: This is the same drug that was used in the past for ulcerative
colitis. It can suppress the bone marrow.
DMARDs are started
to prevent x-ray
abnormalities.
The following are alternate DMARDs:
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Rituximab: Anti-CD-20 antibody
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Anakinra: IL-1 receptor antagonist
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Tocilizumab: IL-6 receptor antagonist. Added to methotrexate
if it is ineffective.
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Leflunomide: Pyrimidine antagonist that is similar in effect to
methotrexate, with less toxicity
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Abatacept: Inhibits T-cell activation
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Gold salts: Rarely used because of toxicity, such as nephrotic syndrome
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