Wednesday, 22 Jan 2020

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Pearls Part 2: Common Sense Rheumatology 

"Experience is a hard teacher, she give the test first then the lesson after." - Vernon Law.  

We live in an era where you need evidence in order to believe, but life’s experiences should not be discounted even if we do not have the statistics to support them…yet.  Dr. Sterling West has shared Rheumatology Secrets in his published book.  He has helped many fellows and rheumatologists on their initial board certification and maintenance of certification (MOC) exams.   Many of his observations do not have statistical analyses applied to them, only common sense. I am sharing with you some of what he presented at the 2019 ACR conference in Atlanta, Georgia session #5T028 “Rheumatology Top Secrets & Pearls.”

  1. If patients have to go up and down the stairs, to prevent falls-- advise them to put the good leg up first when going up the stairs. When they go down the stairs, they should initiate their gait with their bad leg down first. A way to remember this is Good Leg UP to Heaven, Bad Leg DOWN to Hell (a.k.a. billing and compliance).   

  2. In patients who have severe hepatic dysfunction with elevated INRs, do not use prednisone as it may not be converted to its active form; use prednisolone instead. 

  3. Colchicine in combination with cyclosporine at any dose can cause a myopathy. 

  4. Calcium (after corrected for albumin levels) multiplied by the phosphorus levels must be > 24 to mineralize bone.

  5. Ask about energy drink consumption in patients who have gout; these drinks are high in sugars and can double the risk for flares. It’s not just seafood, alcohol and red meat.  

  6. Mycophenolate mofetil absorption is interfered by proton pump inhibitors (PPIs); dissolution of mycophenolate mofetil is hindered by a higher pH . Think about the population of patients who need both medications, e.g. those with systemic sclerosis (SSc).  Consider getting mycophenolic acid levels or using enteric coated mycophenolic acid.

  7. When examining synovial fluid, at 40X magnification, 1 white blood cell (WBC) in a high power field (hpf) is equivalent 500 WBCs/uL. So if you see 5 WBC/hpf, the patient’s synovial fluid WBC =2500 cells/uL, consistent with an inflammatory fluid.  You don’t have to wait for the lab report.

  8. In patients who are intolerant to azathioprine, try 6-mercaptopurine. 

  9. Nonherpetic vesiculobullous lesions in patients with systemic lupus erythematosus respond well to dapsone.

  10. In all patients who have acute interstitial lung disease (ILD) or nonspecific interstitial pneumonia (NSIP), look for mechanics hand on the radial side of the index finger. Some cases of mechanic’s hands are very subtle.  (My pearl: check anti-synthetase antibodies in patients with isolated idiopathic ILD). 

 

These are but a few secrets he shared with the crowd; for more hints, please go to ACR Beyond to view his presentation, or better yet, consider getting his book.  In Pearls Part 3, Dr. John Stone will enlighten us on the particulars of vasculitis.

Read Part 1: The "P" in Prednisone Stands for Poison...and Other Pearls

Kathryn Dao, MD, FACP, FACR, is the Associate Director of Clinical Rheumatology at Baylor Research Institute in Dallas. She is in clinical practice at the Arthritis Care and Research Center in Dallas, TX and is actively involved in patient care, medical education, and clinical research.  Her interests include Rheumatoid Arthritis, Systemic Lupus Erythematosus, Gout, Infections with Biologics, Osteoporosis, and Drug Safety. She has served as the co-editor for the American College of Rheumatology “Drug Safety Quarterly” 2010-2013.   

 

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