Pregnancy should be avoided if there is neurological, renal and cardiac abnormality in SLE.

If the mother has “anti-Ro antibody” (SSA), there may be congenital complete heart block of the baby, due to transplacental transfer of antibody. With anti Ro or anti La antibodies in mother, there is 2% risk of giving birth to a baby with neonatal lupus syndrome.

This is characterized by skin rash, hepatitis and fetal heart block.

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What are the criteria for remission of RA?

-No joint pain
-No fatigue
-No joint tenderness
-Morning stiffness less than 15 minutes
-No soft tissue swelling
-ESR less than 30 mm in 1st hour.

At least 5 criteria must be present for
at least 2 consecutive months.

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Sulfasalazine

Side effects:
-GIT upset (anorexia, nausea, vomiting, diarrhea)
-Skin rash
-Stevens Johnson syndrome
-Reversible sterility in males
-Blood dyscrasias (agranulocytosis,megaloblastic anemia and hemolytic anemia)
-Hemolysis in patients with G6PD deficiency.
Periodic check up:
-CBC
-LFT
-RFT

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Rituximab

In RA, also lymphoma, vasculitis
MOA: is an antibody directed against the CD20 receptor

•Adverse effects include
-Hypogammaglobulinaemia
-Infusion reactions
-Increased risk of infections
-Progressive multifocal leucoencephalopathy a serious and potentially fatal infection of the CNS caused by reactivation of JC virus.Rare.

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Tocilizumab is an Anti-interleukin 6 (IL-6) receptor used in RA.

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Anakinra is an Anti-interleukin (IL-1) receptor antagonist may be used in RA.

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Anti-TNFα: "Biological drugs"

-Etanercept
-Infliximab
-Adalimumab
-Certolizumab
-Golimumab

Used in RA
•Common side effects: Hypersensitivity reaction, headache, hypotension. Reactivation of latent tuberculosis may occur. Sometimes lymphoma may occur.

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Leflunomide

DMARD, may be used in RA.

•Side effects—Skin rash, diarrhea, reversible alopecia, hepatotoxicity, carcinogenic and teratogenic.

It needs a washout of 2 years before conception (3 months in man and 2 years in female), so avoid in women who want to be pregnant.

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Belimumab is a biological drug acting as an Antibody to BAFF; inhibits B-cell activation.May be used in SLE.

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Abatacept

Biological drug.
MOA: Inhibits T-cell activation.
Used: in RA.

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Ustekinumab

Biological drug.
MOA: Antibody to IL-12 and IL-23.
Used: in PsA, psoriatic arthritis.

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Secukinumab

Biological drug.
MOA: Antibody to IL-17A.
Used: in PsA.

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Canakinumab

Biological drug.
MOA: Antibody to IL-1β.
Used: in JIA, adult onset Still's disease, Gout.

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Retinopathy is the serious complication, but this is rare before 6 years of treatment in Hydroxychloroquine and Chloroquine.

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Differences between primary and secondary Raynaud’s syndrome.

1-Age
P- 15-30 years, less than 30 years
S- More than 30 years

2-Gender
P- Female >male
S- F: M, 4:1

3-Family history
P- Present
S- Absent

4-Symmetry
P- Symmetrical
S- Asymmetrical

5-Gangrane&Ulceration
P-Absent
S-Present

6-ANA
P- negative
S- positive

7-Capillary nail-fold loops test
P- negative
S- positive "fallout".

P-Primary
S-Secondary

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Other features in SScl,"rare":

-Entrapment neuropathy
-Facial nerve palsy
-Autonomic dysfunction
-Hypothyroidism
-Impotence
-Primary liver cirrhosis
-Pneumonitis
-Pleural effusion
-Alveolar cell carcinoma.

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In Raynaud’s syndrome

Drugs to be avoided:

-Beta-blocker
Non-selective agents
•Alprenolol
•Bucindolol
•Carteolol
•Carvedilol
•Labetalol
•Nadolol
•Penbutolol
•Pindolol
•Propranolol
•Sotalol
•Timolol
-Ergotamine
-Oral contraceptive
-Sympathomimetic:
-Alpha and beta agonists
Salbutamol, phenylephrine, isoproterenol, and dobutamine.

Drugs may be given:

-Calcium antagonist (diltiazem and nifedipine)
-ACE inhibitor
-Angiotensin II receptor blocker
(valsartan)
-Aspirin
-Epoprostenol"prostacyclin analog"
-Sympatholytic" alpha blocker not beta "Prazosin (α1 inverse agonist).

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Rheumatic disorders that maybe associated with secondary Raynaud's phenomenon:

[systemic scleroderma (85%), SLE (35%), DM (30%), Sjögren syndrome, rheumatoid arthritis, polyarteritis nodosa].

Others:
Diseases with abnormal blood proteins (cryoproteins, cold agglutinins, macroglobulins)

Drugs (β-adrenergic blockers, nicotine)

Aterial diseases (arteriosclerosis obliterans, thromboangiitis obliterans).

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Causes of proximal myopathy:

-Myopathy (limb girdle, fascioscapulohumeral), except myotonic dystrophy which causes distal.
-Myasthenia gravis
-Muscular dystrophy
-Myasthenic myopathic syndrome (Eaton-Lambert syndrome).


1-Inflammatory:
• Polymyositis
• Dermatomyositis
• Inclusion body myositis (predominantly distal effects).

2-Endocrine:
Endocrine/metabolic
• Hypothyroidism
• Hyperthyroidism
• Acromegaly
• Cushing’s syndrome
(including iatrogenic, steroids)
• Addison’s disease
• Conn’s syndrome
• Diabetic amyotrophy
• Hyperparathyroidism.

3-Metabolic:
• Osteomalacia
• Hypokalaemia (liquorice, diuretic and purgative abuse)
• Hypercalcaemia (disseminated bony metastases)
• Paraneoplastic
• Carcinomatous neuromyopathy
• Periodic paralysis
•Carnitinedeficiency
•Phosphofructokinase deficiency
•Myophosphorylase deficiency.

4-Rheumatology:
• Dermatomyositis, Polymyositis, SLE, RA, SScl.

5-Toxic:
• Alcohol (chronic and acute syndromes)
• Amphetamines/cocaine/heroin
• Vitamin E
• Organophosphates
• Snake venoms.

6-Drugs:
• Glucocorticoids
• Statins
• Amiodarone
• β-blockers
• Opiates
• Chloroquine
• Ciclosporin
• Vincristine
• Clofibrate
• Zidovudine
• Fibrates
• Pencillamine
• Colchicine
• Tumour necrosis factor
inhibitors.

7-Infections:
• Viral (HIV, cytomegalovirus, rubella, Epstein–Barr, echo)
• Parasitic (schistosomiasis, cysticercosis, toxoplasmosis)
• Bacterial (Clostridium perfringens, staphylococci, tuberculosis, Mycoplasma).

مجمع من عدة كتب.
مهم جداً،قد يجي writing، أو بيتكرر كثير على هيئة all of the following except.

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CPK may be normal in dermatomyositis:

1- If dermatomyositis is associated with internal malignancy.
2- Due to long standing disease with atrophy of muscles.
3- Due to the presence of inhibitors in blood.

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Causes of high CPK:

1-Exercise
2-Intramuscular injection
3-Muscle trauma or road traffic accident, prolonged immobilization after a fall
4-Convulsion
5-Alcoholism
6-Dermatomyositis or polymyositis
7-Acute myocardial infarction (CPK-MB)
8-Myopathy
9-Rhabdomyolysis
10-Chronic liver disease (CLD)
11-Motor neuron disease
12-Hypothyroidism
13-Muscular dystrophy
14-Viral myositis
15-Drugs—statins, busulfan, narcotics, colchicine ,pencillamine and chloroquine.

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