1High-yield associations
| Finding or trigger | Classic association | The exam point |
|---|---|---|
| Aseptic monoarthritis and fever in a remote First Nations teenager | Acute rheumatic fever | In high-risk groups monoarthritis is a major criterion (RHDAustralia 2025); echo every case. |
| Rash, fever and eosinophilia weeks after starting allopurinol | DRESS or SJS/TEN | HLA-B*5801: consider testing first in Han Chinese, Thai or Korean ancestry (TGA PI 2026). |
| Pancytopenia after allopurinol is added to azathioprine | Xanthine oxidase blocks thiopurine breakdown | Avoid, or give a quarter of the azathioprine dose (TGA PI). |
| New headache, jaw claudication and high ESR after 50 | Giant cell arteritis | High-dose glucocorticoid at once (EULAR 2018). PBS lists tocilizumab for active GCA. |
| Sinusitis, haemoptysis, PR3-ANCA, active urine sediment | Granulomatosis with polyangiitis | Induce with rituximab or cyclophosphamide plus glucocorticoid. PBS lists avacopan for induction. |
| Thrombosis with all three antiphospholipid antibodies | Triple-positive antiphospholipid syndrome | Warfarin, not a DOAC: DOACs carried more thrombosis in trials. |
| Sjögren disease with persistent parotid swelling and low C4 | MALT lymphoma | Biopsy a persistently enlarged gland; cryoglobulins add risk. |
| Diffuse scleroderma, new hypertension, rising creatinine | Scleroderma renal crisis | ACE inhibitor, titrated up despite rising creatinine; high-dose steroids raise the risk. |
| Inflammatory back pain, uveitis, HLA-B27 | Axial spondyloarthritis | NSAIDs first; csDMARDs don't help axial disease (ASAS-EULAR 2022). PBS lists biologics for AS and nr-axSpA. |
| Heliotrope rash, Gottron papules, anti-TIF1-gamma | Cancer-associated dermatomyositis | Search for an underlying cancer at diagnosis and keep screening. |
| Chondrocalcinosis and MCP hook osteophytes at 45 | CPPD from haemochromatosis | Check iron studies, calcium, magnesium and phosphate. |
2Australia-only high-yield (won't be in UK or US banks)
Biologic and targeted DMARDs (PBS, October 2026). Authority Required, initial and continuing: severe active RA, severe psoriatic arthritis, ankylosing spondylitis and nr-axSpA. Rituximab: Highly Specialised Drugs program, unrestricted. RA: methotrexate-based triple therapy first (Australian Living Guideline, 2021).
JAK inhibitors (TGA PI warnings, 2025 to 2026). Use only if no suitable alternative at 65 or older, with atherosclerotic disease or cardiovascular risk factors, or with malignancy risk.
Lupus and vasculitis (PBS and TGA, October 2026). PBS lists anifrolumab for SLE, tocilizumab for active GCA and avacopan for ANCA vasculitis induction. Belimumab is TGA registered for SLE and lupus nephritis but was not found in the PBS medicine index in October 2026.
Gout (TGA PIs 2022 to 2026; ARA medicine sheet 2026). Allopurinol: start low, titrate to target urate, up to 900 mg. Flare: colchicine 1 mg, then 0.5 mg an hour later, no repeat within 3 days; halve at CrCl 50 mL/min or less. PBS lists febuxostat for chronic gout (streamlined); avoid in major cardiovascular disease (TGA).
Hydroxychloroquine (Australian Living Guideline, 2026). Higher risk (over 5 mg/kg real weight, CKD, tamoxifen, macular disease): baseline within a year, then yearly; others yearly from 5 years. SD-OCT plus automated fields.
Osteoporosis (RACGP and Healthy Bones Australia 2024; PBS, October 2026). Very high risk: refer for an anabolic agent first. PBS lists romosozumab (first-line and second-line) and teriparatide for severe established osteoporosis. Never interrupt denosumab; if stopping, a bisphosphonate for 12 months or more.
Acute rheumatic fever (RHDAustralia, edition 3.3, 2025). High risk: First Nations people in rural or remote areas; possibly urban First Nations, Maori and Pacific people. Benzathine benzylpenicillin G every 28 days; with RHD and documented ARF, at least 10 years or to age 35 (moderate) or 40 (severe), whichever is longer, then reassess (Table 10.3). See Physify's Rheumatic Fever course.
3Sample questions (Physify format)
1. A 68 year old man with seropositive rheumatoid arthritis has active disease despite methotrexate and leflunomide, and qualifies for PBS-subsidised targeted therapy. He stopped smoking five years ago after 30 pack-years and has treated hypertension. He would prefer a tablet. Following the Australian product information, what is the most appropriate next treatment?
- A. Tofacitinib, as he prefers an oral agent
- B. Adalimumab, with methotrexate continued
- C. Baricitinib 4 mg daily, with lipid monitoring
- D. Upadacitinib, as its warning is weaker than tofacitinib's
- E. Prednisolone 10 mg daily long term instead
Answer: B
B. Correct. Every JAK inhibitor's TGA product information says to use it only if no suitable alternative exists in people 65 or older, or with cardiovascular risk factors such as long-time smoking. A TNF inhibitor is a suitable alternative.
A. Preference for a tablet does not outweigh his age and smoking history.
C. Baricitinib carries the same warning; lipid monitoring does not remove the risk.
D. The upadacitinib warning is the same, drawn from the tofacitinib safety study.
E. Long-term glucocorticoid is not a substitute for a DMARD and adds its own harms.
2. A 54 year old man of Han Chinese ancestry has recurrent gout flares and an eGFR of 45 mL/min/1.73 m2. Allopurinol is planned. Which step before starting it best reduces his risk of a severe cutaneous adverse reaction?
- A. Start at 300 mg daily so urate falls quickly
- B. Give prednisolone cover for the first month
- C. Test for HLA-B*5801 before the first dose
- D. Start colchicine alongside it to prevent a rash
- E. Check TPMT activity before it is started
Answer: C
C. Correct. The TGA product information advises considering HLA-B*5801 screening where the allele is common, naming Han Chinese, Thai and Korean ancestry, and notes CKD may add to the risk. A carrier should not start allopurinol unless there is no reasonable alternative.
A. A high starting dose raises the risk, especially in CKD; start low and titrate.
B. Steroid cover does not prevent the reaction and may delay its recognition.
D. Colchicine reduces flares when urate-lowering starts; it does not prevent hypersensitivity.
E. TPMT guides thiopurine dosing, not allopurinol.
3. A 13 year old Aboriginal girl from a remote community has had a hot, swollen right knee for four days. Aspirated fluid is sterile. Her temperature is 38.2 C, ESR 40 mm/h and anti-DNase B raised; ECG and echocardiogram are normal. Under the 2025 Australian guideline, what is the diagnosis?
- A. Definite ARF: one major and two minor manifestations
- B. Possible ARF: monoarthritis is only a minor manifestation
- C. Probable ARF: the ESR is below the 60 mm/h threshold
- D. Post-streptococcal reactive arthritis, not ARF
- E. No ARF: a normal echocardiogram excludes it
Answer: A
A. Correct. In high-risk groups aseptic monoarthritis is a major manifestation, and fever of 38 C or more and ESR of 30 mm/h or more are minor ones. With evidence of Strep A infection, that is definite ARF (RHDAustralia 2025).
B. Monoarthritis is minor only in low-risk groups.
C. The 60 mm/h ESR threshold applies to low-risk groups.
D. The guideline says this diagnosis should rarely, if ever, be made in high-risk populations.
E. ARF without carditis is common; a normal echo sets the duration of prophylaxis, not the diagnosis.