GCC Nursing Guide — Autoimmune & Rheumatological Disease

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SLE — Overview

Systemic Lupus Erythematosus (SLE) is a multisystem autoimmune disease characterised by immune complex deposition and widespread organ inflammation. It predominantly affects women of childbearing age (F:M ratio = 9:1).

Key Autoantibodies

Complement

Low C3/C4 = active disease (consumed by immune complexes). Rising anti-dsDNA + falling complement = impending flare.

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ACR/EULAR 2019 Classification Criteria

Entry criterion: ANA titre ≥1:80. Score ≥10 = SLE classification.

Domain	Criterion	Score
Constitutional	Fever	2
Mucocutaneous	Malar rash / photosensitivity	6
	Discoid rash	4
	Oral ulcers / alopecia	2
Arthritis	Synovitis ≥2 joints	6
Neuropsychiatric	Seizures / psychosis / mononeuritis multiplex	5
Serosal	Pleuritis / pericarditis	5
Renal	Nephritis — proteinuria / haematuria / renal biopsy	8–10
Haematological	Haemolytic anaemia / leucopenia / thrombocytopenia	3–4
Immunological	Anti-dsDNA / Anti-Smith / antiphospholipid Ab	6
Complement	Low C3 / Low C4	3–4

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SLEDAI Score — Disease Activity Monitoring

The SLE Disease Activity Index (SLEDAI) quantifies disease activity across organ systems. Scores are weighted — renal and CNS manifestations carry highest weight.

SLEDAI 0

Inactive disease / remission

Target for most patients on maintenance therapy

SLEDAI 1–5

Mild activity

Monitor closely, consider optimising hydroxychloroquine

SLEDAI ≥6

Moderate–Severe flare

Escalate therapy — consider IV methylprednisolone, specialist review

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Lupus Nephritis

⚠️

Most serious complication of SLE. Affects 40–60% of SLE patients. Leading cause of long-term morbidity.

Nursing Assessment — Surveillance

Urinalysis at every visit — haematuria, proteinuria
24-hour urine protein or spot protein:creatinine ratio (PCR)
eGFR / creatinine — trend over time
Blood pressure — hypertension worsens nephritis
Oedema assessment (periorbital, peripheral)

ISN/RPS Biopsy Classes

Class I/IIMesangial — generally mild

Class IIIFocal proliferative — moderate risk

Class IVDiffuse proliferative — most common, most severe

Class VMembranous — heavy proteinuria

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Lupus Cerebritis & Antiphospholipid Syndrome

Neuropsychiatric SLE (NPSLE)

Psychosis, seizures, stroke-like episodes, cognitive impairment
Neurological observations mandatory — GCS, focal neurological signs
MRI brain preferred imaging modality
Differentiate from steroid-induced psychiatric symptoms

Antiphospholipid Syndrome (APS)

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Triad: Thrombosis (arterial/venous) + recurrent miscarriage + positive antiphospholipid antibodies (anticardiolipin, lupus anticoagulant, anti-β2GPI).

Long-term anticoagulation with warfarin (target INR 2–3 venous; 2.5–3.5 arterial)
Monitor INR closely — SLE patients at higher bleeding/clotting risk
Catastrophic APS: multi-organ thrombosis — ICU-level care, IVIG, plasmapheresis

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SLE Drug Monitoring & GCC Context

Key Drug Monitoring

HydroxychloroquineAnnual ophthalmology (retinopathy)

AzathioprineFBC + LFTs every 3 months

MycophenolateFBC + renal function every 3 months

PrednisoloneBP, glucose, DEXA, calcium/D3

Belimumab (anti-BAFF)Infusion reactions, infection surveillance

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Hydroxychloroquine is first-line for ALL SLE patients (unless contraindicated) — reduces flares, nephritis risk, and mortality.

GCC-Specific Considerations

SLE prevalence is higher in Arab and South Asian women living in the GCC — ethnic predisposition compounded by environmental factors.

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Sun exposure in the GCC is extreme year-round. UV light is a potent SLE flare trigger. Sun avoidance education is critical — SPF 50+, protective clothing, avoid peak sun (10am–4pm). Many patients are initially reluctant to limit outdoor activity.

Patient Education Points

Avoid outdoor activities during peak sun hours
Window film (UV-blocking) for car/home
Stress is a common flare trigger — psychosocial support
Contraception counselling (oestrogen-containing OCP can worsen SLE/APS)
Pregnancy in SLE requires specialist planning — preconception counselling

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RA — Overview & Pathophysiology

Rheumatoid Arthritis is a chronic symmetrical inflammatory polyarthritis causing synovial inflammation, cartilage destruction, and bone erosion. Predominantly affects MCP and PIP joints (spares DIP — distinguishes from OA).

ACR/EULAR 2010 Classification (Score ≥6 = RA)

Joint involvement1 large (0) → ≥10 small (5 pts)

SerologyRF/ACPA low-pos (2) → high-pos (3)

Acute phase reactantsNormal CRP/ESR (0) → abnormal (1)

Duration<6 weeks (0) → ≥6 weeks (1)

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DAS28 — Disease Activity Score

DAS28 uses 28-joint count (tender + swollen joints), ESR or CRP, and patient global assessment (VAS 0–100mm).

Remission< 2.6Target of treat-to-target strategy

Low Activity2.6 – 3.2Minimal joint damage risk

Moderate3.2 – 5.1Review & consider step-up

High Activity> 5.1Escalate therapy urgently

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Treat-to-target: Aim for remission (DAS28 <2.6) or low disease activity. Review every 1–3 months until target achieved.

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Extra-Articular Manifestations of RA

Systemic / Skin

Rheumatoid nodules (elbows, sacrum, lung)
Vasculitis — nail fold infarcts, ulcers
Felty's syndrome (RA + splenomegaly + neutropenia)

Pulmonary

Interstitial lung disease (ILD) — UIP pattern
Pleural effusions
Caplan syndrome (RA + pneumoconiosis)
Obliterative bronchiolitis (MTX-related)

Cardiovascular / Other

Accelerated cardiovascular disease (2× risk)
Anaemia of chronic disease
Atlantoaxial subluxation (C1–C2) — cervical spine assessment pre-GA
Keratoconjunctivitis sicca (dry eyes)

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csDMARDs in RA

MethotrexateFirst-line DMARD

Folic acid 5mgAlways co-prescribe with MTX (not same day)

HydroxychloroquineMild RA, combination therapy

SulfasalazineCombination therapy; safe in pregnancy

LeflunomideAlternative if MTX intolerant

Methotrexate Monitoring

FBC + LFTs every 3 months (once stable)
Baseline renal function — renally cleared
Avoid NSAIDs (↑ MTX toxicity)
STOP if WBC <3.5 or ALT >3× ULN
Sick day rule: hold MTX during acute infection
Contraindicated in pregnancy — teratogenic (folate antagonist)

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Biologic DMARDs

Anti-TNF Agents

Other Biologics

Abatacept (CTLA4-Ig)T-cell co-stimulation blockade

Rituximab (anti-CD20)B-cell depletion

Tocilizumab (anti-IL6R)IL-6 blockade

Baricitinib / TofacitinibJAK inhibitors (oral)

Pre-Biologic Screening — Mandatory

TB screening: Quantiferon Gold (IGRA) or Mantoux + CXR — reactivation risk
Hepatitis B serology (HBsAg, anti-HBc) — reactivation risk with rituximab especially
Hepatitis C, HIV status
Varicella status — VZV vaccination if seronegative (give BEFORE starting)
DIVA chest X-ray baseline

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Joint Protection & Nursing Education

Joint Protection Principles

Spread load across larger joints
Avoid sustained grip or pinch
Use two hands rather than one
Wrist splints during high-demand tasks
Avoid positions of deformity

OT / Adaptive Equipment

Jar openers, built-up handled cutlery
Lever taps, key turners
Raised toilet seats
Splinting for ulnar deviation
Referral to occupational therapist

Exercise & Physiotherapy

Regular low-impact exercise reduces disability
Hydrotherapy beneficial during active flare
Range of motion exercises daily
Strengthening during remission
Foot orthotics for MTP joint involvement

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Vasculitis Classification by Vessel Size

Large Vessel Vasculitis

Aorta and major branches. GCA: age >50, temporal artery. Takayasu: young women, subclavian involvement — pulseless disease.

Medium Vessel Vasculitis

PAN: HBV-associated, renal/mesenteric arteries. Kawasaki: children — coronary artery aneurysm risk, IVIG treatment.

Small Vessel — ANCA-Associated

cANCA/PR3 → GPA; pANCA/MPO → MPA or EGPA. Renal, pulmonary, ENT involvement.

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Giant Cell Arteritis (GCA) — Emergency

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OPHTHALMIC EMERGENCY — visual loss is irreversible.

Do NOT wait for biopsy result before starting steroids. Start high-dose prednisolone immediately.

Clinical Features

Age >50 years (almost exclusively)
Severe temporal/scalp headache
Scalp tenderness — painful to comb hair
Jaw claudication (pathognomonic — pain on chewing)
Amaurosis fugax → sudden visual loss (anterior ischaemic optic neuropathy)
Raised ESR (>50 mm/hr), raised CRP

Emergency Management

Prednisolone 60mg oral immediately (IV methylprednisolone if visual symptoms)
Urgent ophthalmology review (within hours)
Temporal artery biopsy — arrange within 1–2 weeks (steroids do not invalidate within 2 weeks)
Add aspirin 75mg unless contraindicated
Gastric protection (PPI) with steroids
Bone protection — calcium/D3, DEXA scan

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ANCA-Associated Vasculitis Nursing

GPA (Wegener's)

Upper/lower airway + renal. Saddle-nose deformity, sinusitis, haemoptysis, rapidly progressive GN. cANCA/PR3.

EGPA (Churg-Strauss)

Asthma + eosinophilia + vasculitis. pANCA/MPO. Cardiac involvement common. Peripheral neuropathy.

Nursing Surveillance — ANCA Vasculitis

Urine dipstick at every visit — haematuria indicates renal relapse
Haemoptysis monitoring — pulmonary haemorrhage is life-threatening
ENT assessment — nasal crusting, epistaxis, hearing loss
Skin purpura — palpable purpura (non-blanching)
Monitor ANCA titres and creatinine for relapse detection

Kawasaki Disease Nursing Points

Children — fever >5 days + 4 of 5 criteria (rash, conjunctivitis, mucositis, lymphadenopathy, extremity changes)
IVIG 2g/kg + aspirin — reduces coronary artery aneurysm risk
Echocardiography — assess coronary arteries

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Cyclophosphamide Therapy — Nursing Safety

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High-risk chemotherapy agent. Requires specialist nursing protocols, monitoring, and patient education.

Bladder Toxicity

Acrolein metabolite causes haemorrhagic cystitis. Prevent with:

Mesna co-administration (uroprotectant)
High fluid intake — 2–3L/day
Void frequently — do not hold urine
Monitor urine for haematuria
Long-term: bladder cancer surveillance

Bone Marrow Suppression

Nadir at 10–14 days post-IV dose.

FBC fortnightly during induction
STOP if WBC <3.0 or neutrophils <1.5
PCP prophylaxis (co-trimoxazole)
Infection surveillance mandatory
G-CSF if severe neutropenia

Other Toxicities

Teratogenicity — contraception essential
Premature ovarian failure — fertility counselling before starting
Nausea/vomiting — antiemetic pre-medication
Hair thinning
Rituximab now preferred over cyclophosphamide for GPA/MPA induction where available

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Systemic Sclerosis — Classification

Limited SSc (lcSSc)

CREST syndrome:

Calcinosis
Raynaud's phenomenon
Eosinophageal dysmotility
Sclerodactyly
Telangiectasia

Anti-centromere antibody. PAH is leading cause of death in lcSSc.

Diffuse SSc (dcSSc)

Widespread skin involvement proximal to elbows/knees. Rapid progression. Anti-topoisomerase I (anti-Scl-70).

ILD is leading cause of death in dcSSc. Scleroderma renal crisis risk higher.

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Raynaud's Phenomenon

Digital vasospasm triggered by cold or emotional stress. Phases: white (ischaemia) → blue (cyanosis) → red (reperfusion).

Nursing Management

Warming measures — gloves, socks, heated gloves for severe cases
Avoid cold triggers — teach cold avoidance strategies
Stop smoking — nicotine causes vasospasm
Nifedipine (calcium channel blocker) — first-line pharmacotherapy
Iloprost IV infusion — severe/digital ulcer-threatening Raynaud's
Sildenafil (PDE5 inhibitor) — refractory cases
Sympathectomy — last resort for severe digital ischaemia

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In GCC: air conditioning exposure is a common and overlooked Raynaud trigger. Patients should carry warm wraps to offices and shopping malls.

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Scleroderma Renal Crisis — Emergency

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Medical emergency: Rapidly rising BP (often >150/90 acutely) + AKI in dcSSc.

Typically within first 4 years of diffuse SSc. High-dose steroids (>15mg/day) are a precipitant — avoid if possible.

Management

ACE inhibitor (captopril or lisinopril) URGENTLY — dramatically improves outcomes
Target BP reduction: 20mmHg per day (not abrupt — risk of watershed infarction)
Monitor creatinine daily — renal function may continue to deteriorate before improving
Dialysis may be required acutely — renal recovery possible weeks–months later
Do NOT stop ACEi even if creatinine rises initially

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Hypertension in any SSc patient = check creatinine + urinalysis immediately. Renal crisis can present without severe hypertension occasionally.

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Pulmonary Complications in SSc

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Pulmonary complications are the leading cause of mortality in SSc. ILD (especially dcSSc) and PAH (especially lcSSc) must be screened for regularly.

ILD (Interstitial Lung Disease)HRCT, PFTs 6-monthly

PAH (Pulmonary Art. Hypertension)Echo annually, RHC if PAH suspected

ILD TreatmentMycophenolate, nintedanib

PAH TreatmentSildenafil, bosentan, prostacyclins

Respiratory Nursing Assessment

Dyspnoea on exertion — Borg scale / MRC dyspnoea scale
SpO₂ at rest and with exertion (6-minute walk test)
New or worsening dry cough — ILD indicator
Bibasal crackles on auscultation — ILD finding
Right heart failure signs: raised JVP, ankle oedema, RV heave

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Digital Ulcers, GI Involvement & Skin Care

Digital Ulcers

Very painful ulcers on fingertips — risk of gangrene, osteomyelitis, amputation if untreated.

Iloprost IV infusion — promotes healing, reduces new ulcer formation
Bosentan (oral) — prevents new digital ulcers
Meticulous wound care — non-adherent dressings
Pain management — often requires opioids acutely
Infection surveillance — ulcers frequently colonised
Vascular surgery referral if gangrene threatened

GI Involvement

GORD — PPI therapy, head elevation, small frequent meals
Oesophageal dysmotility — eat sitting upright, avoid lying within 2hrs of eating
Small bowel dysmotility — bloating, bacterial overgrowth (cyclical antibiotics)
Malabsorption — nutritional assessment, supplementation
Anorectal — faecal incontinence (biofeedback, PFMT referral)
Weight loss monitoring

Skin & Facial Care

Regular emollient regimen — twice daily minimum
Tight skin — range of motion exercises, facial stretching
Telangiectasia — cosmetic camouflage if distressing
Calcinosis deposits — avoid trauma, do not squeeze
Mouth opening exercises — reduced oral aperture affects eating/dental hygiene
Dental hygiene referral — microstomia complicates dental care

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GCC Context: SSc and connective tissue diseases are prevalent in the Gulf region. Air conditioning creates persistent cold environments — a major Raynaud's trigger. Higher diagnostic awareness is needed in GCC rheumatology services, particularly among South Asian expatriate populations.

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Drug Monitoring Schedule

Drug	Monitoring Tests	Frequency	Stop/Action If
Methotrexate	FBC, LFTs, creatinine	Every 3 months (once stable)	WBC <3.5, ALT >3×ULN, creatinine rising
Hydroxychloroquine	Annual eye review (Humphrey VF, OCT)	Annually from year 5 (year 1 if risk factors)	Bull's eye maculopathy on OCT
Azathioprine	FBC, LFTs	Every 3 months (once stable)	WBC <3.5, MCV rising, LFTs >3×ULN
Cyclophosphamide	FBC, U&E, urine dipstick	Fortnightly during induction (±weekly if high-risk)	WBC <3.0, haematuria (persistent)
Mycophenolate	FBC, renal function	Every 3 months	WBC <3.0, rising creatinine
Rituximab	FBC, immunoglobulins, pre-dose B-cell count	Pre-infusion + 3-monthly	IgG <5g/L (infection risk), neutropenia
Anti-TNF	FBC, LFTs, TB surveillance	Every 3–6 months	Active infection, TB reactivation signs
Leflunomide	FBC, LFTs, BP	Monthly for 6 months, then 3-monthly	ALT >3×ULN, WBC falling, hypertension

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Infection Surveillance in Immunosuppressed

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Immunosuppressed patients may not mount fever or leukocytosis. Any deterioration, new symptoms, or subtle change requires urgent infection screen.

Opportunistic Infection Prevention

PCP prophylaxis: co-trimoxazole 480mg daily during high-dose steroid (>20mg/day prednisolone >4 weeks)
Fungal prophylaxis: fluconazole if high-risk (prolonged steroid + lymphopenia)
CMV surveillance: in patients on cyclophosphamide + high-dose steroids
TB reactivation: vigilance on anti-TNF, rituximab — any new respiratory symptoms
Herpes zoster: common on biologics — antivirals promptly (aciclovir/valaciclovir)

SICK DAY RULES

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Steroids: NEVER stop abruptly. During acute illness: double the steroid dose. Vomiting = go to ED for IV hydrocortisone.

MTX/Leflunomide: Hold during acute febrile illness or GI upset. Resume when recovered.

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Vaccination in Immunosuppressed Rheumatology Patients

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NO live vaccines on biologic DMARDs, cyclophosphamide, or high-dose steroids.

Contraindicated Live Vaccines (on immunosuppression)

Safe (Inactivated) Vaccines — Recommended

Timing of Vaccination

Ideally complete all vaccinations BEFORE starting biologics
Rituximab: vaccines ideally given ≥4 weeks before or ≥6 months after infusion
VZV (Shingrix — non-live): safe on most biologics

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Corticosteroid Side Effects & Monitoring

Metabolic

Hyperglycaemia — monitor glucose, HbA1c; new-onset steroid diabetes
Hypertension — BP at every visit
Hyperlipidaemia — lipid profile annually
Weight gain / truncal obesity
Electrolyte: hypokalaemia

Musculoskeletal / GI

Osteoporosis — calcium 1000–1200mg/day + Vit D3 800–1000IU/day
DEXA scan at start and annually
Bisphosphonate (alendronate/risedronate) if long-term >7.5mg/day
PUD / GI bleed — PPI co-prescription
Myopathy — proximal weakness
Avascular necrosis (femoral head)

Adrenal Insufficiency

Never stop steroids abruptly after >3 weeks
Sick day rules — double dose during febrile illness
Stress dosing for surgery, trauma
Carry steroid card / MedicAlert
Signs of AI: fatigue, hypotension, nausea, confusion

Neuropsychiatric

Mood changes, euphoria, insomnia, psychosis
Distinguish from underlying disease activity (NPSLE)
Cataracts, glaucoma — annual eye review if long-term steroids

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Autoimmune Medication Monitoring Planner

Monitoring Schedule Generator

Drug

Indication

Dose / Frequency

Start Date

Baseline Tests Required

Monitoring Schedule

Pre-treatment Checklist

Key Drug Interactions

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DHA / DOH / SCFHS / QCHP Exam Focus: Autoimmune disease questions frequently tested in GCC licensing exams. These boards favour pattern recognition, emergency priorities, and drug safety. Click each question to reveal the answer.

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SLE — Key Exam Points

Q: What is the F:M ratio in SLE, and which antibody is most specific for SLE?

A: F:M = 9:1. Anti-dsDNA and Anti-Smith are most specific. ANA is highly sensitive but not specific. Anti-dsDNA titres track disease activity (rise before flare).

Q: A SLE patient has haematuria, proteinuria, and rising creatinine. What is the most important next investigation?

A: Renal biopsy — to classify lupus nephritis (ISN/RPS classes I–V). Class III and IV (proliferative) require aggressive immunosuppression. Histology guides treatment.

Q: Which drug must ALL SLE patients receive, and what annual monitoring does it require?

A: Hydroxychloroquine — reduces flares, nephritis, and mortality. Requires annual ophthalmology review (Humphrey visual field + OCT macular) from year 5 (year 1 if high-risk) to detect bull's eye retinopathy.

Q: What is antiphospholipid syndrome (APS) and how is it managed?

A: APS = thrombosis (arterial or venous) + recurrent miscarriage + positive antiphospholipid antibodies (anticardiolipin, lupus anticoagulant, anti-β2GPI). Treatment: long-term warfarin (INR 2–3 for venous thrombosis; 2.5–3.5 for arterial). DOAC use is controversial in APS — warfarin preferred.

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RA & DAS28 — Exam Points

Q: State the DAS28 score thresholds for remission, low, moderate, and high disease activity.

A: Remission <2.6 | Low activity 2.6–3.2 | Moderate 3.2–5.1 | High >5.1. Treat-to-target aims for DAS28 <2.6 (remission) or at minimum <3.2 (low disease activity).

Q: Before starting a biologic DMARD (anti-TNF), what mandatory screening is required?

A: TB screening (Quantiferon Gold IGRA + CXR), Hepatitis B (HBsAg + anti-HBc), Hepatitis C, HIV status, varicella serology (vaccinate if negative before starting), baseline FBC/LFT/renal function.

Q: Which joints are predominantly affected in RA, and how does this differ from OA?

A: RA predominantly affects MCP and PIP joints (proximal). OA affects DIP joints and CMC joint of thumb (distal). RA spares DIP joints. RA is symmetrical; OA is often asymmetrical initially.

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Vasculitis — Exam Points

Q: Name the three ANCA-associated vasculitides and their ANCA associations.

A: GPA (Granulomatosis with polyangiitis / Wegener's) — cANCA / PR3. MPA (Microscopic polyangiitis) — pANCA / MPO. EGPA (Eosinophilic granulomatosis with polyangiitis / Churg-Strauss) — pANCA / MPO (often negative, eosinophilia key feature).

Q: A 68-year-old woman has a 3-day history of severe unilateral headache, jaw pain on chewing, and blurred vision in one eye. What is the diagnosis and immediate management?

A: Giant Cell Arteritis (GCA) with impending visual loss. IMMEDIATE: High-dose prednisolone 60mg oral (or IV methylprednisolone 500mg if visual symptoms). DO NOT wait for biopsy. Urgent ophthalmology review. Temporal artery biopsy within 1–2 weeks. Visual loss in GCA is irreversible — minutes matter.

Q: What is the primary nursing concern with cyclophosphamide therapy, and how is it prevented?

A: Haemorrhagic cystitis — caused by the toxic metabolite acrolein. Prevention: Mesna (uroprotectant given with each dose), high fluid intake (2–3L/day), frequent voiding, urine dipstick monitoring. Long-term: risk of bladder cancer — urological surveillance.

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Scleroderma & Quick Reference

Q: What is CREST syndrome and which antibody is associated with it?

A: CREST = Calcinosis + Raynaud's + oEsophageal dysmotility + Sclerodactyly + Telangiectasia. Associated with anti-centromere antibody. This is limited systemic sclerosis (lcSSc). PAH is the main cause of death in lcSSc.

Q: A diffuse SSc patient has rapidly rising blood pressure and worsening renal function. What is the emergency treatment?

A: Scleroderma renal crisis. Immediate ACE inhibitor (captopril/lisinopril) — this dramatically improves outcomes. Gradual BP reduction (20mmHg/day). Monitor creatinine daily. Dialysis may be needed acutely, but renal recovery is possible weeks later. Do NOT stop ACEi if creatinine rises initially.

Q: Which vaccines are absolutely contraindicated in patients on biologic DMARDs?

A: All LIVE vaccines: MMR, Live VZV (chickenpox/shingles live vaccine), Yellow Fever, BCG, Oral Typhoid, Live intranasal influenza. Inactivated vaccines (influenza injection, pneumococcal, Shingrix [recombinant — non-live], hepatitis B) are SAFE and recommended.

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Quick Reference — Autoimmune Summary

Disease	Key Antibody	Most Serious Complication	First-line Treatment	Key Nursing Action
SLE	Anti-dsDNA, Anti-Smith	Lupus nephritis (class IV)	Hydroxychloroquine + steroids ± MMF	Urine dipstick, sun avoidance, ophthalmology
RA	RF, Anti-CCP (ACPA)	ILD, accelerated CVD, AAI subluxation	Methotrexate + folic acid	DAS28, joint protection education, TB screen pre-biologic
GCA	None specific (ESR ↑↑)	Irreversible visual loss	High-dose prednisolone IMMEDIATELY	Ophthalmology urgently — do NOT delay steroids
GPA/MPA	cANCA/PR3 (GPA), pANCA/MPO (MPA)	RPGN, pulmonary haemorrhage	Rituximab or cyclophosphamide + steroids	Daily urinalysis, haemoptysis monitoring, Mesna with CYC
SSc (diffuse)	Anti-Scl-70 (anti-topoisomerase I)	Scleroderma renal crisis, ILD	ACEi for renal crisis; MMF for ILD	BP monitoring, renal function, Raynaud's/digital ulcer care
SSc (limited)	Anti-centromere	PAH	Sildenafil/bosentan for PAH; nifedipine for Raynaud's	Annual echo, SpO₂ monitoring, GI positioning