B6.037 Oligoarthritis Flashcards
definition of oligoarthritis
1-4 joints not just arthritis; inflammation/synovitis is present >6 weeks duration almost always asymmetric lower extremity predominant
what is JIA
juvenile idiopathic arthritis
age of JIA patients
<6
especially 1-4 years
race of JIA patients
typically white
northern European
different courses of JIA after 6 months
first 6 months: 1-4 joints
persistent (50%) = stays 4 or less
extended (50%) = >4 joints after 6 months
sex of JIA patients
3:1 girls: boys
in Asia, more boys
negative blood tests in JIA
RF
IgG anti-CCP (ACPA)
blood tests that has 8% chance of being positive in JIA
HLA-B27
prevalence in the general white population
autoantibody positive in 75-85% of JIA patients
ANA
common joints affected by JIA
knee > ankle > others
what might be an associated skin complication of JIA?
psoriasis
esp if the patient has wrist involvement
what is the uveal tract
pigmented part of the eye
choroid, ciliary body, and iris
symptoms of acute anterior uveitis
pain
photophobia
blurred vision
redness
in which JIA patients would you expect ocular inflammation
ANA+
oligoarticular-onset
25% get inflammatory eye disease, but few present with symptoms
what monitoring is done for patients with ANA+, oligoarticular onset, LE predominant arthritis
slit lap screening
do ANA- JIA patients have ocular involvement
no often
potential long term ocular complications in ANA+ JIA patients
synechiae
cataracts
glaucoma
band keratopathy
what is synechiae
iris attaches to cornea or attaches to lens
initial pharmacotherapy for JIA
intra articular glucocorticoid
second step of therapy for JIA
NSAIDs motrin = ibuprofen Naprosyn = naproxen tolectin = tolmetin Mobic = meloxicam Celebrex = celecoxib
third step of therapy for JIA
methotrexate
TNF a or abatacept
-cept suffix meaning
protected from rapid degradation by attachment to Fc receptor
6 forms of JIA
- PsA (2-15%)
- systemic onset (10-15%) Stills
- RF+ polyarticular onset (5-10%)
- RF- polyarticular onset (10-30%)
- HLA-B27+ oligoarticular onset
- ANA+ oligoarticular onset (30-60%)
what is PsA
psoriatic arthritis
what is systemic onset JIA (Stills)
presents with serious symptoms that resemble leukemia or a horrible infection
what is RF+ polyarticular onset JIA
adult RA presenting in kids
typically a negative prognosis for joints
tends to occur in slightly older kids
what is RF- polyarticular onset JIA
children are younger than in RF+ and have a better prognosis for joints
what is HLA-B27+ oligoarticular onset JIA
ankylosing spondylitis
more common in males around 9-13
peripheral arthritis initially, with back complaints much later
how often does PsA accompany psoriasis?
25% of the time
how often do patients have psoriasis prior to being diagnoses with PsA?
70%
how often does PsA precede a diagnosis of psoriasis?
15%
other 15% coincident onset or undiagnosed psoriasis
CASPAR criteria for PsA
> 3 points, 99% spec/92% sens
- 2 pts psoriasis
- 1 pt past psoriasis or FH
- 1 pt psoriatic nail changes
- 1 pt RF-
- 1 pt dactylitis
- 1 pt radiographic juxtaarticular new bone
where is psoriasis most common
scalp, retroaural, EACs
extensor extremities
umbilicus, gluteal cleft/perianal
racial predilection of PsA
whites 2:1
sex of PsA patients?
equal overall
males: axial (3:1) and classical (vide infra)
females: RA-like
age of onset of psoriasis in PsA
mid-teens-20s
age of onset of joint complaints in PsA if there was prior skin involvement
a decade after skin involvement
genetic influences on PsA
35-70% monozygotic concordance
12-20% dizygotic concordance
1st degree relatives of PsA 27-50x greater risk
specific genes found in PsA
HLA-B27 + in only axial pts (50%)
HLA-B38 and B39 in general PsA
categories of PsA (not mutually exclusive)
asymmetric, oligoarticular (15-20%) symmetric, polyarticular (50-60%) "classical" (2-5%) isolated axial (2-5%) arthritis mutilans (5%)
asymmetric, oligoarticular PsA
associated with dactylitis / ray involvement
symmetric, polyarticular PsA
RA like usually seronegative (95% of the time)
classical PsA
uncommon
predominant DIP involvement
dactylitis present
nail involvement
isolated axial PsA
only SI joint involvement (asymmetric)
+/- spinal involvement
syndesmophytes large /nonmarginal
what are syndesmophytes
vertical bony spurs
like dripping wax down the spine?
arthritis mutilans
very dysmorphic hands
very little bone growth
can pull fingers out to a normal length, but they shrink back
what is enthesitis
inflammation of a tendon/ligament insertion into bone
what is dactylitis
sausage fingers/toes
common extraarticular manifestations of PsA
enthesitis dactylitis nail pitting other nail changes (onycholysis, onychodystrophy) conjunctivitis acute iritis
rare extraarticular manifestations of PsA
stomatitis
urethritis
nonspecific colitis
dilation of aortic arch base
treatment of PsA
NSAIDs intraarticular steroids methotrexate leflunomide apremilast TNFa inhib anti-IL17 anti-IL12/23 JAK inhibitor costim blockade
use of methotrexate in PsA
oral, 7.5-25 mg once a week subQ same dosage; better bioavailability take w 1 mg folic acid daily can help both skin and joints not helpful for spine or nails
use of leflunomide in PsA
pyrimidine antagonist
20 mg qd
side effects similar to mtx
less helpful for skin than mtx
use of apremilast in PsA
pde4 inhibitor
30 mg bid
approved for skin and joints
excellent safety profile
use of TNFa inhibitors in PsA
4 subQ doses per week
1 IV dose every 4-8 weeks
more risky/ greater payoff
use of anti-IL17 in PsA
secukinumab approved for PsA
every 4 weeks subQ after a 5 shot weekly loading phase
use of anti-IL12/23 in PsA
ustekinumab
every 12 weeks subQ after 2 loading doses 4 weeks apart
use of janus kinase inhibitor in PsA
tofacitinib
11 mg oral qd
drugs to avoid in PsA
prednisone
hydroxychloroquine
use of abatacept in PsA
costimulatory blockade
subQ weekly or IV every 4
MAINSTAYS of therpay in PsA
glucocorticoids and NSAIDs almost always insufficient
mainstays: mtx and TNFa inhib
