Lecture 9: Arthritis Part 1 Flashcards
MC form of joint disease
Arthritis
90% of all patients will have radiographic evidence of arthritis in weight bearing joints by age….
40
Who is OA of the hands and knees MC in?
Females
But men complain more
Why do osteophytes develop in articular margins?
It is where they try to repair it
Is OA relieved by rest?
Yes
What does OA typically reduce?
Range of motion
What are bony enlargements of the DIP and PIP called?
- DIP: Herberden nodes
- PIP: Bouchard nodes
Peanut Butter, Dip in Herbs
Does OA cause elevations in ESR?
No
Also does not show inflammatory synovial fluid
Diagnostic modality of choice for OA?
XR
What is typically seen on XR for OA?
- Narrowing of joint space
- Osteophyte formation
- Lipping of marginal bone
- Thickened, subchondral bone
First line therapy for mild OA
3-4g of acetaminophen daily
Caution in liver dz and heavy alcohol
What is the issue with NSAIDs vs acetaminophen for OA?
NSAIDs have more SEs
Which NSAID has low systemic absorption but is good for pain?
Voltaren gel
Which PO NSAIDs are safe to use with coumadin?
Celebrex?
Selective COX-2 inhibitor
When might we administer PPI with NSAIDs?
For High risk OA patients
What can we inject into joints for OA?
- Intra-articular steroids
- Hyaluronic acid (last resort, symptomatic relief)
Where is natural hyaluronic acid from?
- Rooster Combs
- Cow
When is surgery indicated for OA?
- Pain at rest
- Restricted walking
Total replacements
How does gout typically present?
MONOarticular buildup of gout
Who is primary gout MC in?
Men older than 30y
What is considered hyperuricemia?
> 6.8
MC joint affected in gout
MTP of big toe
Looks like a bunion
What is the characteristic lesion of gouty arthritis?
Tophus
Monosodium urate crystal deposit + Foreign body rxn
What is podagra?
A tophus of the MTP joint of the big toe
Where does gouty arthritis rarely affect?
- Hips
- Shoulders
How does a gout attack present?
- Sudden
- Noctunral
- Asymmetric
- Swelling
- fever sometimes
What diagnostic study confirms gouty arthritis?
Joint fluid analysis showing sodium urate crystals (needle-like and negatively birefringent with light microscopy)
What is a “rat bite” on XR?
Punched out erosions with overhanging rim or cortical bone (seen in gouty arthritis)
When do you treat hyperuricemia?
Only if symptomatic, otherwise diet modifications!
What is the main diet modification for gout?
Avoiding purine-rich foods
Also drink water, avoid alcohol
What is first-line tx for management of pain in gouty arthritis?
- Naproxen BID
- Indomethacin Q8h
MC SEs of colchicine?
GI effects
Usually a loading dose then maintenance
When are corticosteroids primarily used for acute gout?
- People who can’t take NSAIDs
- For dramatic attacks
Which corticosteroid is used primarily for joint injection during acute gout?
Triamcinolone
If mono-articular
Between Triamcinolone and Methylpredinosolone, which is more likely to lead to bursitis?
Triamcinolone per kevin
When is colchicine best used for gout?
Prophylaxis
What common drug classes can lead to hyperuricemia?
- Thiazides
- Loop diuretics
- Niacin
When is urate lowering therapy indicated and what is the goal?
- Frequent arthritis (> 2 attacks annually)
- Tophaceous deposits
- CKD stage 2 or worse
- Goal: < 6
First-line therapy for urate lowering therapy?
Xanthine oxidase inhibitors: Allopurinol & Uloric
What is the main HSR that occurs with allopurinol?
Rash progressing to TEN associated w/o vasculitis & hepatitis
What is the main concern with Uloric?
CV outcomes
What does probenecid do?
Increase uric acid excretion by kidney
Indicated when xanthine oxidase inhibitor fails or not good enough
Cannot use if CrCl < 50
For chronic tophaceous arthritis, how do we get the body to resorb the urate crystals?
Keep serum uric acid < 6
What distinguishes pseudogout from gout?
Pseudo has Positive birefringent rhomboid-shaped crystals on synovial fluid analysis.
How does rheumatoid arthritis (RA) differ from gouty?
RA is synovitis of MULTIPLE joints, and is symmetrical
Who is RA MC in?
Women, also tends to occur early at 40-50
Male is typically 60+
What are the pathologic findings in the joint associated with RA?
Formation of a pannus
How long and when is stiffness prominent in RA?
- Most prominent in the AM
- Lasts GREATER THAN 30 mins, up to hours
Image of late RA
Where do RA nodules typically occur over?
Bony prominences
What does presence of RA nodules correlate with?
Serum rheumatoid factor
Besides joint stuff, what else does RA present with?
- Dryness of eyes, mouth, mucous membranes
- ILD
- Pericarditis or pleural dz
- Felty syndrome (splenomegaly + neutropenia)
- Small vessel vasculitis
What is the most specific blood test for RA?
Anti-CCP antibodies
What confirms the inflammatory nature of RA?
Joint fluid analysis
R/o superimosed septic arthritis
What kind of imaging is specific for RA?
Radiograph changes (stocking-glove distribution)
After 6 months
In later RA, what occurs to joint spaces?
Uniform narrowing of joint spaces
Primary tx for RA
DMARDs
Once diagnosed with RA
What is the role of corticosteroids in RA?
Bridging to DMARDs
What is the max # of injections of triamcinolone we want to give for RA?
4 a year
What is the initial DMARD of choice for RA?
Methotrexate
Takes 4-6 weeks
What do you need to monitor/educate about with methotrexate use?
- Teratogenic
- Gastric irritation/stomatitis
- Avoid alcohol
- Folic acid 1mg daily
What is the 2nd line therapy for RA?
Sulfasalazine
Main SEs of sulfasalazine
- Neutropenia
- Thrombocytopenia
- Hemolysis in G6PD
CI in someone with an ASA allergy
Need CBC Q2-4wks for 3 months, then every 3 months
When are TNF inhibitors used for RA?
Inadequate response to MTX
Usual combo is TNF + MTX for RA
