Management of OA

Question 1

Describe the two broad classifications of arthritis

Answer 1

inflammatory or mechanical

acute/chronic/acute on chronic

Question 2

List some diagnostic investigations for arthritis

Answer 2

• Jt aspirates: culture, crystals, cell count
• Autoimmune serology: RF, CCP, ANA/ENA, ACE, ANCA
• Infectious screen: viral and bacterial serologies, STI Ur PCRs
• HLA B27, serum uric acid
• Imaging: Xrays, MRI

Question 3

Describe the classification criteria for RA and PsA

Answer 3

(ACR/EULAR 2010)
- Definition of “JOINT INVOLVEMENT”
- Any swollen or tender joint (excluding DIP of hand and feet, 1st MTP, 1st CMC)
- Additional evidence from MRI / US may be used for confirmation of the clinical findings
- JOINT DISTRIBUTION (0-5)
- 1 large joint = 0
- 2-10 large joints = 1
- 1-3 small joints (large joints not counted) = 2
- 4-10 small joints (large joints not counted) = 3
- >10 joints (at least one small joint) = 5
- SEROLOGY (0-3)
- Negative RF AND negative ACPA =0
- Low positive RF OR low positive ACPA = 2
- High positive RF OR high positive ACPA = 3
- SYMPTOM DURATION (0-1)
- <6 weeks = 0
- ≥6 weeks = 1
- ACUTE PHASE REACTANTS (0-1)
- Normal CRP AND normal ESR = 0
- Abnormal CRP OR abnormal ESR = 0
- ≥6 = definite RA

CASPAR criteria for PsA
1. Skin psoriasis:
- Present on examination — two points,
- OR Previous psoriasis on history — one point,
- OR family history of psoriasis, if the patient is not affected — one point
2. Nail lesions (onycholysis, pitting) — one point
3. Dactylitis (present or past, documented by a rheumatologist)- one point
4. Negative rheumatoid factor — one point
5. Juxta-articular bone formation on radiographs (distinct from osteophytes) — one point
- PsA if >= 3 points out of 5

Question 4

Describe the management of septic arthritis

Answer 4

• Surgical urgency
• Jt aspirate before antibiotics
• Orthopaedic jt washout + Abx
• NSAIDs

Question 5

Describe the management of crystal arthtitis

Answer 5

• Acute Mx: NSAIDs, prednisone, colchicine
• +/- Chronic Mx:
  
  • Gout: Urate lowering therapy (diet, allopurinol, febuxostat), and metabolic disease management
  • ## Pseudogout: exclude secondary causes (DM, hyperparathyroidism, thyroid dz, haemachromatosis)
  • Acute Mx: NSAIDs, prednisone, and/or colchicine, large jt steroid/LA injection
  • +/- Chronic Mx: Avoid secondary causes (diuretics, dehydration)
    
    • Diet: avoid shellfish, red meats/offal, beer, fructose, encourage cherry juice/milk
    • Gout Diet Guidelines
    • Urate lowering therapy/allopurinol titration with initial prophylaxis (colchicine/prednisone)
    • metabolic disease management (obesity, hyperlipidaemia, HTN, OSA)

Question 6

Describe the management of inflammatory arthritis

Answer 6

• Prompt recognition and early rheumatology referral, to prevent jt erosions and disability
• Acute Rx: NSAIDs, prednisone, fish oil
• Chronic Mx: keep active/spinal exercises, disease modifying anti-rheumatic drugs (DMARDS), biologics
• Comorbidities: accelerated IHD, extra-articular dz (skin, lungs, bowel, renal)

Question 7

Describe the management of mechanical perarthritis

Answer 7

• Haemarthrosis, bursitis, fractures, sprains: RICE (rest, ice, compression, elevation), immobilization

Question 8

Management of back pain

Answer 8

• exclude red flag: possible fracture, tumour infection, neurological deficit
• Possible spondyloarthritis: age<50, night/early morning symptoms, buttock pain, pain >3months, symptoms worsen with immobility, and/or improves with physical activity, exercise, or marked NSAIDs response.

LBP Management
- avoid imaging unless yellow/red flags
- Low Back Pain Treatments
- Education/reassurance
- Core strength exercises, hydrotherapy
- Pharmacological: paracetamol, NSAIDs, neuroleptics
- Adjunct Rx: TENS, gels

Question 9

Describe management of knee pain

Answer 9

exclude non-OA pains
- Knee Pain Treatments
- Education
- Wt loss diet, hydrotherapy
- Pharmacological: turmeric, MSM, glucosamine SULFATE/chondritin, topical NSAIDs, paracetamol, PO NSAIDs,
- Adjunct Rx: steroid/LA injections

Question 10

Describe a schema to come up with some differential diagnoses for arthritides

Answer 10

• if onset is acute or chronic: chronic is almost certainly autoimmune (think young female; joints stiff for over an hour, systemic symptoms) or osteoarthritis
• joints involved: if one its likely to be septic or crystal (think obese drinker), if oligo: think crystal, mechanical, soondylos (reactive, AS (young man), PsA); if poly: autoI, viral or general OA
• where: DIPS= OA and PsA, hands autoI or viral, spine: spondylo or OA, PsA possible but less likely, toes esp podagra: gout (could be bunion), knees/hips = OA

note that bursitis eg at knee or toe can mimic gout