Rheum/osteo arthritis Flashcards
Rheumatoid Arthritis
Pathophysiology:
chronic inflammatory disease with uncontrolled proliferation of synovial tissue and a wide array of multisystem comorbidities. The body confuses synovial tissue for a foreign body and attacks synovial surfaces
Rheumatoid Arthritis
general
Most commonly diagnosed inflammatory arthritis
Females > males ( 3:1) between 30-50 years of age
Can be triggered by stress, infection, environmental, smoking; genetic
Higher likelihood to also have IBS, FM, SLE, Sjogren’s, thyroiditis
Present with pain worse in am improves as the day goes on, “stiffness,” deformity, muscle weakness, fatigue, malaise
Can have extraarticular manifestations
DIP joints are usually uninvolved
Most common joints: PIP, wrist, metacarpals
Most common cause of death is cardiovascular
More joints involved worse prognosis
On average life expectancy is 12 years less than the general population
RA
Physical Exam Findings
Low-grade fever
Slightly elevated pulse
Rheumatoid nodules on extensor surfaces of the forearm
Bilateral Joint swelling ( fingers, wrists, elbows, shoulders, hips, knees, ankles, toes, and neck) without erythema; decreased range of motion and possible heat
Distal interphalangeal joints are rarely involved
Epitrochlear, axillary, and cervical lymphadenopathy
RA
Extra-articular manifestations of RA (18% to 41%)
Cardiovascular: pericarditis and myocarditis
Pulmonary: Pleural effusions and pulmonary rheumatoid nodules most common manifestations, pleurisy, pneumonitis, and fibrosis
Vasculitis: skin ulcerations, infections, or neuropathy
Ocular: retinitis, scleritis, uveitis, and peripheral ulcerative keratitis (corneal melt), Sjogren’s disease
Osteopenia and osteoporosis
Anemia of chronic disease
Spine instability: caution in patient post-fall/trauma, increases fall risk
Rheumatoid nodules: (20%) elbows and finger joints
Rheumatoid Arthritis
Workup and Tx
Xray hand and feet (r/o osteo; will show soft tissue swelling and demineralization of joint) “periarticular osteopenia”
aspiration of joint fluid ( r/o gout/septic arthritis)
labs ( ESR and CRP elevated, RF + 80%, ACPA/anti-CCP + 95%)
CBC, CMP
- if going to treat with biological need negative Hepatitis C/B and TB testing
Treatment: rheumatology collaboration, physical therapy/occupational therapy, Rx therapy
RA
RA
differential diagnoses
+ skin changes: SLE, systemic sclerosis, psoriatic arthritis
+ shoulder/hip pain in elderly: polymyalgia rheumatica
Recurrent self-limiting symptoms: crystal arthropathy
+ multiple trigger points: FM ( can co-exist with RA)
RA
Tx
Nonbiologic DMARD
Methotrexate- 1st line
Alternative therapies leflunomide ( GI SE), Sulfasalazine or hydroxychloroquine- if low disease activity, seronegative
Add folic acid daily
Biologic DMARD
TNF inhibitors-1st line
Pain control
NSAIDS and/or corticosteroids
1,200–1,500 mg of calcium and 800–1,000 IU of vitamin D daily to prevent glucocorticoid-induced osteoporosis
Therapeutic Lifestyle Changes
Complimentary Therapies
Exercise
Physical Therapy
*remission in 10-50% of patients. Remission more likely in males, non-smokers, < 40 years, late on set disease ( > 65), seronegative
Rheumatoid Arthritis Summary
Female, 30-50 years age ( fam hx/smoker) with at least one joint swelling unexplained other etiology
Symmetrical pain w morning stiffness > 6 weeks, spares DIP
Diagnosis
RF+, anti-CCP+, elevated CRP, ESR
Treatment ( baseline GFR/LFTs)
DMARD (methotrexate preferred)
Biologics (r/o hepatitis/TB)
Tumor necrosis factor usually add on/second line
Goal of therapy
Pain management and maintain joint space
Long term
Monitor for cardiovascular disease and lymphoma; extraarticular manifestations
Which of the following is an extra-articular manifestation of rheumatoid arthritis?
A. vasculitis
B. xanthelasma
C. coronary artery aneurysms
D. malar rash
A. vasculitis
Juvenile Rheumatoid Arthritis ( juvenile idiopathic arthritis)
general
Chronic synovitis and extra-articular manifestations age < 16 at onset lasting > 6 weeks
Female/male ratio 2:1; female age of onset 1-3 yoa; males age of onset 8-12 yoa
Juvenile Rheumatoid Arthritis
work up
Labs: 10-15% + RF, + ACPA antibody; usually have elevated CRP, ESR;
if have + ANA increased risk uveitis
Imaging: soft tissue swelling, periarticular osteoporosis, joint destruction uncommon
Juvinile RA- subtypes
Systemic ( 15% cases)
Fever spikes, myalgias, polyarthralgia, salmon-pink maculopapular rash in pm w fever
Minimal articular findings
Juvinile RA- subtypes
Pauciarticular (50% cases)
Involves 4 or fewer joints; if + ANA increased risk for asymptomatic uveitis may lead to blindness
Juvinile RA- subtypes
Polyarticular (35% of cases)
Systemic involvement of 5 or more joints; assoc low grade fever, fatigue, rheumatoid nodules
Which of the following diseases usually has a symmetric presentation?
Which of the following diseases usually has a symmetric presentation?
A) osteoarthritis
B) gout
C) septic arthritis
D) rheumatoid arthritis
D) rheumatoid arthritis
What is most common complication associated with juvenile rheumatoid arthritis and a positive ANA?
A. glomerulonephritis
B. Myocarditis
C. Sjogren syndrome
D. Uveitis
E. Vasculitis
D. Uveitis
Which of the following describes the pathophysiology associated with rheumatoid arthritis?
A) degenerative wear and tear of joint
B) T cell-mediated pannus formation that attacks synovial tissues
C) joint damage from repetitive microtrauma
D) joint damage from bacteria
B) T cell-mediated pannus formation that attacks synovial tissues
45-year-old female presents with recurrent flare up of rheumatoid arthritis. She is currently taking ibuprofen. What medication is indicated to slow progression and prevent further joint destruction?
A. diclofenac (NASID)
B. prednisone (glucocorticoid)
C. infliximab (TNF-inhibitor)
D. methotrexate (DMARD)
A- no benefit to another nsaid
b. Prednisone used for acute flare symptom relief- no improvement on disease
c. 2nd line after conventional DMARD consider biologic ( for TNF need to monitor labs and make sure no active infection – Hepatitis B, TB, HIV)
d. DMARD
Which antibody is most specific to Rheumatoid arthritis?
A. Anti-cyclic citrullinated peptide (anti-CCP)
B. ANA
C. Rheumatoid Factor
D. ESR
A-
B- not specic
c. Can be seronegative
A patient presents with acute diarrhea after starting a medication to treat gout. What medication is most likely the cause of his symptoms?
A. ibuprofen
B. prednisone
C. allopurinol
D. colchicine
D. colchicine
Characteristics of Synovial Joints
Articular cartilage
Made of hyaline
Covers the ends of bones
Provides shock absorption, stability, and lubrication
Synovial membrane
Loose, vascularized connective tissue
Secretes synovial fluid into the joint cavity for lubrication
Joint/articular capsule
A fibrous connective tissue that surrounds the bony ends forming the joint
Osteoarthritis (OA)
general
Irreversible, progressive multifactorial disease affecting the entire joint
Most common form of arthritis (> 70% of all cases of arthritis)
Traditionally known as “wear and tear arthritis”
Incidence:
Affects ~41 million people in the United States (www.arthritis.org)
Prevalence increases with age
80–90% of individuals < 65 years have radiographic osteoarthritis (OA)
Symptoms are generally not noticed until after the age of 50
OA
Primary and Secondary OA
Primary Osteoarthritis
Idiopathic form
Secondary Osteoarthritis
Caused by another disease or condition
Obesity
Repeated trauma or surgery to the joint
Infection
Congenital abnormalities (scoliosis)
Metabolic disorders:
Gout
Hemochromatosis- MCPs
Bone disorders:
Paget’s disease
OA
RF
Age - ↑ with age
Obesity
Sex: Women > Men
Physical activity and repetitive use
Joint injury
Muscle weakness or dysfunction
Genetics and family history
OA
Commonly Affected Joints
Hands
PIP and DIP joints
CMC joint
Feet
1st MTP joint
Shoulder
Hips…younger age!
Knees
Spine
Neck
Low back
OA
Patho
Degradation of the articular cartilage and remodeling of bone due to an active response of chondrocytes in the cartilage and the inflammatory cells in the surrounding tissues
Release of degradative enzymes from chondrocytes causes breakdown of collagen and proteoglycans→ destruction of the articular cartilage
Exposure of underlying subchondral bone → sclerosis and reactive remodeling changes (formation of osteocytes and subchondral bone cysts)
Progressive loss of joint space over time
OA
Jointpain
Gradual onset of achy pain
Asymmetric
More severe with:Activity and Weight bearing
Relieved with rest
Later in the disease:
Painis more constant
Affectssleepand level of activity
Radicularpainresults from: (pain that shoots down)
Spondylolisthesis
Nerve impingement
Spondylolisthesis: displacement of a vertebra forward in relation to the vertebra below
OA
Joint stiffness
Most noticeable upon awakening or after being inactive
Duration < 30 minutes
Improves with movement
Swelling of the joint
Limited range of motion (ROM)
Sensation of joint instability, locking, buckling
Crepitus- Crackling, crunching, grinding or grating noise
OA
PE
Joint line tenderness
Limited range of motion (ROM)
Crepitus with passive ROM
Evidence of osteophytes
DIP joints: Heberden’s nodes
PIP joints: Bouchard’s nodes
First CMC joint: thumb squaring
Knee varus or valgus deformities
OA
Dx
Clinical diagnosis that is confirmed with imaging
Radiography
Classic findings:
Joint space narrowing (asymmetric)
Subchondral sclerosis
Osteophytes
Subchondral cysts (late)
Findings do not correlate well with symptoms
No specific blood test for the diagnosis of osteoarthritis
1 - Joint space narrowing
2 -Osteophytes
3 - Joint destruction
4 - Involvement of the carpometacarpal (CMC) jointwhich is very common
OA
Supportive Labs
Used to exclude other causes of arthritis
Everything should be normal
Arthrocentesis with synovial fluid analysis
Non-inflammatory with a WBC count < 2,000 cells/μL
Crystal analysis to rule out gout and pseudogout
Laboratory testing
Negative rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP)
Normal erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP)
Negative antinuclear antibody (ANA)
OA
TLC Tx
Goals of management include alleviating pain and minimizing the loss of physical function
General conservative measures
Lifestyle modifications:
Minimize weight bearing activities
Good posture
Sleeping on a firm mattress
Wearing supportive shoes
Weight loss
Physical therapy to increase:
Strength
Flexibility
Range of motion
Endurance
Assistive devices:
Cane, brace, splints, and taping
Hot and cold therapy
OA
Pharm tx
Acetaminophen (Tylenol)
Oral and topical nonsteroidal anti-inflammatory drugs (NSAIDs)
Muscle relaxants
Cyclobenzaprine, methocarbamol
Relieve pain from strained muscles
Use with caution in elderly patients
Duloxetine (Cymbalta) – second-line agent
Can be used in patients with contraindications to NSAIDs
Alternative for those who do not respond to first-line therapies
Corticosteroids
Should not be used chronically
Can be used orally or as an intra-articular injection
Hyaluronic acid
Intra-articular injection
Supplements
Glucosamine & chondroitin
Evidence is limited
Opioids – BE CAREFUL!
Can be considered for short-term use
For patients who fail or are not candidates for other treatments
Consider referral to a chronic pain management clinic
Tramadol (Ultram) is the only opioid medication listed as a medication option through the Arthritis Foundation
OA
Surgical Management
Reserved for patients with advanced disease who have failed other treatments
Total joint arthroplasty (replacement) is the most common procedure
