Week 12 Rheumatologic Disorders Flashcards
Osteoarthritis
* Common cause of joint pain and disability
* “Wear and tear” arthritis
* Cartilage breakdown, bony overgrowth
* Mild inflammatory component, Genetics, Prior Injuries
* Commonly affects the hands, CMC joint (base of thumb), knees, spine, hips
Osteoarthritis presentation
Increasing pain/aching with activity
Overuse
Morning stiffness < 30 minutes
GONA
1.Pain with activity
2.Swelling
3.Stiffness
4.Deformity
5.Decreased range of motion, creaking joints (crepitus)
6.Instability
7.Loss of function
OA diagnostics
X-ray films: joint space narrowing d/t cartilage loss, osteophytes
Mostly clinical diagnosis
OA treatment
- PT: cannot rebuild cartilage, so we buildup the muscles surrounding the joint to compensate and strengthen
- OT: Can help with building hand strength and find tools to help with ADLs, can help with splinting
Analegsics
* Tylenol (1st line) 3g or < per day
* NSAIDs (If not Contraind., may need GI protection - PPI, check GFR)
* Careful w/comorbid. cardiac disease, kidney disease
* Steroids- may help with IA joint injections. There is a low-grade inflammatory component of OA.
* U/S guided, Synvisc (cushion support)
* Limit to Q 3-4 months for next injection to reduce risks of bone damage
* Conservative management until it is unbearable pain, then replacements. Want to send to ortho before they become too old or ill to be a good candidate for replacement
* Joint replacement: Hips, knees, ankles, shoulders, etc.
Rheumatoid Arthritis
- Autoimmune condition affecting the synovial membranes leading to synovial thickening and inflammatory joint effusions – hot fluid in joints
- Leads to symmetrical, peripheral, joint swelling, pain, and stiffness
- Untreated may lead to irreversible joint damage through destruction of ligaments, cartilage, and bone leading to loss of function - Inflammation in the joint leads to destruction of ligaments, causing sublocation of joints
- Cartilage and bone destruction causes bony deformities that are irreversible, sometimes require joint replacement.
- You can have irreversible damage within the first few months of onset.
- Chronic inflammation leads to bony joint damage, cartilage breakdown, laxity of the tendons and ligaments leading to subluxation of the joints
Women > Men
40-60y/o
Key Features of RA + PE
Clinical DX?
Symptoms > 6 weeks’ duration
* Lifelong condition (usually)
Swollen Inflamed Joints
* Palpable synovial swelling leading to pain, stiffness, tenderness, hot, sometimes erythematous joints
* Morning stiffness >1 hour, stiffness with immobility that improves with activity
Symmetrical and polyarticular
* Typically involves wrists, MCP, PIP, & MTP joints, but can also involve the elbows, ankles, knees, shoulders, hips
* Typically spares certain joints
* Thoracolumbar spine
* DIPs of the fingers and IPs of the toes
DX CLINICALLY
PE
- Joint swelling w/fluid, joint tenderness (tender,warm,swollen)
- Late stages: classic deformities, nodules in skin
RA things to ask
- Recent illness? Fevers, chills? Sick contacts?
- R/o ifxn arthritis
- How long does morning stiffness last?
- Family history of arthritis?
- History of rashes? Psoriasis?
- Respond to NSAIDs, Tylenol?
When thinking about a possible inflammatory arthritis…get a comprehensive hx, ruling out possibility of infectious disease as well (Lyme, Parvovirus)
Positive response to NSAIDs? → May point in the direction of an inflammatory disorder.
RA diagnostics
Best lab test?
X-ray - see bony erosions - help to monitor disease down line (aggressive tx of erosions present)
RF (poor specificity) high titer early = BAD
Anti-CCP antibody - diagnostic + prognostic tool
ESR/CRP
Synovial fluid analysis
Can do this workup prior to sending them to Rheumatology
Key points for RA overall
- The sicker they are and the faster they get that way, the worse prognosis
- Early intervention can make big a difference in long term outcomes
- Essential to establish a treatment plan early in the disease
- Quick referral is key. Better to send someone who doesn’t have RA, than to not send someone who does.
- Swelling is confined to areas of joint capsule
- Synovial thickening feels like a firm sponge: “Boggy” Joints, Swan neck and Boutonniere Deformities
People rarely end up with hands like these now because of the treatments we have
Systemic manifestations a/w RA
- Fatigue
- Raynaud’s Phenomenon
- dry eyes, dry mouth (secondary Sjogren’s Syndrome)
- Interstitial Lung Disease
- Pleuritis, pericarditis
- Vasculitis
At RISK for:
* CAD
* HTN
* MI
* Vascular disease
* Lymphoma
RA treatment principles
- REFER to Rheumatology
- Determine where the patient stands in the spectrum of disease
- When damage begins early, start aggressive treatment early
- Use the safest treatment plan that matches the aggressiveness of the disease
- Monitor treatment for toxicity
- Monitor disease activity, revise Rx as needed
- What we are thinking about when beginning treatments…we want to get the best clinical results with the least amount of medication risk/toxicity
Pharm RA treatment
NSAIDs
* Symptomatic relief, No change in disease progression
Prednisone/Medrol (low dose long term)
* May substitute if NSAID not efficacious
* Also used as bridge therapy
Intra-articular steroids
* Useful for flares in individual joints
DMARDS (May be on 1-3 at one time) Disease-modifying-antirheumatic-drugs
* Plaquenil (Hydroxychloroquine)
* Sulfasalazine
* Methotrexate
* Leflunomide
* Azathioprine
* Biologics (often in combination with DMARD or alone)
- Prednisone works for everyone, but the goal is to get them off the prednisone because of side effects.
- In primary care, prior to their referral, you might try for symptom control NSAIDs for mild inflammation or Prednisone for Moderate to Severe inflammation.
- Avoid “Bursts” if they have diffuse swelling, and try a longer taper (3-4 weeks starting with 15-20 mg and dropping by 5 mg each week). If only 1-2 joints, may do a burst folowed by NSAIDS (not at the same time)
Bioloigics for RA tx (unsure if need to know for PC)
INHIBIT INFLAM RESPONSE
TNF inhibitors
* Remicade IV
* Enbrel SC
* Humira SC
* Cimzia SC (2x/mo)
* Simponi SC (1X/mo)
Costimulation Modulator
* Orencia SC & IV
B Cell Depletion
* Rituxan I
IL1 inhibitor
* Anikinra SC (not so effective in RA but works well in auto-inflammatory diseases like FMF)
* Kevzara SC 200mg (2X/month)
IL-6 inhibitor
* Actemra SC & IV (q 4 wks.)
“Jak” Kinase Inhibitor
* Tofacitinib (Xeljanz), PO daily medication. JAK’s play a role in inflammation of the joints, if inhibited: less inflammation, pain and stiffness.
PDE4 Inhibitor (Ps Arth)
* Otezla (Apremilast) 30 mg BID maintenance
IL 17 Inhibitor (Ps Arth)
* Taltz 80 mg SC once a month
IL 12/23 antibody Ps Arth, Crohns
* Stelara (Ustekinumab) 90 mg every 8 weeks
When to refer for RA
- Multiple inflamed joints
- Isolated inflamed joint not explained by something else (gout, infection, injury)
- Polyarthralgias not explained by OA (can be subtle)
- In interim for joint pain/swelling:
o Mild- moderate symptoms: NSAIDs (Ex. Naproxen 500 mg Q 12 hours) OR low dose pred (5-10 mg)
o Mod-severe symptoms: Prednisone taper (Ex. 20 mg X 7 days, drop by 5 mg weekly)
ACR/ELAR Classification criteria
A score of 6 points or more indicates a high likelihood of rheumatoid arthritis with a sensitivity of 82% and specificity of 61%. CRP, C-reactive protein; ESR, erythrocyte sedimentation rate.
Role of PC in RA
NSAIDS & Steroids until rheumatology appointment. ACR – patients should be seen within 6 weeks.
In a patient with inflammatory arthritis, the presence of a rheumatoid factor and/or anti-citrullinated protein antibody, elevated C-reactive protein level, or elevated erythrocyte sedimentation rate is consistent with a diagnosis of rheumatoid arthritis
Psoriatic Arthritis and manifestations
- Associated with the skin/nail condition
- Usually seronegative
- Asymmetrical oligoarthritis or symmetrical polyarthritis (similar to RA)
- Enthesitis, Dactylitis, & Tenosynovitis
- DIPs often affected,
- May affect the spine (sacrolitis/spondylitis)
- See inflammation in the surrounding joint structures (tendons, ligaments, attachment sites, bursa) more so than with Rheumatoid Arthritis
- Characteristic “sausage digits” associated with psoriatic. DIPs rarely involved in other arthopathies
Dactylitis
Psoriatic Arthritis
When to refer?
- Patient with hx or possible hx of psoriasis and new joint symptoms (including low back pain/stiffness)
- Patient with any clear inflammatory joint symptoms
Ankylosing Spondylitis manifestations, joints involved, lab, and treatment
4/5 following features:
* < 40 yrs at onset
* Insidious onset
* Improves with exercise
* No improvement with rest
* Pain at night, improves with awakening
- RA does not affect the back (occasionally the C-spine)
- Inflammatory back arthritis, with extraspinal involvement as well (peripheral joints, periarticular inflammation) causing bones in spine to fuse
- May not see in person w/hx of arthritis/normal ROS
- HLA B 27 +
- Eye involvement
- IBD/IBS
- Treated with biologics, NSAIDs
Polymalgia Rheumatica definition
- Inflammatory rheumatic condition causing aching/stiffness in the neck, shoulders, hip girdle.
- Areas of pain usually in upper body from BL shoulders down to nipple line and area over shorts
- Cause is unknown.
PMR symptoms and RFs
- Symptoms arise from G-H joint synovitis, biceps tenosynovitis, subacrombial bursitis, along with hip synovitis/bursitis.
- Affects joint bursa, not muscle.
- Age at least 50 (usually >70 years old)
- F > M
PMR Pt Hx
- Acute onset of pain lasting weeks in 2 or more “axial” areas, including neck, shoulder, pelvic girdle
- Morning stiffness for 1+ hours