Kelley's Textbook of Rheumatology,. 8th Edition, 2008. What are we looking for in
RA? Synovitis. Erosions. Extra-articular Manifestations. Key Words for ...
Disclosures None
Seth Compton, MD Fellow of Rheumatology University of Mississippi Medical Center
Steroids
Steroids Thank you for coming
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Outline
Arthritis in Mississippi
Osteoarthritis
Approximately 650,000 affected 30% of the state population 35% of women affected 27% of men affected
Rheumatoid Arthritis Monoarthritis Systemic Lupus Erythematosus Fibromyalgia
• Joint inflammation/swelling/warmth/erythema • Joint deformity (visual or by imaging) Arthritis: • Loss of range of motion • Characterized symptomatically by prolonged (> 1hr) AM stiffness
Rheumatoid Arthritis
Arthralgia: • Joint pain (with no observable inflammation)
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Rheumatoid Arthritis
What are we looking for in RA? Synovitis Erosions Extra‐articular Manifestations
Kelley’s Textbook of Rheumatology, 8th Edition, 2008.
Key Words for Inflammatory Arthritis AM stiffness > 1 hour Symmetric joint involvement Joint swelling Erosions on imaging Rheumatoid nodules
Rheumatoid Factor RA RF in Rheumatic Disease Disease Incidence RA 75% JIA 20% AS 90%
RF in Non‐Rheumatic Disease Infection Endocarditis Hepatitis Acute Viral Parasitic TB Lung Disease Interstitial Fibrosis Chronic Bronchitis Silicosis
Anti-CCP antibodies: Specific (90-95%), low sensitivity (50-60%)
Other Cirrhosis Sarcoidosis Chronic Hepatitis Malignancy Post Vaccination MI Aging
Kelley’s Textbook of Rheumatology, 3rd Edition.
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ACR Classification Criteria (2010)
Early RA vs OA Rheumatoid Arthritis
Osteoarthritis
Joint Involvement
Score
Acute Phase Reactants
Score
1 med‐large
0
Trauma Congenital abnormalities
Normal ESR & CRP
0
Predisposing Factor Smoking, susceptibility epitopes (HLA‐ DR4)
2‐10 med‐large
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Morning stiffness
Increases through the day and with use
Abnormal ESR or CRP
1
Early Symptoms
1‐3 small
2
Joints Involved
MCPs, wrists, PIPs most often DIPs and weight‐bearing
4‐10 small
3
Physical Findings
Soft tissue swelling, warmth
>10 (>1 small)
5
Age at Onset
Childhood & adults; peak 50’s Increases with age
Bony osteophytes, minimal soft tissue swelling early
Radiologic Findings Periarticular osteopenia, marginal erosions
Subchondral sclerosis, osteophytes
Laboratory Findings
Normal
Increased CRP, RF, anti‐CCP, anemia
ACR Classification Criteria (2010)
Serology RF & CCP neg
0
Low (+) RF or CCP
2
High (+) RF or CCP
3
Duration 6 weeks
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Treatment of RA
Score >6 consistent with RA
NSAIDS Hydroxychloroquine (Plaquenil)
Med‐large joints: elbows, shoulders, hips, knees,
ankles Low (+) serology 10‐15 mg of prednisone
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Tocilizumab Certolizumab and Golimumab Rituximab Abatacept Adalimumab Anakinra Infliximab Etanercept Leflunomide
Changes in the Treatment of RA Old
Emphasis on treating
symptoms of the disease Less aggressive treatment in
early stages
Sulfasalazine Immunosuppressants
NSAIDs considered least
Antimalarials
toxic. MTX and Steroids considered most toxic
Cortisone Gold 1940
1950
1960
1970
1980
1990
of joints
Earlier diagnosis and use of
Methotrexate Penicillamine
1930
New
Emphasis on limiting destruction
aggressive treatments
Higher doses of MTX Combination DMARD therapies Biologics (BRMs) shown to be
highly effective (alone and esp. in combination with DMARDs)
2000
History of DMARD Use
Pearls
Pearls
If checking a Rheumatoid Factor, would check
Plaquenil: Annual eye screening
hepatitis panel concomitantly Most DMARDs count as “High Risk Medication” Typically we only give 3‐4 month supply of drugs like MTX, SSZ, etc due to lab monitoring If pt asks for temporary refill of DMARD, would:
TNF therapy: Malignancy risk unclear Continue age‐appropriate cancer screening Increased risk of infections DO get flu shot DON’T get Varicella vaccine
Defer to rheumatologist OR If filling, get a CBC/CMP
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Pearls Most Rheumatic drugs take time to work Plaquenil: 4‐6 weeks Methotrexate: 3‐6 weeks TNF’s: 1‐3 weeks Prednisone: Yesterday
Incidence of OA
Osteoarthritis
Osteoarthritis
Arthritis (million) 3 1.3
Osteoarthritis Rheumatoid Arthritis Gout
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Hand Radiograph
OA General Features Clinical
Lab
Radiograph
Age >50
ESR 6.7 mg/dL monosodium urate supersaturates the serum and precipitates into tissues. Prolonged tissue deposition gout and tophi. Most patients with elevated uric acid do not experience clinical disease.
Two Reasons for Gout Impaired renal excretion of uric acid Most common
Fibromyalgia
Overproduction of uric acid Typically inherited
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Fibromyalgia I’ll let you know if I find something that works
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