1 / 56

Update in Rheumatology

Update in Rheumatology. Wilmer L. Sibbitt, Jr., M.D. 1 1 Departments of Internal Medicine, Rheumatology and Neurology University of New Mexico Health Sciences Center , Albuquerque, NM, USA. Educational Objectives: 1. To be aware of advances in diagnosis of rheumatic diseases

Anita
Download Presentation

Update in Rheumatology

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Update in Rheumatology Wilmer L. Sibbitt, Jr., M.D. 1 1Departments of Internal Medicine, Rheumatology and Neurology University of New Mexico Health Sciences Center , Albuquerque, NM, USA

  2. Educational Objectives: 1. To be aware of advances in diagnosis of rheumatic diseases 2. To understand the application of new antirheumatic therapies

  3. Disclosure • Wilmer L. Sibbitt, Jr., MD is: • an employee of the University of New Mexico Health Sciences Center • funded in part by research grants from the National Institutes of Health and Ferring Pharmaceuticals, Inc • an expert consultant for - Becton Dickinson, Inc., - AVANCA Medical Devices, Inc., - Meditech Dupross, Inc., - Ferring Pharmaceuticals, Inc. - Avasca Medical, Inc. - IMS Expert Services, Inc., • Co-founder of AVANCA Medical Devices, Inc, (acquired by Global Medical Solutions, Inc) and Avasca Medical, Inc. (IP acquired by Abbott Interventional)

  4. Joint Swelling What is the Cause?

  5. Major Rheumatic Diseases • Osteoarthritis • Rheumatoid Arthritis • Systemic Lupus erythematosus • Systemic Sclerosis • Spondyloarthropathies • Poly-Dermatomyositis • Crystal - Induced Arthritis • Septic Arthritis • Vasculitis

  6. Joint Swelling - Synovial EffusionArthrocentesis and Injection therapy

  7. Reasons to Perform Arthrocentesis • Noninflammatory - a non-inflammatory effusion can only be confirmed by arthrocentesis. • Crystal-induced arthritis - can only be diagnosed definitely by arthrocentesis. • Hemorrhagic Effusion - can only be excluded by arthrocentesis. • Infectious - Infectious arthritis and the causative organism can only be diagnosed definitely with arthrocentesis. • Painful Effusion - A painful effusion is most easily decompressed with arthrocentesis. • Injection therapy - The effusion should be decompressed and infection excluded prior to intraarticular injection therapy.

  8. Update on Arthrocentesis and Intraarticular Therapy • Anesthesia - Patients prefer local anesthesia. • One needle two syringe technique - permits anesthesia, dilation of joint space, arthrocentesis, and IA injection with one needle stick. • Use of antineedlestick safety devices - required by Joint Commission; reduces risk to provider • Use of safety aspiration syringes - reduces pain and complications and improves IA outcome for patients. • Use of sonographic image guidance - reduces pain and complications and improves IA outcome for patients. • Frequency of intraarticular corticosteroid injections - IA injections can be up q 3 months. • Intraarticular Hyaluronate - New IA HA preparations, now 1 injection preparations.

  9. Arthrocentesis - Anesthesia Options • Pre-procedure local anesthesia with lidocaine. • Pre-procedure local anesthesia with topical ethyl chloride or other coolants. • General anesthesia - most common in children. • No pre-procedure local anesthesia. • Marcaine (bipuvicaine) is not a good immediate agent for local anesthesia and in continuous intraarticular anesthesia in orthopaedics has been associated with cartilage injury. • New Data: >90% patients prefer local anesthesia with lidocaine for IA procedures Park KS et al:Should local anesthesia be used for arthrocentesis and joint injections? Rheumatol Int. 2009 Apr;29(6):721-3.

  10. Anesthesia and Arthrocentesis: Pain Scores 8.9± 0.9 96% 4.8± 1.2 4% Arthrocentesis without Anesthesia Pain Score Arthrocentesis with Anesthesia Pain Score 96% of Patients Prefer Anesthesia From: Park K et al 2007, J Rheumatol. 2006;33:771-8

  11. One Needle Two Syringe Technique • Technique developed by interventional radiologists • One needle (21 or 22 gauge for arthrocentesis, 22 or 25 gauge for dry joint or small joints, 0.5 inch for small joints, 1-1.5 inch for intermediate joints, 1.5 to 2.0 inch for large joints, 6-9 mm spinal needle for hip) • 1-3 ml syringe for small joints, 3-10 ml for larger joints, 5-20 ml for effusions. • Chlorhexidine antisepsis. • Place 1 to 5 mls 1% lidocaine into syringe. • Be certain needle can be removed with finger tips • Advance needle while alternatively aspirating and injecting. • In dry joint, dilate joint space with lidocaine • After dilating joint space or obtaining synovial fluid, rotate syringe off of needle, place treatment syringe on, aspirate, and then inject. Sibbitt WL Jr et al J Rheumatol. 2009 Sep;36(9):1892-902

  12. Select an Appropriate Size Syringe • 1 ml - IP, MCP • 3 ml - IP, MCP, Wrist, Ankle • 5 ml - Wrist, Ankle, Shoulder, Knee • 10 ml - Knee • 20 ml - Knee, especially large effusions. 1 ml 3 ml 5 ml 10 ml 20 ml

  13. Mark Anatomy with Pen and Choose Approach Patella Lateral Suprapatellar Bursa Anteriolateral Inferiopatellar Approach Patellar Tendon Tibial Plateau

  14. Antisepsis with Chlorhexidine

  15. 22 g 1.5 inch Needle - Repetitively Aspirate and Inject Lidocaine, Adjust Needle Position As Necessary Aspiration Injection

  16. Joint Space Encountered when Synovial Fluid is Returned or Needle Touches Joint Cartilage Synovial Fluid Returned After Touching Cartilage, Easy Injection of Lidocaine without Resistance

  17. After Lidocaine Injection, Syringe Exchange is Performed Needle in Intraarticular Position, Fluid in Hub 1)Twist RPD off of Needle 2) or Rotate Needle off of RPD

  18. Attach IA Therapy Syringe and Inject Inject IA Therapy 1)Twist Syringe on Needle2) or Rotate Needle on Syringe

  19. Anti-Needlestick Devices • Needlestick Safety and Prevention Act, OSHA, and JCHAO mandate healthcare worker safety (HCW) and antineedlestick devices • 10-30 needlesticks/100,000 needles • High risk HCV, HBV, HIV, chronic disability • Safety devices reduce NS by 70% Adams D et al J Hosp Infect 2006:64:50-5. • Safety devices can be used effectively for IA procedures and reduce needlesticks Moorjani GR et al Arthritis Rheum. 2008 Jun 24;58(7):1907-1914.

  20. Anti-Needlestick Devices • Retractable syringes: Procedur-SF, Integra, BakSnap, SafePro, InviroSnap, VanishPoint (VP) - Disadvantage premature activation, restriction of needle length to 1.5 in, splatter, and with VP fixed needle. • Shielded Needles: Eclipse, SafetyGlide, SureGuard, Magellan - Disadvantage restriction of needle length to 1.5 in, bulky • Shielded Syringes: Safety-Lok, Monoject Safety, DAS syringe - Disadvantage restriction of needle length to 1.5 in, bulky, somewhat awkward Moorjani GR et al Arthritis Rheum. 2008 Jun 24;58(7):1907-1914.

  21. Anti-Needlestick Devices • Combination with patient safety devices: RPD syringe with Shielded needle Moorjani GR et al Arthritis Rheum. 2008 Jun 24;58(7):1907-1914.

  22. 100% Conventional Syringe Control Safety Syringe Percent Signi- ficant Pain (VAPS≥5) 50% 0% Baseline Pain (p>0.55) Anesthesia Pain (p<0.001) Pain at 6 months (p=0.46) Procedure Pain (p<0.001) Pain at 2 weeks (p<0.002) Patient Safety Devices - RPD Syringe Michael AA et al. Device effect on local injection therapy of osteoarthritis: A randomized controlled trial. Arthritis Rheum 2008.

  23. US-Image Guidance Portable US Unit with Multiple Imaging and Doppler Capabilities

  24. Ultrasound-Directed Procedures US - IA Injection with Assistant US - IA Injection with One-hand

  25. Summary: Safety Devices for IA • -safety devices mandated by Needlestick Safety and Prevention Act, OSHA, and JCHAO • - safety devices cost more than conventional needles and syringes($0.50 to $2.00 US) • - safety devices reduce needlesticks to HCW and injuries to patient • - reduce complications including hemorrhage • - improve arthrocentesis yield • - reduce needle trauma and is less painful. • - significantly improves responder rate and reduces non-responder rateof IA injections Sibbitt WL Jr et al J Rheumatol. 2009 Sep;36(9):1892-902

  26. Ultrasound Guidance for IA Injections Sibbitt WL Jr et al J Rheumatol. 2009 Sep;36(9):1892-902

  27. Ultrasound Guidance for IA Injections Sibbitt WL Jr et al J Rheumatol. 2009 Sep;36(9):1892-902

  28. Summary: US- Guidance for IA • US image guidance is increasingly used in rheumatology • - is more time-consuming and more costly • - cost-effectiveness is uncertain • - improves arthrocentesis success and yield • - permits more accurate placement. • - is less painful. • - significantly improves responder rate and reduces non-responder rate of IA injections Sibbitt WL Jr et al J Rheumatol. 2009 Sep;36(9):1892-902

  29. Osteoarthritis: A Progressive Disease

  30. Updated Therapy for Osteoarthritis • Glucosamine or Glucosamine/Chondroitin supplements • Reduce injury to joint (weight loss, treat gout, etc). • Acetaminophen and analgesics • Conventional or COX-2 Inhibitor NSAIDS • IA injections with corticosteroids • IA injections with hyaluronic acid • Reconstructive surgery American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Recommendations for the Medical Management of Osteoarthrits of the Hip and Knee, Arthritis & Rheumatism. 2000:43;1905-1915

  31. Hyaluronate for Intraarticular Injections • First isolated by Palmer and Meyer from bovine eyes in 1934 • Marketed for human use in the early 1980s using HA derived from rooster comb • Polysaccharide chain made of repeating Polysaccharide chain made of repeating disaccharide units of N-acetylglucosamine and glucuronic acid • Synthesized naturally by Type B synoviocytes

  32. IA INJECTION OF HYALURONIC ACID • Usually Grade 1-3 OA • Failed local measures, acetaminophen, NSAIDS, and 1-2 corticosteroid injections, especially with ultrasound • Advantageous to avoid or delay total joint arthroplasty • No infection • Exclusion of confounding arthritides • No hypersensitivity to HA • Can afford cost $300 to $450 for HA

  33. HYALURONIC ACID PREPARATIONS • Euflexxa(1% sodium hyaluronate) 3-injection series (one week apart), Bioengineered • Orthovisc(1% sodium hyaluronate) 3-injection series (one week apart), Bioengineered • Hyalgan(1%sodium hyaluronate) 3-5-injection series (one week apart), • Supartz(1% sodium hyaluronate) 3-5-injection series (one week apart), • Synvisc(HylanG-F 20) 3-injection series (one week apart), - Synvisc-One, 1 injection

  34. Effect of IA Hyaluronate (Hyaluronan) Hyaluronan

  35. Injection of Hyaluronate (Hyaluronan) One-Needle Two Syringe Technique

  36. Updated Therapy for RA • 1st-Low dose corticosteroids - short/long term • 1st -Methotrexate - long term • 2nd - Leflunomide - long term • 2nd - Anti-TNF Agents (anti-Tumor Necrosis Factor) - best overall therapy • 3rd - Kineret ® (anakinra) - IL-1 receptor • 3rd - Orencia ® (abatacept)- anti-T cell agent • 3rd - Rituxan® (Rituximab) – anti-B cell therapy • 1st-3rd - Corticosteroid joint injections • 4th - Reconstructive surgery Reference: American College of Rheumatology 2008 Recommendations for the Use of Nonbiologic and Biologic Disease-Modifying Antirheumatic Drugs in Rheumatoid Arthritis Arthritis & Rheumatism. Vol. 59, No. 6, June 15, 2008, pp 762-784

  37. Methotrexate • Obtain PPD, Chest X-ray, renal and hepatic tests, and exclude HCV before starting • Good long-term efficacy and tolerability • Slows radiographic measured erosions • Hi-risk in elderly and renal impaired patients • Chemical monitoring indicated • Hepatic biopsy rarely indicated • Be aware of pulmonary toxicity in first 4 months of therapy

  38. Anti-TNF Drugs • Enbrel® - entanerocept - SC - 50 mg/wk • Humira® - adalimumab - SC - 40 mg/q 2wks • Remicade® -infliximab - IV - 3-10mg/kg/4-8 wks • Cimzia® - certolizumab - SC - 400 mg/4 wks • Simponi® - golimumab - SC - 50-100 mg/4 weeks

  39. Anti-TNF Drugs TNF-MTX TNF Percent Responding MTX Placebo Months

  40. Orencia ® (abatacept) anti-T cell agent • Fully human soluble immunoglobulin fusion protein • Selective Co-stimulation Modulator • Interferes with CD80/86-CD28 interaction. • 30 min IV infusions at 0, 2, and then q 4 weeks. • < 60 kg 500 mg, 60-100 kg 750 mg and weighing >100 kg 1000 mg. • 50.4 % response (ACR) rate at 6 months (19.5% placebo) • Infections, headache, flu-like symptoms, infusion reactions, nausea.

  41. Orencia ® (abatacept) anti-T cell agent

  42. Rituxan® (Rituximab)anti-B cell agent • depletes CD20+ B-cells • methylprednisolone 100 mg IV, then • two-1000 mg IV infusions at 0 and 2 weeks. • 51 % response rate at 6 months (14% placebo) • Infections, flu-like symptoms, infusion reactions, severe mucocutaneous reactions.

  43. Warning with Biologic Anti-Rheumatic agents! • Active infection - TB, HCV, HCB should be excluded. • Biologic agents should not be given with any active infection. • If PPD +, must receive prophylactic therapy • Patients should receive non-live vaccines • Vaccinate for pneumococcus and influenza. • Infections should be promptly treated and agent withheld at least temporarily • Herpes Zoster (shingles) should be recognized and treated promptly. • Be aware of increased incidence of lymphoma.

  44. Chronic or Tophaceous Gout

  45. Acute Gout

  46. Diagnostic Tests for Gout • Serum uric acid x several times • Athrocentesis for crystal examination • Exclusion of RA, SLE, infection, CPPD, Reiter’s syndrome • Hand and foot radiographs • CBC, Cr, uric acid, Ca, Electrolytes Hepatic enzymes, UA • 24 hr urine for creatinine and uric acid

  47. Hyperuricemia Syndromes • Stage 1 -Asymptomatic hyperuricemia (uric acid < 7.0 mg/dl) • Stage 2 - Acute gouty arthritis (acute gout) • Late Stage 2 - Intercritical gout (frequently occuring acute gout) • Stage 3 - Tophaceous or chronic gout • Uric acid nephrolithiasis • Acute uric acid nephropathy • Chronic sodium urate nephropathy or interstitial nephritis

More Related