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Introduction. Interactive format Clinical featuresLaboratory featuresExtra-articular featuresManagement considerations and paradigmsPrognosis. Case Presentation:55 YOF complains of months of bilateral hand pain. She describes progressive morning stiffness lasting 3 hours with wrist, MCP, and PIP pain and swelling. She has also noted some discomfort and perhaps swelling in her wrists, shoulders, knees, and toes. Review of systems is unremarkable. Wh9451
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1. RHEUMATOID ARTHRITISfor the internist... Christopher Parker
CPT (P), MC, USA
Rheumatology Service
WRAMC
2. Introduction Interactive format
Clinical features
Laboratory features
Extra-articular features
Management considerations and paradigms
Prognosis
4. Rheumatoid nodule
5. Rheumatoid Arthritis
6. Case Presentation: Physical exam is notable for swelling, tenderness, and warmth in the elbows, wrists, MCPs, PIPs, knees, and MTPs with non-tender soft tissue nodules over the olecronon.
What is the difference between arthritis and arthralgia?
Are there further tests that can be done to confirm the diagnosis?
8. RA: Erosion Progression
9. Laboratory Exam WBC = 5.2
H/H = 10/30 with normal RDW
PLT= 475k
ESR= 75
RF= 450
ANA= positive TSH= normal
CK= normal
P1-3 + uric acid normal
U/A normal
10. Work-up of an inflammatory arthritis CBC, BUN/Cr, calcium, LFTs, uric acid, UA, HIV, RF, ANA, CPK, CXR
further serologic evaluation and specific tests geared toward the presentation and results from above tests
radiographs have a higher yield with chronic symptoms (> 6 weeks)
11. Laboratory abnormalities anemia of chronic disease
thrombocytosis in active disease
low white cell count in Felty’s
ESR
CRP
12. Rheumatoid factor series of antibodies that recognize the Fc portion of an IgG molecule
any serotype
most IgM
many conditions associated with RF positivity - chronic inflammation
70% RA positive at onset, overall 85% in first two years
associated with more severe disease, extra-articular manifestations, mortality
14. DDX of a positive RF normal - 1-4%, 10-25% over age 70
systemic autoimmune diseases
infections
malignancy
chronic liver disease
pulmonary diseases
15. ANA in RA 25% RA are positive for ANA
other serologies usually negative
? more severe disease (RA) with worse prognosis
17. RA - Definition chronic systemic inflammatory disorder
unknown etiology
diarthroidal joints
synovium affected
bone, cartilage, ligaments
deformity
extra-articular manifestations
18. RA - Definition clinical diagnosis
symmetric polyarthritis of small joints
subacute
acute
rheumatoid factor positivity
erosive disease
19. RA - Epidemiology worldwide distribution
all races
female > male 3:1
1% adults in U.S.
genetic associations
HLA-DR4, DR1
20. Case Study 29F presents with 3 weeks of pain and swelling in the wrists, MCPs, and PIPs. She has 2 hours of morning stiffness. She also complains of extreme fatigue and having difficulty keeping up with her four year old boy. Her son is well but had a rash a few weeks ago. Her exam confirms symmetric polyarticular inflammatory arthritis.
Could she have something other than RA?
21. Parvo Arthritis
23. RA - differential diagnosis Common diseases
spondyloarthropathies
CTDs
polyarticular gout
CPPD
viral infections
fibromyalgia
24. RA - differential diagnosis Uncommon
hypothyroidism
SBE
hemochromatosis
hypertrophic pulmonary osteoarthropathy
hyperlipoproteinemias
hemoglobinopathies
relapsing polychondritis
25. RA - differential diagnosis Uncommon
rheumatic fever
sarcoidosis
lyme disease
amyloid
HIV
malignancies/paraneoplastic syndromes
26. RA - differential diagnosis Rare
familial mediterranean fever
multicentric reticulohistiocytosis
whipple’s disease
angioimmunoblastic lymphadenopathy
27. Case Study 60WM with RA presents with progressive worsening of his joint complaints over the last few months with intermittant fever, swelling of his “glands”, and painful lesions on his finger tips. ROS notable for 5lb wt loss. Exam confirms polyarthritis and small digital infarctions.
Could all of his symptoms be explained by RA?
28. Extra-articular manifestations General
fever, lymphadenopathy, weight loss, fatigue
Dermatologic
palmar erythema, nodules, vasculitis
Ocular
episcleritis/scleritis, scleromalacia perforans, choroid and retinal nodules
29. Extra-articular manifestations Cardiac
pericarditis, myocarditis, coronary vasculitis, nodules on valves
Neuromuscular
entrapment neuropathy, peripheral neuropathy, mononeuritis multiplex
Hematologic
Felty’s syndrome, large granular lymphocyte syndrome, lymphomas
30. Extra-articular manifestations Pulmonary
pleuritis, nodules, interstitial lung disease, bronchiolitis obliterans, arteritis, effusions
Others
Sjogren’s syndrome, amyloidosis
31. Felty’s syndrome classic triad
RA, splenomegaly, leukopenia
generally a neutropenia (<2000/mm3)
thrombocytopenia may occur
complications
infections, non-healing leg ulcers
most require no additional treatment for cytopenias
splenectomy?
32. Case Study You are tasked to “back fill” for a small army community hospital as a primary care provider…
GYN exam for perimenopausal 45WF
MSK exam
On NSAIDs
No complaints of pain
Are NSAIDs enough?
What other medications could you use?
34. RA - Management Nonpharmacologic
rest
fatigue, splinting
pain relief
heat, cold, ultrasound, paraffin, massage
physical therapy
occupational therapy
Patient education
35. RA - Management Pharmacologic
analgesics
NSAIDs - full dose
corticosteroids
prednisone at low dose - “bridge”, “burst”
intra-articular steroids
36. Disease modifying agents every patient should be considered for at least one modifying agent
limitations
may not prevent damage
may not have lasting effect
may not be tolerated due to toxicity
37. DMARDs hydroxychloroquine
mild non-erosive disease
combinations
200 mg bid
eye exams
38. DMARDs Sulfasalazine
1 gm bid - tid
CBC, LFTs
onset 1 - 2 months
Methotrexate
most commonly used drug
fast acting (4-6 weeks)
po, SQ - weekly
CBC, LFTs
39. DMARDs IM Gold
slow onset (3-6 months)
weekly then monthly injections
CBC, UA before each injection
Oral Gold
less effective
slow acting (4-6 months)
daily
CBC, UA
40. DMARDs Azathioprine
100-200 mg daily
CBC, LFTs
?malignancy potential
onset 2 - 3 months
D-Penicillamine
daily
slow onset (3-6 months)
CBC, UA
autoimmune phenomenon
41. DMARDs Cyclosporin A
daily
BP, UA
Cyclophosphamide
refractory cases
CBC
Chlorambucil
CBC
42. New Therapies for RA Enbrel
Soluble tumor necrosis factor fusion protein
Arava
Leflunomide
43. Chimeric A2 (cA2) Monoclonal Antibody
44. DMARDs over the counter remedies
report use of vitamins, health aids, unusual diets
“natural” does not mean “safe”
45. Case Study: Follow Up During your training you became comfortable with the use of prednisone + HCQ and begin treatment including prophylatic therapy for OP with calcium, vitamin D, and discuss ERT. You recommend follow up appointment in 4-8 weeks.
What objective parameters will you use to determine if your therapy is effective?
46. Response to therapy AM stiffness, total number swollen, tender joints, (S1T2W+)
perception of pain
perception of overall response
health assessment measurement
ESR, CRP levels
physician’s assessment
47. Criteria for Remission (ACR) no fatigue
morning stiffness for 15 minutes or less
no joint pain
no joint tenderness or pain on motion
no soft tissue swelling in joints or tendon sheath
ESR <30 mm/hr (women) or 20 mm/hr (men)
5 of 6 present for 2 months
no vasculitis, pericarditis, pleuritis, myositis, weight loss, fever
48. RA - long term prognosis RA shortens survival and produces disability
1/3 leave work force in five years
aggressive DMARD TX can reduce disability by 30% in 10-20 years