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RHEUMATOLOGY

RHEUMATOLOGY. Rheumatoid arthritis Fibromyalgia Osteoporosis Ankylosing spondylosis Juvenile Idiopathic arthritis Reactive Arthritis Gout, Pseudogout Misc . RHEUMATOID ARTHRITIS. Maryam Nauman. In UK, 26,000 new cases diagnosed per year,

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RHEUMATOLOGY

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  1. RHEUMATOLOGY

  2. Rheumatoid arthritis • Fibromyalgia • Osteoporosis • Ankylosing spondylosis • Juvenile Idiopathic arthritis • Reactive Arthritis • Gout, Pseudogout • Misc

  3. RHEUMATOID ARTHRITIS Maryam Nauman

  4. In UK, 26,000 new cases diagnosed per year, • More than 690,000 cases already living with this condition ECONOMIC IMPACT Loss of job, reduced working hours, off sick, reduced family income Annual impact of RA in Western Europe 42 billion Euros RA costs £8 billion/year to UK economy

  5. 37 Year old presents to you with pain in joints very suggestive of Rheumatoid arthritis • Asymmetric arthritis more than 6 weeks duration • Absence of soft tissue swelling • Morning stiffness more of than 1 hour duration for at least 6 weeks duration • Normal X-rays

  6. DIAGNOSIS-ACR Criteria • • AM STIFFNESS (1 h) • • INFLAMMATORY ARTHRITIS OF ≥ 3 JT AREAS • • INFLAMM ARTHRITIS OF HAND JTS (wrist MCP PIP) • • SYMMETRIC ARTHRITIS • • RHEUMATOID NODULES • • SERUM RHEUMATOID FACTOR OR ANTI-CCP • • RADIOGRAPHIC CHANGES TYPICAL OF RA • FOR ≥ 6 WKS • Any 4 = rheumatoid arthritis • Specificity: 40-60%, 95-100%

  7. Classification criteria for RA (score-based algorithm: a score of ≥6/10 is needed for classification of a patient as having definite RA) Joint involvement 1 large joint- 0, 2-10 large joints-1 1-3 small joints (with or without involvement of large joints) -2 4-10 small joints (with or without involvement of large joints) -3 >10 joints (at least 1 small joint)- 5 Serology (at least 1 test result is needed for classification) Negative RF and negative ACPA-0 Low-positive RF or low-positive ACPA-2 High-positive RF or high-positive ACPA-3 Acute-phase reactants (at least 1 test result is needed for classification) • Normal CRP and normal ESR-0 • Abnormal CRP or abnormal ESR-1 Duration of symptoms •   <6 weeks- 0 • ≥6 weeks-1

  8. Who would you refer to specialist • 37 year old female with pain effecting small joints of both hands • 54 year man old with pain and tenderness in hip joint • 35 year old female with fever, generalised tiredness and increased CRP and positive RF

  9. Referral for specialist opinion • Any person with suspected persistent synovitis of undetermined cause REFER URGENTLY IF ANY OF THESE ARE AFFECTED • Small joints of hands or feet are affected • More than one joint is affected • There has been a delay of 3 months or longer between onset of symptoms and seekin medical advice

  10. PHARMACOLOGICAL MANAGEMENT INVERTED PYRAMID • NSAIDS, ANALGESICS • – For pt who may not have RA • – To ease pain while waiting for the 6 week point for • spontaneous improvement • • DMARD • – In any patient with RA without contraindication • – Methotrexate, hydroxychloroquine, sulfasalazine • – leflunomide • • MORE THAN ONE DMARD: 3>2 = biologic; 2>1 • – If you do not want to give biologic – cost, toxicities • • BIOLOGIC AGENT PLUS METHOTREXATE • – For any patient without excellent response to DMARD

  11. DMARD

  12. ANTI-TNF THERAPY • @-TNF Inhibitors- active arthritis, have undergone trial of 2 DMARDS inc methotrexate • Infliximab-IV infusion • Etanercept- in children also-s/c injections • Adalimumab-s/c inj • Anti IL1-Kineret,Ticlizumab, Rituximab, Abataccept orencia

  13. Fibromyalgia Nicolas Milhavy GP ST1 VTS

  14. Not well understood despite widespread research in the USA, Canada and Europe…… Can have a definite trigger or can come on gradually out of the blue

  15. Diagnosis • A history of chronic and widespread pain (CWP) • ‘Pain and fatiguability with multiple hyperalgesic tender sites (11/18)’

  16. American College of Rheumatology – Classification (1990) • Pain in the left and right side of the body, pain above and below the waist and axial skeletal pain (shoulder and buttock included on each side and lower back pain considered lower segment pain) for at least 3 months

  17. American College of Rheumatology – Classification (1990) 2. Pain (not tenderness) with digital palpation in 11/18 sites • Occiput – bilaterally • Low cervical C5-C7 • Trapezius – bilateral • Supraspinatous – above scapula • Second rib – bilateral • Lateral epicondyle – bilateral • Gluteal – bilateral • Greater trochanter – bilateral • Knee - bilateral

  18. ‘Manchester’ Definition Pain must be present in 2 separate sections of a body quadrant to be positive

  19. Epidemiology • CWP prevalence is above 10% if American College of Rheumatology definition is used • CWP prevalence is 5% with ‘Manchester’ definition • Twice as high in females • Fibromyalgia • 0.7-4.8% in comparable studies using ACR criteria • 90% female, peaks aged 40-50

  20. Clinical picture • Pain – axial and diffuse, felt all over • Pain worsened by stress, cold and activity, association with EM stiffness • Parasthesiae in hands and feet common • Analgesics and NSAIDs ineffective and may worsen symptoms • Poor sleep pattern – wake exhausted and poor concentration • Anxiety and depression scores are high • Unexplained headaches, urinary frequency and abdominal symptoms are common • Clinical findings unremarkable

  21. Pathogenesis • A poor, unrefreshing sleep pattern – unable to enter the 4th phase of sleep (deep refreshing sleep) • Muscles do not relax and resting muscle tension is raised – this causes aching all over that means the person cannot sleep well the following night – a vicious circle that is difficult to get out of • Napping in the day worsens symptoms as it means the body cannot enter the restorative phase • Low levels of NTs in the brain and abnormal processing of sensory stimuli – light touch and movements can cause significant pain that is real with no structural explanation • Reduced aerobic fitness • Behavioural affective symptoms

  22. Differential Diagnosis • Hypothyroidism • SLE • Sjorgren’s • Psoriatic arthritis • Inflammatory myopathy • Hyperparathyroidism • Osteomalacia

  23. Diagnosis • Exclude differential • FBC, ESR, TFTs, U and Es, Calcium, CK, phosphate, ANA, RhF and immunoglobulins

  24. Management • Good explanation • To patient and the family • Relieve concerns of sinister causes for pain • Rationalise with lack of sleep and fitness • Avoid unnecessary investigation • Regulate a better and more refreshing sleep pattern • Increase aerobic exercise or physiotherapy (a graded and sustainable exercise regime) • Low dose amitriptylline, dothiepin or fluoxetine • Consider CBT or counselling • MDT approach with rheumatology and pain clinic

  25. Prognosis • Poor • 20% are symptom free at 5 years • Treatment may help with coping strategies

  26. Case History Joblu Khan

  27. Case History Joblu Khan

  28. Mr ARL • 54 year old gentleman • Difficult patient • Well read • Frequent attender • ‘Hypochondriac’

  29. Mr ARL • “Osteoporosis” • “aches and pains all over” • Recent wrist fracture

  30. Mr ARL • Winter (December) 2010 • Fall onto outstretched hand (L hand) • ED • 999 • # wrist L • Backslab 6/52 • Finger, elbow and shoulder exercises • Discharged from ortho recently • Dr S Hameed (SHO)

  31. Mr ARL • Consultation • Risk Stratification

  32. Body weight ‘chubby’ (BMI 25 to 30) Nutritional Takeaway and microwave meals Lifestyle Enjoys walking the dog Limited knee pain Ex smoker (10 pack year history) 2 cans of Guinness most nights Family history Mother osteoporosis Severe COPD PMH HTN High cholesterol Diabetes Mellitus (diet controlled) Mild OA L knee DH Amldoipine Simvastatin Paracetamol PRN Mr ARL

  33. Mr ARL • Bld tests (random) • FBC, ESR • U&Es • LFTs (ALP 154 (40 – 129)) • Bone • TSH • Testosterone • Random glucose (11.2 mmol/L) • Cholesterol (4.5 mmol/L)

  34. Mr ARL • DEXA scan • T score of – 2.6 • What is the diagnosis? • Treatment of choice? • Need to refer? • Follow up investigations needed?

  35. Mr ARL

  36. Osteoporosis • Systemic skeletal disease • Low bone mass and micro-architectural deterioration • Increase in bone fragility and susceptibility to facture • Considerable morbidity and mortality • Increasing in developing countries • Increasingly elderly population

  37. Investigate • Previous low trauma fractures • # from fall from standing • Loss of height/kyphosis (? Vertebral #) • Age > 60 and female sex • Recurrent falls • Glucocorticoid use • FH of osteoporosis • Secondary causes

  38. Diagnostic evaluation • Degree of osteopenia • DEXA • Establish current fracture risk • Establish future fracture risk • Monitor effect of treatment • Osteopenia • Tscore – 1 and – 2.5 • Osteoporosis • T score <2.5

  39. Diagnostic evaluation • Exclude secondary osteoporosis • Primary hypoparathyroidism (serum Ca) • Thyrotoxicosis (TSH) • Myeloma (ESR, plasma electrophoresis, BJ proteins) • Osteomalacia (serum Ca, Phosphate, ALP) • Malabsorption syndrome (FBC) • Hypogonadism in men (testosterone)

  40. Management • Anti resorptive drugs • Etidronate • Didronel® • Alendronate • Risedronate • Ibandronate • Raloxifene • SERM • HRT • Testosterone therapy • Hypogonadism • Calcitonin • Calcium and Vit D • Calcichew D3 forte

  41. Management • Formation stimulating drugs • Recombinant fragment of parathyriod hormone • Specialist centres • Strontium ranelate • Treating secondary causes • Partial recovery • Preventing falls • Predisposing causes • Postural hypotension • Physiotherapy • Hip protectors

  42. Preventing osteoporosis • Optimize peak bone mass • Exercise • Regular and weight bearing • Dietary calcium • Reduce rate of bone loss • HRT • Exercise • Calcium intake • Moderate alcohol intake • Stop smoking • Prophylactic treatment • ? Cost effectiveness

  43. Osteoporosis • Determine risk • Preventable • Treatment effective • ? Guidelines • QOF?

  44. Case Presentation Ulfat Younis

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