RHEUMATOLOGY
OSTEOARTHRITIS (OA) RHEUMATOID ARTHRITIS (RA)
• Chronic degeneration of the WHOLE synovial joint due to a combination of: • Autoimmune mediated chronic joint inflammation
• Fibrillation and fissuring of cartilage surface with chondrocyte clumping and • Synovial membrane hyperplasia (TNF-a and IL-6)
Cause
hyperplasia ((MMP-1,13 and collagenases)) • Leucocyte recruitment – angiogenesis
• Typically affects large jts (hips, knees, DIP, CMC (saddle jt), wrist) • Formation of pannus (hyperplastic and inflamed synovium)
• Modifiable = Overweight, repetitive usage or injury (meniscal, ACL tear), • FHx of RA or autoimmune disease
Vit D def., myalgia, repetitive work • Young females
RF
• Non-modifiable = older (over 45yo) , female, FHx, Ethnicity (Asian), RA, endo • Genetics: HLA DR1 and DR4
(haemochromatosis, acromegaly)
• Activity related jt Pain (improved w/ rest, worse on activities) • Activity related jt Pain (improved w/ activity, worse on rest)
• Early AM stiffness (< 30 mins) • Symmetrical distal polyarthropathy
• Large joints affected (mono, oligo, poly) esp. DIP and 1st MCP • PIP and MCP joints (DIP sparing)
• Impaired mobility and physical function -® reduced ADL • Early AM stiffness (> 30mins) ® improved on activity (worse on rest)
• Extra-articular manifestations
• Ø Dry eye syndrome +/- Episcleritis, scleritis
Classical Signs Ø Pulmonary fibrosis (Caplan’s syndrome) = most common
Ø Bronchiolitis obliterans (inflamed small airways)
• Bony hard Joint swelling
Ø Felty’s syndrome (RA, neutropenia, +SM)
(osteophyte formation)
S+S Ø Secondary Sjogren (sicca syndrome)
• Bouchard’s nodes (PIP) and Ø Anaemia of chronic disease
Exam Heberden’s nodes (DIP) Ø LN, amyloidosis, carpel tunnel syndrome
• Squaring at base of thumb (CMC) Signs:
• Crepitus, • Soft tender tissue swelling
• Reduced ROM • Z-deformity of thumb
• Muscle wasting + weak grip • Swan neck deformity (hyperextended PIP with flexed
DIP)
• Boutonniere’s deformity (hyperextended DIP with flexed PIP due to FDS tendons pulling
on distal phalynx caused by tear in central slip in extensor components of fingers)
• Ulnar deviation of fingers at knuckles (MCP)
• Hand muscle wasting
• Neck pain and parasthesia ® Atlantoaxial subluxation (medical ED)
• Chondrocalcinosis ® elderly ® 20-40mg prednisone daily or colchicine • Septic arthritis (bacterial, viral, fungal) – Hep B, parvovirus
0.5mg twice daily • Crystal arthropathy (gout, pseudogout)
• Inflammatory arthritis (SpA, RA, crystal, vasculitis, septic) ® • Spondyloarthropathies ® recent infections (STI, GI), asymmetrical, lower
DDX • Haemochromatosis ® < 50 + no predisposing factors limb, axial
• Fibromyalgia • OA
• Tendinopathy • CT disease (Sjogren, SLE)
• Osteonecrosis • Vasculitis
• Psychosocial ® lower SES, education • Psychosocial – A+D
Comp. • Fracture • Reduced QoL
• Reduced QoL
AVOID UNNECESSARY IMAGING (e.g. weight bearing X-ray or MRI) • FBC, EUC, LFT, ESR/CRP, serum urate
• Little correlation between OA symptoms w/ radiological findings • RF, anti-CCP, HLA-B27, ANA, anti-dsDNA, ANCA
• XR (LOSS) = Loss of articular cartilage, osteophyte growth, subchondral cysts, • Joint aspirate – M/C/S + Polarised microscopy
subchondral sclerosis • USS or XR hands and feet (LESS) ® Loss of joint space, bony erosions, soft tissue
Ix o Sunrise view of patella (Laurin skyline view) swelling, periarticular osteopenia
o PA in 45 deg of knee flexion (best to view JSN) (Rosenberg view) • MRI C-spine ® Atlantoaxial subluxation = in cervical spine when axis (C2) and
odontoid peg shift within atlas (C1) causing spinal cord compression
• If reactive arthritis suspectedè Chlamydia PCR and stool culture PCR
(salmonella, shigella)
• Patient education è knowledge, attitudes (brochures, • knowledge, attitudes (brochures, websites e.g
Education
websites e.g MyJointPain.org.au) MyJointPain.org.au)
Education
• INTEGRATED APPROACH towards prevention and modifiying MDT Approach = PT, OT, dietician, EP, psychologist
risk factors to slow disease progression
Non- • PT/EP ® splints, walking aid, education and joint care and
MDT Approach = PT, OT, dietician, EP, psychologist pharm protection (land based exercise)
• Wt loss (dietician) (lifestyle) • OT ® equipment housing modification
• land-based exercise (PT) = low impact aerobic fitness •
o at-home exercise (quad strengthen) Acute Mx:
Non-
o hydrotherapy • 1st line NSAID + PPI
pharm
o tai-chi and swimming
(lifestyle) • 2nd line 5-10mg prednisone oral od,
• assistive devices / orthotics (OT)
Long-term Mx:
o walking stick
Pharm 1st line = MTX (+ 5mg folic acid taken on different day), or
o 4WWW
[Trial sulfasalazine or leflunomide
o Elastic or back support
Mx topical 2nd line Use 2 of the above
• Topical NSAIDs ® knee and hand OA therapies] 3rd line MTX + biologics (anti-TNF (infliximab,
• Topical capsaicin
adalimumab, etanercept)
Pharm • Oral NSAIDs (better than paracetamol) ® add PPI
[stepwise] o Monitor EUC (AKI), LFT (hepatotoxic) 4th line MTX + rituximab
o Warn PUD/Bleed *Nb: pregnant women have improved symptoms due to increased
*AVOID opioids (codeine, morphine) steroid production during pregnancy
1. Intra-articular steroid injections Urgent orthopaedic referral if:
a. temporary reduction in inflammation and symptom Surgery • Septic arthritis
improvement • Sig. joint deformity
2. Joint surgery if mod-severe symptoms:, sig. QoL affect Worse prognostic factors:
Surgery
a. Knee arthroscopy + meniscus debridement Ø Younger onset
b. High tibial osteotomy (HTO) – young active Ø Male
c. Unicompartmental arthroscopy - >60yo and thin Ø More joints and organs affected
d. TKR ® last line (can be converted from HTO) Ø Presence of RF and anti-CCP
Ø Erosions on XR
• Non-urgent rheumatology review (if pharmacotherapy needs escalating or diagnostic • Non-urgent rheumatology review è uncertainty diagnosis, or considering
uncertainty) withdrawing DMARD
• Orthopaedic surgical review ® severe Sx • ++ ESR/CRP + RF, ANTI-CCP
• Persistent jt inflammation at 6 wks
FU • GPMP of OA
• Das28 (Disease activity score) – assess 28 joints and point given for (1) swollen,
• Goals, expectations, action items to review in 4-6/12
(2) tender joints and (3) ESR/CRP result è monitor Rx response
• ≥3 health professionals (5x subsidised visits/year) • Monthly EUC, LFT for first 6/12 (if started on DMARD)
• Print copy for pt and add document to medical records • Check CVD risk (lipids and HbA1C) ® statin, BP, OP
, SERONEGATIVE SPONDYLOARTHOPATHIES
Reactive Arthritis
Ankylosing Spondylitis Psoriatic Arthritis
“Reiter’s syndrome”
Inflammatory condition affecting spine mainly Synovitis in response to recent infection trigger Inflammatory arthritis associated with psoriasis (arthritis
Def
causing progressive stiffness and pain develops within 10 years after psoarisis)
• Young adult males in 20s • STI (C+G) or gastroenteritis • Psoriasis
RF
• HLA-B27 • HLA-B27 • HLA-B27
Ø SIJ tenderness Ø Acute monoarthritic (Affecting single • Symmetrical polyarthritis = mainly females affecting
Ø Lower back and buttock pain swollen joint usually knee) hands, wrists, ankles and DIP
Ø Worse PM – nocturnal waking Ø Recent infection • Asymmetrical pauciarthritis – mainly affecting digits
Ø AM stiffness > 30 mins (improved during • Spondylitic pattern (mainly men) ® back stiffness,
day) “Can’t see, can’t pee or climb a tree” sacroiliitis, atlanto-axial jt
Signs
Ø Schober’s test = distance bending forward Signs:
Sx < 20cm = lumbar restriction • onycholysis (separation from nail bed),
• dactylitis
• nail pitting
• psoriasis plaques
• enthesitis
Ø Chest pain = costovertebral and Ø Bilateral non-infective conjunctivitis Ø Bilateral non-infective conjunctivitis
costosternal joints Ø Anterior uveitis Ø Anterior uveitis
Ø Enthesitis Ø Circinate balanitis Ø Aortitis
Ø Anaemia Ø Keratoderma blennorrhagia – red papules Ø Amyloidosis
Ø Anterior uveitis that become hyperatotic
Ø Achilles tendinitis
Assoc. Ø Apical pulm fibrosis (1% of patients)
Ø AR and aortitis
Ø HB due to heart fibrosis
Ø IBD
Comp. Vertebral fractures Arthritis mutilans (joint completely destroyed)
Ø FBC, EUC, CRP/ESR Investigations to exclude septic arthritis: Ø FBC, EUC, CRP/ESR
Ø HLA-B27 genetic test Ø FBC Ø HLA-B27 genetic test
Ø XR spine and sacrum Ø EUC Ø XR changes
o Periostitis – inflamed periosteum causing
o bamboo spine (fusion of facet, spine Ø CRP
thickened irregular bone outline
and SIJ) + Squaring verterbral bodies Ø Joint aspirate ® M/C/S o Ankylosis – bones coming together causing jt
Ix o syndesmophytes = bony growths Ø Crystal exam – exclude gout, pseudogout stiffening
within ligaments
o Osteolysis – bone destruction
o subchondral sclerosis and erosions o Dactylitis – inflamed digit (soft tissue swelling)
Ø MRI spine = bone marrow oedema o Pencil-in-cup appearance – central erosion of
bone beside joint causing one bone to appear
hollow while other is narrow and sits in cup
Conservative Once septic arthritis excluded: Ø Non-urgent rheum & dermatologist referral
Ø Stop smoking Ø NSAID Ø NSAID – for pain
Ø Exercise and mobilisation (PT) Ø Intra-articular steroid injections Ø DMARD
Ø Bisphosphonates for OP Ø Systemic steroids (if multiple joints) Ø Anti-TNF
Medical: Ø Ustekinumab= last line (if anti-TNF fails) ® MAB
Ø NSAID (trial for 2-4 wks before switching) For recurrent cases (after 6/12) targets IL- 12 and 23
Ø Steroids PO/IM (for acute flares) Ø Non-urgent rheum referral Monitor for arthritis mutilans:
Ø Anti-TNF Ø DMARDs Ø Occurs in phalanxes ® osteolysis of bones around
Mx Ø Anti-IL17 (secukinumab) Ø Anti-TNF joint causing digit shortening and skin folds develop
Surgery Ø “telescopic finger”
Ø Severe spine/joint deformity
COMMON AUTOIMMUNE MEDS
MTX Sulfasalazine Leflunomide Hydroxychloroquine Anti-TNF Rituximab
Ø Inhibit folate Ø Immunosupp Ø Interfere with Ø Usu. anti-malarial Ø Blocking TNF Ø Anti-CD20 MAB on
metabolism and anti- pyrmidine production Ø Disrupts toll-like reduces B cell surface
Ø Taken w/ folic inflammatory for RNA/DNA receptors to disrupt inflammation
acid 5mg per Ø Safe during antigen presentation Ø MABs = antibody
MoA week on pregnancy w/ Ø Safe during pregnancy to TNF
different day to folic acid Ø . Etanercept =
MTX suppl. binds TNF to Fc
portion of IgG and
to reduce activity.
Ø Bone marrow Ø Reduced Ø PERIPHERAL Ø Nightmares Ø Infection risk Ø NS
suppression + sperm count NEUROPATHY Ø Reduced visual acuity Ø Reactivation of Ø Low plts
leukopenia (male Ø HTN Ø Liver toxicity TB and Hep B Ø Infection risk
Ø Teratogenic infertility) Ø Mouth ulcers Ø Skin pigmentation Ø Reactivation of TB
Ø Pulmonary Ø Bone marrow Ø Rashes and Hep B
A/E
fibrosis suppression Ø Liver toxicity Ø Peripheral
Ø Mouth ulcer Ø Bone marrow neuropathy
Ø Liver toxicity suppression + Ø Liver and lung
Ø leukopenia toxicity
Ø Teratogenic
