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RHEUMATOID ARTHRITIS for the internist...

RHEUMATOID ARTHRITIS for the internist. Christopher Parker CPT (P), MC, USA Rheumatology Service WRAMC. Introduction. Interactive format Clinical features Laboratory features Extra-articular features Management considerations and paradigms Prognosis.

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RHEUMATOID ARTHRITIS for the internist...

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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

  3. 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. What historical features speak for RA?

  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?

  7. RA: Erosion Progression

  8. 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 Laboratory Exam

  9. 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)

  10. Laboratory abnormalities • anemia of chronic disease • thrombocytosis in active disease • low white cell count in Felty’s • ESR • CRP

  11. 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

  12. DDX of a positive RF • normal - 1-4%, 10-25% over age 70 • systemic autoimmune diseases • infections • malignancy • chronic liver disease • pulmonary diseases

  13. ANA in RA • 25% RA are positive for ANA • other serologies usually negative • ? more severe disease (RA) with worse prognosis

  14. RA - Definition • chronic systemic inflammatory disorder • unknown etiology • diarthroidal joints • synovium affected • bone, cartilage, ligaments • deformity • extra-articular manifestations

  15. RA - Definition • clinical diagnosis • symmetric polyarthritis of small joints • subacute • acute • rheumatoid factor positivity • erosive disease

  16. RA - Epidemiology • worldwide distribution • all races • female > male 3:1 • 1% adults in U.S. • genetic associations • HLA-DR4, DR1

  17. 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?

  18. Parvo Arthritis

  19. RA - differential diagnosis • Common diseases • spondyloarthropathies • CTDs • polyarticular gout • CPPD • viral infections • fibromyalgia

  20. RA - differential diagnosis • Uncommon • hypothyroidism • SBE • hemochromatosis • hypertrophic pulmonary osteoarthropathy • hyperlipoproteinemias • hemoglobinopathies • relapsing polychondritis

  21. RA - differential diagnosis • Uncommon • rheumatic fever • sarcoidosis • lyme disease • amyloid • HIV • malignancies/paraneoplastic syndromes

  22. RA - differential diagnosis • Rare • familial mediterranean fever • multicentric reticulohistiocytosis • whipple’s disease • angioimmunoblastic lymphadenopathy

  23. 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?

  24. Extra-articular manifestations • General • fever, lymphadenopathy, weight loss, fatigue • Dermatologic • palmar erythema, nodules, vasculitis • Ocular • episcleritis/scleritis, scleromalacia perforans, choroid and retinal nodules

  25. 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

  26. Extra-articular manifestations • Pulmonary • pleuritis, nodules, interstitial lung disease, bronchiolitis obliterans, arteritis, effusions • Others • Sjogren’s syndrome, amyloidosis

  27. 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?

  28. 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?

  29. RA - Management • Nonpharmacologic • rest • fatigue, splinting • pain relief • heat, cold, ultrasound, paraffin, massage • physical therapy • occupational therapy • Patient education

  30. RA - Management • Pharmacologic • analgesics • NSAIDs - full dose • corticosteroids • prednisone at low dose - “bridge”, “burst” • intra-articular steroids

  31. 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

  32. DMARDs • hydroxychloroquine • mild non-erosive disease • combinations • 200 mg bid • eye exams

  33. 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

  34. 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

  35. 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

  36. DMARDs • CyclosporinA • daily • BP, UA • Cyclophosphamide • refractory cases • CBC • Chlorambucil • CBC

  37. New Therapies for RA • Enbrel • Soluble tumor necrosis factor fusion protein • Arava • Leflunomide

  38. Chimeric A2 (cA2) Monoclonal Antibody Mouse (binding site for TNF-a) Human (IgG1) • Chimeric (mouse/human) IgG1monoclonal antibody • Binds to TNF-a with highaffinity and specificity Knight, et al. Mol Immunol. 1993.

  39. DMARDs • over the counter remedies • report use of vitamins, health aids, unusual diets • “natural” does not mean “safe”

  40. 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?

  41. 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

  42. 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

  43. 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

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