Kevin Latinis, M.D./Ph.D. Division of Rheumatology Dept. of Internal Medicine klatinis@kumc

1. Rheumatology 101:What you need to know for your ambulatory medicine experience Kevin Latinis, M.D./Ph.D. Division of Rheumatology Dept. of Internal Medicine klatinis@kumc.edu

2. Rheumatology 101 • Arthritis-Inflammatory (RA, spondyloarthropathies)-Mechanical (OA) • Lupus • Fibromyalgia • Low back pain and other peri-articular complaints • General musculoskeletal exam (time permitting)

3. Mechanical vs. Inflammatory Arthritis Latinis, K., et al TheWashington Manual Rheumatology Subspecialty Consult., LWW, 2003.

4. Osteoarthritis-Background • Very common-2nd leading cause for disability in USA-In patients 60 and older: affects 17% of men and 30% of women-Estimated that 59.4 million patients will have OA by the year 2020 • Etiology-primary idiopathic-secondary

5. Osteoarthritis-Distribution Bouchard’s Heberden’s Latinis, K., Dao, K, Shepherd, R, Gutierrez, E, Velazquez, C. TheWashington Manual Rheumatology Subspecialty Consult., LWW, 2003.

7. Osteoarthritis-Diagnosis • Clinical • Supported by X-rays • Non-inflammatory lab data, if any

8. Osteoarthritis-Treatment • Pain relief-Analgesics and NSAIDs/Cox-2 Inhibitors • SMOADs (structure modifying osteoarthritis drugs)-Glucosamine Sulfate -see meta-analysis McAlindon et al. JAMA, 283: 3/2000, p. 1469-many under development • Non-pharmacologic approaches-Reduce stress/load on joint-Strengthen surrounding muscles-PT/OT-Weight reduction-Patient education • Limit disability and improve quality of life

9. Osteoarthritis-Treatment • Joint Replacement Surgery-Primarily of knee and hip, but also available in hands, shoulders,& elbows-Indications: 1. pain at rest 2. instability-patients benefit from aggressive PT before & after surgery • Other surgical procedures

10. Clinical Pearl:Arthritis of the DIP joint Psoriatic Arthritis (inflammatory) OA (non-inflammatory)

11. Inflammatory Arthritis • Rheumatoid arthritis • Spondyloarthropathies-Undifferentiated-Ankylosing spondylitis-Psoriatic arthritis-Reactive arthritis (formerly Reiter’s syndrome)-Enteropathic arthritis • SLE, Sjogrens, Scleroderma, Polymyalgia rheumatica, Vasculitis, Infectious (bacterial, viral, other), Undifferentiated connective tissue disease

12. Latinis, K., et al TheWashington Manual Rheumatology Subspecialty Consult., LWW, 2003.

13. Rheumatoid Arthritis-Background • Symmetric, inflammatory polyarthritis • Affects ~1% of our population • Occurs in women 3x more than men • Etiology-Genetic, class II molecules (HLA-DRB1)-Autoimmune-?Environmental

14. Rheumatoid Arthritis-Distribution Latinis, K., et alTheWashington Manual Rheumatology Subspecialty Consult., LWW, 2003.

15. Latinis, K., et al TheWashington Manual Rheumatology Subspecialty Consult., LWW, 2003.

16. Systemic Lupus Erythematosus (Lupus)-Background Definition -An inflammatory multisystem disease of unknown etiology with protean clinical and laboratory manifestations and a variable course and prognosis. -Immunologic aberrations give rise to excessive autoantibody production, some of which cause cytotoxic damage, while others participate in immune complex formation resulting in immune inflammation.

17. Systemic Lupus Erythematosus (Lupus)-Background Clinical features -Clinical manifestations may be constitutional or result from inflammation in various organ systems including skin and mucous membranes, joints, kidney, brain, serous membranes, lung, heart and occasionally gastrointestinal tract. -Organ systems may be involved singly or in any combination. -Involvement of vital organs, particularly the kidneys and central nervous system, accounts for significant morbidity and mortality. -Morbidity and mortality result from tissue damage due to the disease process or its therapy.

18. 1. Serositis: (a) pleuritis, or (b) pericarditis 2. Oral ulcers 3. Arthritis 4. Photosensitivity 10. Malar rash 11. Discoid rash 5. Blood/Hematologic disorder: (a) hemolytic anemia or (b) leukopenia of < 4.0 x 109 (c) lymphopenia of < 1.5 x 109 (d) thrombocytopenia < 100 X 109 6. Renal disorder: (a) proteinuria > 0.5 gm/24 h or 3+ dipstick or (b) cellular casts 7. Antinuclear antibody (positive ANA) 8. Immunologic disorders: (a) raised anti-native DNA antibody binding or (b) anti-Sm antibody or (c) positive anti-phospholipid antibody work-up 9. Neurological disorder: (a) seizures or (b) psychosis Systemic lupus erythematosus classification criteria(SOAP BRAIN MD) ". ..A person shall be said to have SLE if four or more of the 11 criteria are present, serially or simultaneously, during any interval of observation."

19. 53 yo BF with severe generalized weakness, weight loss, and chronic psychosis Alopecia Psychosis Malar rash Arthritis

20. Laboratory Data 139 106 16 7.7 101 298 3.9 4.3 21 1.4 22.3 MCV=83 24 hour urine Protein=514 Absolute lymph=0.5 ESR=119 CH50=67 (118-226) C3=31 (83-185) C4=18 (12-54) ANA + 1:5280 Anti DNA + Direct & Indirect Coombs + Anti-IgG +

22. Arthritis, arthralgias, myalgias: NSAIDS, anti-malarials (eg. Plaquenil), Steroids- injections, oral methotrexate Photosensitivity, dermatitis avoid Sun exposure topical steroids Plaquenil Weight loss and fatigue steroids Abortion, fetal loss ASA immunosuppression Thrombosis anti-coagulants Glomerulonephritis steroids pulse cytotoxics mycophenylate mofetil CNS disease anti-coagulants for thrombosis steroids and cytotoxics for vasculitis Infarction (secondary to vasculitis) steroids cytotoxics prostacyclin Cytopenias steroids IVIG-short term for thrombocytopenia danazol cytotoxics-if bone marrow status is known Treatment of SLE

23. Steroid responsive Dermatitis (local) Polyarthritis Serositis Vasculitis Hematological Glomerulonephritis (most) Myelopathies Steroid non-responsive Thrombosis Chronic renal damage Hypertension Steroid-induced psychosis Infection Steroids in Lupus

24. ANA-When to order and how to follow up on a positive test Latinis, K., et al TheWashington Manual Rheumatology Subspecialty Consult., LWW, 2003.

25. Latinis, K., et al TheWashington Manual Rheumatology Subspecialty Consult., LWW, 2003.

26. Fibromyalgia-Background • Chronic musculoskeletal pain syndrome of unknown etiology • Characterized by diffuse pain, tender points, fatigue, and sleep disturbances • Prevalence is 2-5% with a female to male predominance of 8:1 • Mean age is 30-60

27. Fibromyalgia-Diagnosis

28. 4 3 1 2 6 5 7 8 9

30. Fibromyalgia-Treatment

31. Low back pain and other peri-articular complaints-background • Very common, one of the most frequent reasons to visit primary care physicians • Articular vs peri-articular problems-Articular pain is generally deep or diffuse and worsens with active and passive motion-Periarticular pain usually exibits point tenderness and increased tenderness with active, but NOT passive motion

32. Latinis, K., et al TheWashington Manual Rheumatology Subspecialty Consult., LWW, 2003.

33. Latinis, K., et al TheWashington Manual Rheumatology Subspecialty Consult., LWW, 2003.

34. Latinis, K., et al TheWashington Manual Rheumatology Subspecialty Consult., LWW, 2003.

35. Muscles of the rotator cuff: Supraspinatus Infraspinatus Subscapularis Teres Minor

37. Low back pain and other peri-articular complaints-Treatment • RICE-Rest-Ice-Compression-Elevation • NSAIDs and analgesics • Time • Other

38. General Musculoskeletal Exam • Underutilized by primary care providers • Should be simple and quick • Goal is to recognize signs of rheumatological diseases and determine if it is appropriate to refer to a rheumatologist or manage independently

40. Summary • Arthritis-Inflammatory (RA, spondyloarthropathies)-Mechanical (OA) • Lupus • Fibromyalgia • Low back pain and other peri-articular complaints • General musculoskeletal exam (time permitting)