Osteoarthritis / Rheumatoid arthritis

1. Osteoarthritis / Rheumatoid arthritis Tim Badcock Monday, 10th March 2014

2. Layout • Osteoarthritis • Rheumatoid arthritis • Case studies

3. Osteoarthritis • Definition • Aetiology • Risk Factors • Symptoms and signs • Investigations • Management • Prognosis

4. Definition • Osteoarthritis is a chronic disease of articulating joints characterised by pain, swelling and reduced range of movement. It involves the degradation of cartilage of one or more joints. • Aetiology • Primary – attrition of cartilage from gradual wear and tear from overuse. Associated with increased water content and reduced type 2 collagen • Secondary – erosion of joints already undergoing structural change e.g. gout, RA,

5. Risk factors • Unmodifiable • Structural abnormality e.g. Short femur, scoliosis • Age • Female – thinner cartilage • Achondroplasia / osteochondritis dessicans • Modifiable • Overweight • Excessive exercise • Under exercising • Contributing • Meniscal surgery • Contralateral deformity • Gout • Rheumatoid arthritis • Psoriasis • Septic arthritis • Reactive arthritis • Perthes disease • Ligamental laxity

6. Effects • Commonly hips > knees > DIPS > PIPS > shoulders Signs • Joint swelling, gait abnormalities, warm joint, thickened skin, widened joint (HB – Heberden, Bouchards), reduced power • Xray – joint narrowing, bone cysts, subchondral sclerosis, osteophytes • Often assymetrical Symptoms • Pain > stiffness after use > reduced range of motion • IMPACT ON FUNCTION

8. Investigations • BPS • Social – can they walk to shops, visit friends, drive • Psychological – depression • Biological – bedside (goniometer, weight, height) • Bloods – FBC (CKD), U&E (NSAIDS), LFTs (ALP), ESR (rheumatoid), • Imaging – Xray, MRI joints/ligaments • Special test – DEXA scan

9. Management • Biological – acute {A to E approach, an be a cause of hip fracture} • Lifestyle – lose weight, regular low weight bearing exercise, stop smoking, • Medical – pain management, NSAIDS • Surgical – joint replacement (hemi/total), ligament surgery • Psych – encourage social exercise, treat depression • Social – encourage social activity • MDT – physio, OT (opening jars), walking aids

11. Prognosis • Excellent • Not life limiting • Associated with cardiovascular disease, obesity • Significant impairment of ADLs

12. Rheumatoid arthritis • Definition • Aetiology • Risk factors • Signs and symptoms • Extra-articular manifestations • Investigations • Management • DMARDs

13. Definition • A chronic relapsing inflammatory condition of the joints and ligaments that is characterised by joint laxity, swelling and reduction in function with additional systemic effects • Forms • Juvenile idiopathic arthritis (Pauci/polyarticular) • Still’s disease • Symmetrical polyarthropathy • Vasculitis • RhF +ve and –ve • Felty’s • Caplan’s syndrome

14. Aetiology • Biochemical aetiology • HLA-DR4 association • Anti-cyclic citrullinated peptide (anti-CCP) • RhF is IgM antibodies to circulating IgG that cause immune complexes with destruction(fast progression) • RhA sufferers without RhF are seronegative often IgG to IgG complexes (slow progression). • T cell activation by TNF-α and IL-2/4. • Structural aetiology • Proliferation of synovium to form boggy joints of pannus tissue • increased vascularity and capillary permeability • fibroblast erosions of cartilage and subchondral bone. • Increased synovial fluid content (effusion)

15. Risk factors • HLA-DR4 • Family history • Female • Middle age • Infection triggers • Other autoimmune conditions • Smoking

16. Signs and symptoms • Signs • Warm, boggy joints indicates active disease • Systemic inflammation signs (pyrexia, tachycardia etc. • Joint tender • Muscle wasting • Subluxation • Subcutaneous nodules • Hands – ulnar deviation, MCPs, Boutonniere, swan neck, trigger finger • Stenosing tenosynovitis • Carpal tunnel syndrome • Feet – hammer toes, hallux valgus, MTP loss, loss of arch (pedis planus) • Atlanto-axial ligament • Symptoms • Pain • Reduced movement • Stiffness (morning stiffness lasting >30mins) • Joint instability • Radiological • DOSES • deformity, osteoporosis, subluxation, effusion, swelling

17. Extra-articular • Cardiology • Vasculitis • Pericarditis • Mitral valve prolapse • Respiratory • Rheumatoid nodules (Caplans) • pulmonary fibrosis (Felty’s) • bronchiectasis • pleural effusion • Gastro • Liver fibrosis • Splenomegaly (Felty’s) • Urological • glomerulonephritis • Neuro • peripheral neuropathies (carpal tunnel syndrome) • Skin • rheumatoid nodules – elbows and forearms • Erythema nodosum • Ulceration • Eyes • Scleritis/episcleritis • Sjogren’s syndrome Scleritis Felty’s syndrome Erythema nodosum Caplan’s syndrome

18. Investigations • BPS • Social – can they walk to shops, visit friends, drive • Psychological – depression • Biological – bedside (function!!, goniometer, psoriasis) • Bloods – FBC (DMARDS), U&E (NSAIDS/Fx), LFTs (fibrosis), ESR (rheumatoid), calcium • Imaging – Xray, MRI joints/ligaments, CT chest • Special test – RhF, anti CCP, ANA for anti-Ro and anti-La, Biopsy

19. Management • Social – support groups, specialist nurse • Psychological – screen for depression • Biological – acute / chronic management • Acute – A to E approach, splinting, surgical decompression • Mild = analgesia, NSAIDS, • Severe = steroids, cyclophosphamide

20. Chronic management • Conservative • stop smoking, increase exercise splinting • Medical • Simple analgesia, NSAIDS (diclofenac) • Steroid injections • Oral steroids • DMARDS (methotrexate, sulfasalazine, azathioprine) • Monoclonal antibodies  • Surgical • Decompression, osteotomy, tendon release, • Arthrodesis (fusion of joints), arthroplasty • MDT • Physio, OT, GP

21. Steroids

22. DMARDS • Methotrexate (except pregnancy). Folic acid inhibitor • renal impairment, lung fibrosis, bone marrow suppression, liver abnormalities • Regular FBC, U&E, LFTs every 3-6 months • CXR • Folic acid co-prescribed • Sulfasalazine (if pregnant) 5 aminosalicyclic acid inhibitor (antioxidant) • Thrombocytopenia/neutropaenia, LFT derangement • LFTs • Azathioprine (6-mercaptopurine proanalogue, inhibit purine synthesis) • neutropenia, liver toxicity, pancreatitis • FBC& LFTs 6 monthly • Biologics • rituximab (HTN, pruritus) • TNF-α blockers e.g. Infliximab – infection

23. Case study • 34 year old woman comes to see you. She has a 8 week history of pain affecting the small joint of her hand. The pain is worse first thing in the morning and is associated with stiffness. It takes about 1 hour for the stiffness to improve. She has felt generally unwell over the period too. She has noticed her hands and slightly swollen. She is otherwise well and only takes the OCP. She smokes 10 cigarettes a day and drinks <14 units of alcohol per week. She works as a secretary. She is concerned that she has been late to work recently because of the disruption to her morning routine. ON examination her hands are slightly swollen over the MCP and PIP joints of both hands and are tender to palpation over these joints. There is no obvious deformity to them. She has a temp of 37.5 but has no skin changes to her elbows or scalp. Her right eye is slightly red around the cornea, but not painful.

24. What are your differentials for this lady? • What investigations would you do? • What Xray changes would you expect in RA? • Name the typical hand changes you would see in an exam patient with RA • What are the extra-articular manifestations of RA? • How would you manage this patient? • Name some DMARDs, give a side effect for each of them? • What is the mechanism of action of the biologic agents used to treat RA? • What test should be done before starting biologics? • What are the diagnostic criteria for RA?

25. Test before biologics • TB monospot • CXR • Rheumatoid Arthritis Quality of Life Score (50% reduction in symptoms) • Diagnostic criteria 4/7 • Morning stiffness >1 hour for > 6weeks • Affecting 3+ joints • Hand joints • Symmetrical arthritis • Rheumatoid nodules • Positive RhF or anti-CCP • Xray changes

27. Case study 2 • 67 year old lady come to see you as she is being increasingly troubled by pain in her hands. It mostly affect her thumbs but also the small joints of her fingers. The pain is worse towards the end of the day and after she has been gardening. She has noticed some slight swelling of her joints. The pain is helped by paracetamol when it is at its worst. She is otherwise well except for hypertension which is well controlled on amlodipine 5mg OD. She does not drink alcohol and has never smoked. She is a retired secretary. On examination her hands are not grossly deformed although she does have a mild Z shaped deformity of the thumb. They are generally tender over the PIPs and DIPs of all digits with some hard swellings. She is can do up buttons and write her name, although this causes her some discomfort. She has no skin lesions at her elbows or behind her ear

28. What are your differentials for this lady? • What investigations would you like to do? • What X-ray changes would you expect to find? • How would you manage this lady? • Describe the typical changes you would see on examinations of the hands of a patient with OA