DR. RONAN KAVANAGH MD MRCP Rheumatology Toolbox Inflammatory arthritis QuickTime™ and a H.264 decompressor are needed to see this picture.
May 25, 2015
DR. RONAN KAVANAGH MD MRCP
Rheumatology ToolboxInflammatory arthritis
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Inflammatory arthritis?
•Rheumatoid arthritis
•Psoriatic arthritis
•Reactive arthritis
•Undifferentiated inflammatory arthritis (UIA)
•Ankylosing Spondylitis
3
1 IN 5 GP CONSULTATIONS FOR MUSCULOSKELETAL
PROBLEMS
McCormick A, Fleming D, Charlton J. Morbidity Statistics from General Practice: Fourth national study 1991–1992. London: HMSO; 1995
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Galway GP practice1 – 3.5 WTE GP’s, 6000 patients
1 Personal Communication, Dr. Eamonn O’Shea2 6 month data x 2
total 6200
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Inflammatory arthritis and the GP
Picking them out of a crowd graphic
88
The overwhelmed Irish rheumatologistThe overwhelmed Irish rheumatologist
Acute Viral arthritisAcute Viral arthritis•Acute
•2 -6 weeks usually
•Occasionally longer
•Usually obvious
•Parvovirus
•Adenonirus
•EB virus
•Mumps
•Rubella
•Enterovirus
•Acute
•2 -6 weeks usually
•Occasionally longer
•Usually obvious
•Parvovirus
•Adenonirus
•EB virus
•Mumps
•Rubella
•Enterovirus
58 yr old woman58 yr old woman
•6 week history6 week history
•Hands, wrists, shoulders, knees Hands, wrists, shoulders, knees and feetand feet
•No relief from NSAID’sNo relief from NSAID’s
Tests in suspected IA
Tests in suspected IA
• FBC, SMAC
• ESR, CRP
•RF, CCP
• ANF
•Uric acid
•Dipstick Urine
• FBC, SMAC
• ESR, CRP
•RF, CCP
• ANF
•Uric acid
•Dipstick Urine
ESR•Good predictor of jt damage if elevated
•Useful for following course of disease
• 35% of patients with Early RA have normal
• Sensitive to delays in getting to lab
•Good predictor of jt damage if elevated
•Useful for following course of disease
• 35% of patients with Early RA have normal
• Sensitive to delays in getting to lab
CRP• 1st thing rheumatologist looks for in referral
letter!
•More sensitive than ESR
•Not affected by lab delay
•Good for following course of disease
•Normal in 1/3 patients at presentation
Rheumatoid factor• Positive in about 60%
• Predictor of joint damage
• Positive lots of other conditions
• Titre not good way of following disease
•Higher titres more specific for RA
Anti CCP antibody•New test for RA
• Available most labs
• About as sensitive as RF (58%)
•More specific (98%) for RA
• Better predictor of joint damage than RF
•Can be +ve where RF -ve
ANF (Antinuclear factor)
ANF (Antinuclear factor)
•Classically seen in SLE
• Sensitive but no specific
•+ve in 30-40% of RA
•Marker for severe disease
•Classically seen in SLE
• Sensitive but no specific
•+ve in 30-40% of RA
•Marker for severe disease
All three tests normal in 15%!All three tests normal in 15%!
•Hb 10.8Hb 10.8
•ESR 90ESR 90
•CRP 70CRP 70
•RF 240RF 240
•CCP >200CCP >200
•ANF + veANF + ve
•Normal SMACNormal SMAC
What about Xrays?
•Early erosions mean troubleEarly erosions mean trouble
•Serial xrays used to monitor Serial xrays used to monitor progressionprogression
•Could wait until rheumatologist Could wait until rheumatologist assessmentassessment
Pincus, et al. Rheum Dis Clin North Am. 1993;19:123–151.
Rheumatoid Arthritis: Typical
Course
Rheumatoid Arthritis: Typical
Course• Damage occurs early in most patients
• 50% show joint space narrowing or erosions in the first 2 years
• By 10 years, 50% of young working patients are disabled
• Death comes early
• Women lose 10 years, men lose 4 years
• Damage occurs early in most patients
• 50% show joint space narrowing or erosions in the first 2 years
• By 10 years, 50% of young working patients are disabled
• Death comes early
• Women lose 10 years, men lose 4 years
Rheumatoid Arthritis
• Key points:
• The sicker they are and the faster they get that way, the worse the future will be
• Early intervention can make a difference
• Essential to establish a treatment plan early in the disease
Severe RATypical Treatment
Severe RATypical Treatment
•Pulse of IM / IA or Oral steroids
•Methotrexate Rapid escalation to 20mg pw
•Methotrexate / Hydroxychloroquine
•Methotrexate / Salazopyrin / HCQ
•Methotrexate + Biologic therapies
•Pulse of IM / IA or Oral steroids
•Methotrexate Rapid escalation to 20mg pw
•Methotrexate / Hydroxychloroquine
•Methotrexate / Salazopyrin / HCQ
•Methotrexate + Biologic therapies
What to do while waiting
Steroids and Early RA
•Use if NSAID’s ineffective / poorly tolerated
•Send blood tests (esp CRP and ESR!) BEFORE starting
•Try and stop steroids before assessment by rheumatologist
The acute hot knee
27 year old rugby player27 year old rugby player6 week history
REACTIVE ARTHRITISREACTIVE ARTHRITISPSORIATIC ARTHRITISPSORIATIC ARTHRITIS
UNDIFFERENTIATED INFLAMMATORY UNDIFFERENTIATED INFLAMMATORY ARTHRITISARTHRITIS
AS?AS?GOUT?GOUT?
REACTIVE ARTHRITISREACTIVE ARTHRITISPSORIATIC ARTHRITISPSORIATIC ARTHRITIS
UNDIFFERENTIATED INFLAMMATORY UNDIFFERENTIATED INFLAMMATORY ARTHRITISARTHRITIS
AS?AS?GOUT?GOUT?
27 year old rugby player6 week Hx. Painful swollen knee. Atraumatic
ESR 60ESR 60CRP 28CRP 28
-VE RF / CCP-VE RF / CCP
ESR 60ESR 60CRP 28CRP 28
-VE RF / CCP-VE RF / CCP
Psoriatic Psoriatic arthritisarthritisPsoriatic Psoriatic arthritisarthritis
Ankylosing Ankylosing spondylitisspondylitisAnkylosing Ankylosing spondylitisspondylitis
Reactive Reactive arthritisarthritisReactive Reactive arthritisarthritis
•Arthritis
•Dactylitis
•Enthesitis
•Sacroiliitis
Seronegative arthritidesSeronegative arthritides
70 year old Diabetic
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3 day knee pain and swelling. apyrexial. Knee warm.
70 year old womanRecurrent knee pain and swelling for months. apyrexial. Knee warmish.
60 year old Woman
60 year old Woman
3 years hand and pain
Early Morning Stiffness
Hands, wrists and feet
Hands look ok
3 years hand and pain
Early Morning Stiffness
Hands, wrists and feet
Hands look ok
Don’t forget the feet
•ESR 28ESR 28
•CRP 17CRP 17
•RF 40RF 40
•CCP -veCCP -ve
•ANF -veANF -ve
•ESR 28ESR 28
•CRP 17CRP 17
•RF 40RF 40
•CCP -veCCP -ve
•ANF -veANF -ve
6/10
Text
Nielen MMJ et al, A+R 2004Nielen MMJ et al, A+R 2004
Immunological events precede clinically manifest disease
48 YEAR OLD PAINSORE HANDS AND FEET
•ESR 9mm/hr
•CRP 6mg/dl (<5)
•RF -ve
•CCP-ve
•ESR 9mm/hr
•CRP 6mg/dl (<5)
•RF -ve
•CCP-ve
• Asymmetrical
• Look for nail changes
•RF / CCP -ve
• ESR / CRP often mildly elevated or normal
Psoriatic arthritis
•4 Months4 Months
•Painful hands and feetPainful hands and feet
•Early morning stiffnessEarly morning stiffness
•No joint swellingNo joint swelling
52 year old lady
Metacarpal Squeeze
Metacarpal Squeeze
Metarsal SqueezeMetarsal Squeeze
ResultsResults
ESR normal
CRP 9mg/dl
Negative CCP
Negative RF
No response to NSAID’s
ESR normal
CRP 9mg/dl
Negative CCP
Negative RF
No response to NSAID’s
2/10
Text
ResultsResults
ESR normal
CRP 9mg/dl
Negative CCP
Negative RF
No response to NSAID’s
ESR normal
CRP 9mg/dl
Negative CCP
Negative RF
No response to NSAID’s
Response to IM methyl-prednisolone in Response to IM methyl-prednisolone in inflammatory hand pain: inflammatory hand pain: Evidence for a targeted clinical, ultrasonographic and
therapeutic approach. Patients with inflammatory hand painPatients with inflammatory hand pain
IM methylprednisolone (MP)IM methylprednisolone (MP)
Response (primary outcome) at 4 weeksResponse (primary outcome) at 4 weeks
Responders who relapsed received repeat IM MP Responders who relapsed received repeat IM MP and HCQ.and HCQ.
Karim Z, Quinn MA, Wakefield RJ, et al Ann Rheum Dis. Karim Z, Quinn MA, Wakefield RJ, et al Ann Rheum Dis. 2007;66(5):690-22007;66(5):690-2
Results Results
•77% no synovitis clinically77% no synovitis clinically
•73% responded to IM MP73% responded to IM MP
•Predictors of responsePredictors of response
- US detected synovitis (p<0.001)- US detected synovitis (p<0.001)
- RF +ve (p=0.04)- RF +ve (p=0.04)
•86% who remained on HCQ 86% who remained on HCQ reported a benefit at 1yr. reported a benefit at 1yr.
Conclusions Conclusions
In inflammatory polyarthralgiaIn inflammatory polyarthralgia
•RFRF
•steroid response may be a sign of steroid response may be a sign of subclinical diseasesubclinical disease
•HCQ may be a valid early treatment HCQ may be a valid early treatment optionoption
RA prevention ?RA prevention ?
Pain all over and no clues
•SLE - don’t forget the ANF
•Fibromyalgia
•Menopausal arthralgia
•Hypothyroidism
•Depression / anxiety
•Malignancy
•Septic arthritis less likely in healthy
•Look for clues outside jt
•In young adults think inflammatory
•In middle age think inflammatory / crystal
•In elderly consider everything
The Hot knee
Inflammatory arthritis
in 7 mins in general practice?
History•Duration symptoms
•Joint swelling
•EMS?
•Preceding infections
•Previous episodes?
•Psoriasis
•Response to NSAID’s
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Examination
INDEX JOINTSINDEX JOINTS METACARPAL SQUEEZEMETACARPAL SQUEEZEMETATARSAL SQUEEZEMETATARSAL SQUEEZE
ENTHESITIS?ENTHESITIS? NAIL CHANGES?NAIL CHANGES? ASPIRATE GOUT AND ASPIRATE GOUT AND INFECTIONINFECTION
TestsTests• FBC, SMAC
• ESR, CRP
•RF, CCP
• ANF
•Uric acid
• (Dipstick Urine)
• FBC, SMAC
• ESR, CRP
•RF, CCP
• ANF
•Uric acid
• (Dipstick Urine)
97% of all public rheumatologistsxt
100% of all in private practice
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