Inflammatory arthritis; a quick run through.

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A short presentation aimed at primary care docs walking them through the mechanism and pitfalls in diagnosing inflammatory arthritis. Part of the Rheumatology Toolbox workshop. Stats for an irish population.

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Inflammatory arthritis; a quick run through.

  1. 1. QuickTimeª and a H.264 decompressor are needed to see this picture.Rheumatology ToolboxInflammatory arthritisDR. RONAN KAVANAGH MD MRCP
  2. 2. Inflammatory arthritis?• Rheumatoid arthritis• Psoriatic arthritis• Reactive arthritis• Undifferentiated inflammatory arthritis (UIA)• Ankylosing Spondylitis
  3. 3. 1 IN 5 GP CONSULTATIONS FOR MUSCULOSKELETAL PROBLEMSMcCormick A, Fleming D, Charlton J. Morbidity Statistics from General Practice: Fourth national study 1991–1992. London: HMSO; 1995 3
  4. 4. Galway GP practice1 – 3.5 WTE GP’s, 6000 patients total 6200 1 Personal Communication, Dr. Eamonn O’Shea 2 6 month data x 24
  5. 5. Inflammatory arthritis and the GP5
  6. 6. Picking them out of a crowd graphic
  7. 7. The overwhelmed Irish rheumatologist8
  8. 8. • Acute•Acute usually arthritis 2 -6 weeks Viral• Occasionally longer• Usually obvious• Parvovirus• Adenonirus• EB virus• Mumps• Rubella
  9. 9. 58 yr old woman• 6 week history• Hands, wrists, shoulders, knees and feet• No relief from NSAID’s
  10. 10. Tests in suspected IA• FBC, SMAC• ESR, CRP• RF, CCP• ANF• Uric acid• Dipstick Urine
  11. 11. 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
  12. 12. 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
  13. 13. 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
  14. 14. 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
  15. 15. ANF (Antinuclear factor)• Classically seen in SLE• Sensitive but no specific• +ve in 30-40% of RA• Marker for severe disease
  16. 16. All three tests normal in 15%!
  17. 17. • Hb 10.8• ESR 90• CRP 70• RF 240• CCP >200• ANF + ve• Normal SMAC
  18. 18. What about Xrays?• Early erosions mean trouble• Serial xrays used to monitor progression• Could wait until rheumatologist assessment
  19. 19. 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 Pincus, et al. Rheum Dis Clin North Am. 1993;19:123–151.
  20. 20. 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
  21. 21. Severe RATypical TreatmentTypical Treatment
  22. 22. • Pulse of IM / IA or Oral steroids• Methotrexate Rapid escalation to 20mg pw• Methotrexate / Hydroxychloroquine• Methotrexate / Salazopyrin / HCQ• Methotrexate + Biologic therapies
  23. 23. What to do while waiting
  24. 24. 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
  25. 25. The acute hot knee
  26. 26. 27 year old rugby player6 week history REACTIVE ARTHRITIS PSORIATIC ARTHRITIS UNDIFFERENTIATED INFLAMMATORYARTHRITIS AS? GOUT?
  27. 27. ESR 60 CRP 28 -VE RF / CCP27 year old rugby player6 week Hx. Painful swollen knee. Atraumatic
  28. 28. Seronegative arthritides• Arthritis• Dactylitis Psoriatic arthritis Ankylosing spondylitis• Enthesitis• Sacroiliitis Reactive arthritis
  29. 29. QuickTimeª and a H.264 decompressor are needed to see this picture.70 year old Diabetic3 day knee pain and swelling. apyrexial. Knee warm.
  30. 30. 70 year old womanRecurrent knee pain and swelling for months. apyrexial. Knee warmish.
  31. 31. 60 year old Woman 3 years hand and pain Early Morning Stiffness Hands, wrists and feet Hands look ok
  32. 32. Don’t forget the feet
  33. 33. • ESR 28• CRP 17• RF 40• CCP -ve• ANF -ve
  34. 34. Text 6/10
  35. 35. Immunological events precede clinically manifest diseaseNielen MMJ et al, A+R 2004
  36. 36. 48 YEAR OLD PAINSORE HANDS AND FEET
  37. 37. • ESR 9mm/hr• CRP 6mg/dl (<5)• RF -ve• CCP-ve
  38. 38. Psoriatic arthritis• Asymmetrical• Look for nail changes• RF / CCP -ve• ESR / CRP often mildly elevated or normal
  39. 39. 52 year old lady• 4 Months• Painful hands and feet• Early morning stiffness• No joint swelling
  40. 40. Metacarpal Squeeze
  41. 41. Metarsal Squeeze
  42. 42. Results ESR normal CRP 9mg/dl Negative CCP Negative RFNo response to NSAID’s
  43. 43. Text 2/10
  44. 44. Results ESR normal CRP 9mg/dl Negative CCP Negative RFNo response to NSAID’s
  45. 45. Response to IM methyl-prednisolone in inflammatory hand pain: Evidence for a targeted clinical, ultrasonographic and therapeutic approach. Patients with inflammatory hand pain IM methylprednisolone (MP) Response (primary outcome) at 4 weeks Responders who relapsed received repeat IM MP and HCQ.Karim Z, Quinn MA, Wakefield RJ, et al Ann Rheum Dis. 2007;66(5):690-2
  46. 46. Results• 77% no synovitis clinically• 73% responded to IM MP• Predictors of response - US detected synovitis (p<0.001) - RF +ve (p=0.04)• 86% who remained on HCQ reported a benefit at 1yr.
  47. 47. ConclusionsIn inflammatory polyarthralgia• RF• steroid response may be a sign of subclinical disease• HCQ may be a valid early treatment optionRA prevention ?
  48. 48. Pain all over and no clues• SLE - don’t forget the ANF• Fibromyalgia• Menopausal arthralgia• Hypothyroidism• Depression / anxiety• Malignancy
  49. 49. The Hot knee• 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
  50. 50. Inflammatory arthritis in 7 mins in general practice? in 7 mins in general practice?
  51. 51. History• Duration symptoms• Joint swelling• EMS?• Preceding infections• Previous episodes?• Psoriasis• Response to NSAID’s
  52. 52. INDEX JOINTS METACARPAL SQUEEZE METATARSAL SQUEEZE ENTHESITIS? NAIL CHANGES? ASPIRATE GOUT AND INFECTION INFECTIO QuickTimeª and a H.264 decompressor are needed to see this picture.Examination
  53. 53. Tests• FBC, SMAC• ESR, CRP• RF, CCP• ANF• Uric acid• (Dipstick Urine)
  54. 54. 97% of all public rheumatologistsxt
  55. 55. 100% of all in private practice
  56. 56. www.isr.ie

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