A quick guide for primary care physician dealing with arthritis. It consists of a brief description of OA, RA, SpA, Gout, Fibromyalgia

1. Rachmat Gunadi WachjudiRachmat Gunadi Wachjudi
 Lahir di Garut, 16-1-1955Lahir di Garut, 16-1-1955
PendidikanPendidikan
 SD-SMA : GarutSD-SMA : Garut
 Dokter umum: FK UNSRIDokter umum: FK UNSRI / RSMH/ RSMH PalembangPalembang
 Internist: FK UNPADInternist: FK UNPAD / RSHS/ RSHS BandungBandung
 RheumatologyRheumatology FellowshipFellowship :: Royal Perth HospitalRoyal Perth Hospital
 KonsultanKonsultan ReumatologiReumatologi : FK UI: FK UI / RSCM/ RSCM JakartaJakarta
PekerjaanPekerjaan
 Divisi Reumatologi Departemen / SMF Ilmu Penyakit Dalam RS DrDivisi Reumatologi Departemen / SMF Ilmu Penyakit Dalam RS Dr
Hasan SadikiHasan Sadikinn
OrganisasiOrganisasi
 IDI, PAPDI,IDI, PAPDI, IRA,IRA, PEROSI, PERALMUNI,PEROSI, PERALMUNI, ISPISP, PESLI, PESLI

2. Clinical diagnosis of arthritisClinical diagnosis of arthritis
and managementand management
Rachmat Gunadi WachjudiRachmat Gunadi Wachjudi

3. Rheumatic ailments
1%
1%
6%
4%
4%
69%
3%2%
10%
Osteoarthritis
SLE
Rheumatoid Artritis
Gout
Spondyloarthritis
Systemic Sclerosis
Osteoporosis
Soft Tissue Rheumatism
other type
Pre JKN

4. Rheumatic ailments
2%
5%
3%
27%
3%
10%
2%2%
46%
Osteoarthritis
SLE
Rheumatoid Artritis
Gout
Spondyloarthritis
Systemic Sclerosis
UCTD
Soft Tissue Rheumatism
other type
Post JKN

5. KEY QUESTIONSKEY QUESTIONS
FOR RHEUMATIC PAINFOR RHEUMATIC PAIN
Do you have pain or stiffness in your joints orDo you have pain or stiffness in your joints or
spine?spine?
Do you have difficulties with walking, climbingDo you have difficulties with walking, climbing
stairs or getting up from bed?stairs or getting up from bed?
Do you have difficulties with dressing?Do you have difficulties with dressing?
55

6. PRACTICAL DECISION-MAKINGPRACTICAL DECISION-MAKING IN THE RHEUMATIC DISEASESIN THE RHEUMATIC DISEASES
History and P.E.History and P.E.
Musculoskeletal pain
Artikular Non-articular
Articular Non-articular
Characteristic Diffuse Focal
W/ movement Active-passive Active
Motion Multi-planar Uni-planar
Swelling ++ +
Trauma
Fibromyalgia
Bursitis
Tendinitis
Polymyalgia rheumatica
6 weeks
Acute ChronicSeptic
Gout
Pseudogout
Reactive
Early phase chronic
arthritis
Inflammatory Non-inflammatory
Inflammatory Non-
inflammatory
Pain at rest ++ -
Morning stiffness > 30 mins < 30 mins
Systemic
symptoms
+ -
Inflammatory
marker
Increase Normal
DIP, CMC1, hip, knee
YES 
Osteoarthritis
NO 
Osteonecrosis
Charcot
arthritis
3 joints
< 3
Indolent infection
Psoriatic arthritis
Reactive arthritis
Pauciarticular JA
> 3
ASSYMETRIC
Psoriatic arthritis
Reactive arthritis
SYMMETRIC
PIP, MCP, MTP  Rheumatoid
arthritis
SLE
Scleroderma
Polymyositis
Harrison’s Principles of Internal Medicine
17th
Ed

7. Osteoarthritis-BackgroundOsteoarthritis-Background
Very commonVery common
-2-2ndnd
leading cause for disabilityleading cause for disability
-In patients 60 and older: affects 17% of-In patients 60 and older: affects 17% of
men and 30% of womenmen and 30% of women
-Estimated that 59.4 million patients will-Estimated that 59.4 million patients will
have OA by the year 2020have OA by the year 2020
EtiologyEtiology
-primary idiopathic-primary idiopathic
-secondary-secondary

8. OSTEOARTRITISOSTEOARTRITIS
88
APS. Guideline for the Management of Pain in Osteoarthritis, Rheumatoid Arthritis, and Juvenile Chronic Arthritis. 2nd ed.
Glenview, Ill: American Pain Society; 2002.
• Osteoarthritis principally affects weight-
bearing joints in the knees and hips
• Also affects the feet, ankles, distal
interphalangeal joints, proximal
interphalangeal joints, first
carpometacarpal joints, cervical spine,
and lower spine

9. 99

11. OA ManagementOA Management

12. Inflammatory ArthritisInflammatory Arthritis
Rheumatoid arthritisRheumatoid arthritis
SpondyloarthropathiesSpondyloarthropathies
-Undifferentiated-Undifferentiated
-Ankylosing spondylitis-Ankylosing spondylitis
-Psoriatic arthritis-Psoriatic arthritis
-Reactive arthritis (formerly Reiter’s syndrome)-Reactive arthritis (formerly Reiter’s syndrome)
-Enteropathic arthritis-Enteropathic arthritis
SLE, Sjogrens, Scleroderma, PolymyalgiaSLE, Sjogrens, Scleroderma, Polymyalgia
rheumatica, Vasculitis, Infectious (bacterial,rheumatica, Vasculitis, Infectious (bacterial,
viral, other), Undifferentiated connective tissueviral, other), Undifferentiated connective tissue
diseasedisease

13. Latinis, K., et al
The Washington
Manual
Rheumatology
Subspecialty
Consult., LWW,
2003.

14. What Joints are affected?What Joints are affected?

15. How are the Joints AffectedHow are the Joints Affected
Joints are usuallyJoints are usually
– SwollenSwollen
– WarmWarm
–NOT REDNOT RED (might be a bit purple)(might be a bit purple)

16. NO REDNESS!NO REDNESS!

17. Disability in Early RADisability in Early RA
InflammationInflammation
– SwollenSwollen
– StiffStiff
– SoreSore
– WarmWarm
FatigueFatigue
PotentiallyPotentially
ReversibleReversible

18. Morning StiffnessMorning Stiffness
Prominent FeatureProminent Feature
Greater than 60 minutes of morningGreater than 60 minutes of morning
stiffness (Patients minimize)stiffness (Patients minimize)
Some patients have difficulty answeringSome patients have difficulty answering
the question because they are stiff all daythe question because they are stiff all day
““How long does it take until you are theHow long does it take until you are the
best you are going to be?”best you are going to be?”

19. Periarticular OsteopeniaPeriarticular Osteopenia
Joint Space NarrowingJoint Space Narrowing
ErosionsErosions
Mal-AlignmentMal-Alignment

20. Rheumatoid Arthritis:Rheumatoid Arthritis:
Drug Treatment OptionsDrug Treatment Options
• NSAIDsNSAIDs
• Symptomatic relief, improved functionSymptomatic relief, improved function
• No change in disease progressionNo change in disease progression
• Low-dose prednisone (Low-dose prednisone (≤≤10 mg qd)10 mg qd)
• May substitute for NSAIDMay substitute for NSAID
• Used as bridge therapyUsed as bridge therapy
• If used long term, consider prophylacticIf used long term, consider prophylactic
treatment for osteoporosistreatment for osteoporosis
• Intra-articular steroidsIntra-articular steroids
• Useful for flaresUseful for flaresPaget. Primer on Rheum Dis. 11th edition. 1997:168.

21. Rheumatoid Arthritis:Rheumatoid Arthritis:
Treatment OptionsTreatment Options
• Disease modifying drugs (DMARDs)Disease modifying drugs (DMARDs)
• MinocyclineMinocycline
Modest effect, may work best earlyModest effect, may work best early
• Sulfasalazine, hydroxychloroquineSulfasalazine, hydroxychloroquine
Moderate effect, low costModerate effect, low cost
• Intramuscular goldIntramuscular gold
Slow onset, decreases progression, rare remissionSlow onset, decreases progression, rare remission
Requires close monitoringRequires close monitoring
Alarcon. Rheum Dis Clin North Am. 1998;24:489–499.
Paget. Primer on Rheum Dis. 11th edition. 1997:168.

22. Paget. Primer on Rheum Dis. 11th edition. 1997:168.
Rheumatoid Arthritis:Rheumatoid Arthritis:
Treatment Options (cont’d)Treatment Options (cont’d)
• Immunosuppressive drugsImmunosuppressive drugs
• MethotrexateMethotrexate
Most effective single DMARDMost effective single DMARD
Good benefit-to-risk ratioGood benefit-to-risk ratio
• AzathioprineAzathioprine
Slow onset, reasonably effectiveSlow onset, reasonably effective
• CyclophosphamideCyclophosphamide
Effective for vasculitis, less so for arthritisEffective for vasculitis, less so for arthritis
• CyclosporineCyclosporine
Superior to placebo, renal toxicitySuperior to placebo, renal toxicity

23. 2323
Ankylosing Spondylitis

24. Spondyloarthritis, Psoriasis andSpondyloarthritis, Psoriasis and
PsAPsASpondyloarthritis (SpA)Spondyloarthritis (SpA)
The prevalence of SpA is comparable to that of RA (0.5–1.9%)The prevalence of SpA is comparable to that of RA (0.5–1.9%)1,21,2
Psoriasis (Pso)Psoriasis (Pso)
Psoriasis affects 2% of populationPsoriasis affects 2% of population
7% to 42% of patients with Pso will develop arthritis7% to 42% of patients with Pso will develop arthritis33
Psoriatic ArthritisPsoriatic Arthritis
A chronic and inflammatory arthritis in association with skin psoriasisA chronic and inflammatory arthritis in association with skin psoriasis44
Usually rheumatoid factor (RF) negative and ACPA negativeUsually rheumatoid factor (RF) negative and ACPA negative55
– Distinct from RADistinct from RA
Psoriatic Arthritis is classified as one of the subtypes of spondyloarthropathiesPsoriatic Arthritis is classified as one of the subtypes of spondyloarthropathies
– Characterized by synovitis, enthesitis, dactylitis, spondylitis, skin and nailCharacterized by synovitis, enthesitis, dactylitis, spondylitis, skin and nail
psoriasispsoriasis44
1
Rudwaleit M et al. Ann Rheum Dis 2004;63:535-543; 2
Braun J et al. Scand J Rheumatol 2005;34:178-90;
3
Fitzgerald “Psoriatic Arthritis” in Kelley’s Textbook of Rheumatology, 2009;
4
Mease et al. Ann Rheum Dis 2011;70(Suppl 1):i77–i84. doi:10.1136/ard.2010.140582;
5
Pasquetti et al. Rheumatology 2009;48:315–325
Juvenile SpA
Reactive
arthritis
Arthritis
associated with
IBD
PsA
Undifferentiated
SpA (uSpA)
Ankylosing
spondylitis (AS)
RA: Rheumatoid arthritis

25. Psoriatic ArthritisPsoriatic Arthritis
ACR Slide Collection on the Rheumatic Diseases; 3rd
edition. 1994.
Data on file, Centocor, Inc.

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

27. Systemic lupus erythematosus classification criteria
(SOAP BRAIN MD)
1. SSerositis:
(a) pleuritis, or
(b) pericarditis
2. OOral ulcers
3. AArthritis
4. PPhotosensitivity
10. MMalar rash
11. DDiscoid rash
5. BBlood/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. RRenal disorder:
(a) proteinuria > 0.5 gm/24 h or
3+ dipstick or
(b) cellular casts
7. AAntinuclear antibody (positive ANA)
8. IImmunologic disorders:
(a) raised anti-native DNA
antibody binding or
(b) anti-Sm antibody or
(c) positive anti-phospholipid
antibody work-up
9. NNeurological disorder:
(a) seizures or
(b) psychosis
". ..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."

28. 53 yo BF with severe generalized weakness,
weight loss, and chronic psychosis
Alopecia
Malar rash
Arthritis
Psychosis

29. Treatment of SLETreatment of SLE
Arthritis, arthralgias, myalgias:Arthritis, arthralgias, myalgias:
NSAIDS, anti-malarials (eg.NSAIDS, anti-malarials (eg.
Plaquenil), Steroids-Plaquenil), Steroids-
injections, oral methotrexateinjections, oral methotrexate
Photosensitivity, dermatitisPhotosensitivity, dermatitis
avoid Sun exposureavoid Sun exposure
topical steroidstopical steroids
PlaquenilPlaquenil
Weight loss and fatigueWeight loss and fatigue
steroidssteroids
Abortion, fetal lossAbortion, fetal loss
ASAASA
immunosuppressionimmunosuppression
ThrombosisThrombosis
anti-coagulantsanti-coagulants
GlomerulonephritisGlomerulonephritis
steroidssteroids
pulse cytotoxicspulse cytotoxics
mycophenylate mofetilmycophenylate mofetil
CNS diseaseCNS disease
anti-coagulants for thrombosisanti-coagulants for thrombosis
steroids and cytotoxics forsteroids and cytotoxics for
vasculitisvasculitis
Infarction (secondary to vasculitis)Infarction (secondary to vasculitis)
steroidssteroids
cytotoxicscytotoxics
prostacyclinprostacyclin
CytopeniasCytopenias
steroidssteroids
IVIG-short term forIVIG-short term for
thrombocytopeniathrombocytopenia
danazoldanazol
cytotoxics-if bone marrow statuscytotoxics-if bone marrow status
is knownis known

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

31. Fibromyalgia-DiagnosisFibromyalgia-Diagnosis

32. 1
2
3
4
5
6
7
8
9

34. Fibromyalgia-TreatmentFibromyalgia-Treatment

35. GoutGout

36. Criteria for clinical diagnosisCriteria for clinical diagnosis
American Rheumatism Association sub-committe on classification criteria for gout 1977American Rheumatism Association sub-committe on classification criteria for gout 1977
presence of characteristic urate crystals in the joint fluidpresence of characteristic urate crystals in the joint fluid
Tophus proved to contain urate crystals by negative polarized lightTophus proved to contain urate crystals by negative polarized light
microscopic studymicroscopic study
If none of above, diagnosis is 6/12 clinical, radiographic, andIf none of above, diagnosis is 6/12 clinical, radiographic, and
laboratory criteria include:laboratory criteria include:
1. more than one attack of acute arthritis1. more than one attack of acute arthritis
2. Maximum inflammation within 24 hours2. Maximum inflammation within 24 hours
3. Attack of monoaricular arthritis3. Attack of monoaricular arthritis
4. Joint redness observed4. Joint redness observed
5. first MTP joint painful or swollen5. first MTP joint painful or swollen
6. Unilateral attack involving first MTP6. Unilateral attack involving first MTP
7. Unilateral attack involving tarsal joint7. Unilateral attack involving tarsal joint
8. Suspected tophus8. Suspected tophus
9. Hyperuricemia9. Hyperuricemia
10. Asymmetric swelling within a joint ( roentgenogram )10. Asymmetric swelling within a joint ( roentgenogram )
11. Subcortical bone cysts without erosions ( roentgenogram )11. Subcortical bone cysts without erosions ( roentgenogram )
12. Negative synovial culture during attack of joint inflammation12. Negative synovial culture during attack of joint inflammation

37. 3737

38. Long-term treatmentLong-term treatment
Indication:Indication:
1. Recurrent attacks1. Recurrent attacks
2. Evidence of tophi or chronic gouty arthritis2. Evidence of tophi or chronic gouty arthritis
3. Associated renal disease3. Associated renal disease
4. Patient is young with high serum UA and FH of4. Patient is young with high serum UA and FH of
renal or heart diseaserenal or heart disease
5. Normal serum UA cannot be achieved by life-style5. Normal serum UA cannot be achieved by life-style
modificationsmodifications
Medication:Medication:
1. Allopurinol1. Allopurinol
2. Uricosuric agents: probenecid or sulfinpyrazone2. Uricosuric agents: probenecid or sulfinpyrazone
3. benzbromarone3. benzbromarone

39. Indications for Antihyperuricemic Therapy
in Gout
•Frequent and disabling attacks of acute gouty arthritis
•Clinical or radiographic signs of chronic gouty joint disease
•The presence of tophaceous deposits in soft tissues or
subchondral bone
•Gout with renal insufficiency
•Recurrent nephrolithiasis
•Serum urate levels persistently in excess of 13 mg/dL in men
or 10 mg/dL in women
•Urinary uric acid excretion exceeding 1100 mg/day
•Impending cytotoxic chemotherapy or radiotherapy for
lymphoma or leukemia

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

41. Hatur nuhunHatur nuhun