Inflammatory arthritis; a quick run through.
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The document provides information about inflammatory arthritis for general practitioners. It discusses common types of inflammatory arthritis GPs may encounter like rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis. It also summarizes tests that may help diagnose inflammatory arthritis and emphasizes the importance of early intervention to prevent joint damage.
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Inflammatory arthritis; a quick run through.
- 1. QuickTimeª and a H.264 decompressor are needed to see this picture. Rheumatology Toolbox Inflammatory arthritis DR. RONAN KAVANAGH MD MRCP
- 2. 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 3
- 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 2 4
- 5. Inflammatory arthritis and the GP 5
- 6. Picking them out of a crowd graphic
- 8. The overwhelmed Irish rheumatologist 8
- 10. • Acute •Acute usually arthritis 2 -6 weeks Viral • Occasionally longer • Usually obvious • Parvovirus • Adenonirus • EB virus • Mumps • Rubella
- 11. 58 yr old woman • 6 week history • Hands, wrists, shoulders, knees and feet • No relief from NSAID’s
- 12. Tests in suspected IA • FBC, SMAC • ESR, CRP • RF, CCP • ANF • Uric acid • Dipstick Urine
- 13. 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
- 14. 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
- 15. 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
- 16. 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
- 17. ANF (Antinuclear factor) • Classically seen in SLE • Sensitive but no specific • +ve in 30-40% of RA • Marker for severe disease
- 18. All three tests normal in 15%!
- 19. • Hb 10.8 • ESR 90 • CRP 70 • RF 240 • CCP >200 • ANF + ve • Normal SMAC
- 20. What about Xrays? • Early erosions mean trouble • Serial xrays used to monitor progression • Could wait until rheumatologist assessment
- 21. 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.
- 22. 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
- 23. Severe RA Typical Treatment Typical Treatment
- 24. • Pulse of IM / IA or Oral steroids • Methotrexate Rapid escalation to 20mg pw • Methotrexate / Hydroxychloroquine • Methotrexate / Salazopyrin / HCQ • Methotrexate + Biologic therapies
- 25. What to do while waiting
- 26. 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
- 27. The acute hot knee
- 28. 27 year old rugby player 6 week history REACTIVE ARTHRITIS PSORIATIC ARTHRITIS UNDIFFERENTIATED INFLAMMATORYARTHRITIS AS? GOUT?
- 29. ESR 60 CRP 28 -VE RF / CCP 27 year old rugby player 6 week Hx. Painful swollen knee. Atraumatic
- 30. Seronegative arthritides • Arthritis • Dactylitis Psoriatic arthritis Ankylosing spondylitis • Enthesitis • Sacroiliitis Reactive arthritis
- 31. QuickTimeª and a H.264 decompressor are needed to see this picture. 70 year old Diabetic 3 day knee pain and swelling. apyrexial. Knee warm.
- 32. 70 year old woman Recurrent knee pain and swelling for months. apyrexial. Knee warmish.
- 33. 60 year old Woman 3 years hand and pain Early Morning Stiffness Hands, wrists and feet Hands look ok
- 34. Don’t forget the feet
- 35. • ESR 28 • CRP 17 • RF 40 • CCP -ve • ANF -ve
- 36. Text 6/10
- 37. Immunological events precede clinically manifest disease Nielen MMJ et al, A+R 2004
- 38. 48 YEAR OLD PAIN SORE HANDS AND FEET
- 39. • ESR 9mm/hr • CRP 6mg/dl (<5) • RF -ve • CCP-ve
- 40. Psoriatic arthritis • Asymmetrical • Look for nail changes • RF / CCP -ve • ESR / CRP often mildly elevated or normal
- 41. 52 year old lady • 4 Months • Painful hands and feet • Early morning stiffness • No joint swelling
- 43. Metarsal Squeeze
- 44. Results ESR normal CRP 9mg/dl Negative CCP Negative RF No response to NSAID’s
- 45. Text 2/10
- 46. Results ESR normal CRP 9mg/dl Negative CCP Negative RF No response to NSAID’s
- 47. 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
- 48. 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.
- 49. Conclusions In inflammatory polyarthralgia • RF • steroid response may be a sign of subclinical disease • HCQ may be a valid early treatment option RA prevention ?
- 51. Pain all over and no clues • SLE - don’t forget the ANF • Fibromyalgia • Menopausal arthralgia • Hypothyroidism • Depression / anxiety • Malignancy
- 53. 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
- 54. Inflammatory arthritis in 7 mins in general practice? in 7 mins in general practice?
- 55. History • Duration symptoms • Joint swelling • EMS? • Preceding infections • Previous episodes? • Psoriasis • Response to NSAID’s
- 56. 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
- 57. Tests • FBC, SMAC • ESR, CRP • RF, CCP • ANF • Uric acid • (Dipstick Urine)
- 60. 97% of all public rheumatologistsxt
- 61. 100% of all in private practice
- 62. www.isr.ie