DR. RONAN KAVANAGH MD MRCP

Rheumatology ToolboxInflammatory arthritis

QuickTime™ and aH.264 decompressor

are needed to see this picture.

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

44

Galway GP practice1 – 3.5 WTE GP’s, 6000 patients

1 Personal Communication, Dr. Eamonn O’Shea2 6 month data x 2

total 6200

55

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

QuickTime™ and aH.264 decompressor

are needed to see this picture.

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

QuickTime™ and aH.264 decompressor

are needed to see this picture.

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

www.isr.iewww.isr.ie