First Presentation of Joint Pain - Acurity · First Presentation of Joint Pain ... • ReA • CTD...
Transcript of First Presentation of Joint Pain - Acurity · First Presentation of Joint Pain ... • ReA • CTD...
Andrew Harrison
• Rheumatologist • Wellington Regional Rheumatology Unit, HVDHB • Bowen Centre, Crofton Downs, Wellington
• Assoc. Prof. in Medicine, University of Otago Wellington • Clinical Leader, Research, CCDHB
First Presentation of Joint Pain
• Advisory board member for AbbVie NZ and Pfizer NZ • Research grants from Roche and Abbvie • Sponsorship to attend conferences from AbbVie, Roche and
Pfizer • Consultancy work for AbbVie to develop educational materials
for GPs and rheumatologists
Disclosures
• No qualifications or experience in primary care
Disclaimer
• To provide a structured approach to the assessment of new-onset arthritis
• To review the important data needed to inform diagnosis and prognosis
• To understand the influence of different patterns of clinical and laboratory features on diagnosis and prognosis
• To recognise the cases that require urgent referral and/or treatment to optimise long-term outcome
Learning Objectives
Why Bother?
Why Bother?
Rationale for Early Immunomodulatory Treatment
• In RA, early use of corticoteroids improves long-term outcome • DMARDs
• reduce symptoms • reduce erosive progression • reduce need for NSAIDs and long-term corticosteroids
• Early treatment associated with drug-free remission
A Diagnostic Algorithm
Joint symptoms ? inflammatory ? non-inflammatory
• Pain helped by activity worse with activity
• Stiffness prolonged short-duration
• Restricted movement helped by activity fixed
• Swelling soft tissue hard tissue
A Diagnostic Algorithm
? mechanical ? degenerative ? neuropathic Consider: • OA • soft tissue
syndromes • FMS
Joint symptoms ? inflammatory ? non-inflammatory
• Pain helped by activity worse with activity
• Stiffness prolonged short-duration
• Restricted movement helped by activity fixed
• Swelling soft tissue hard tissue
A Diagnostic Algorithm
? mechanical ? degenerative ? neuropathic Consider: • OA • soft tissue
syndromes • FMS
Joint symptoms ? inflammatory ? non-inflammatory
• Pain helped by activity worse with activity
• Stiffness prolonged short-duration
• Restricted movement helped by activity fixed
• Swelling soft tissue hard tissue
Small joint / distal ? objective synovitis • swelling/tenderness • MTP squeeze Consider: • RA • PsA • ReA • CTD • viral • OA • haemochromatosis • vasculitis: HSP / GPA
A Diagnostic Algorithm
? mechanical ? degenerative ? neuropathic Consider: • OA • soft tissue
syndromes • FMS
Joint symptoms ? inflammatory ? non-inflammatory
• Pain helped by activity worse with activity
• Stiffness prolonged short-duration
• Restricted movement helped by activity fixed
• Swelling soft tissue hard tissue
Small joint / distal ? objective synovitis • swelling/tenderness • MTP squeeze Consider: • RA • PsA • ReA • CTD • viral • OA • haemochromatosis • vasculitis: HSP / GPA
Large joint / proximal
Limb girdle Consider • PMR • OA shoulders/hips • soft tissue syndromes • statin myopathy • RA
A Diagnostic Algorithm
? mechanical ? degenerative ? neuropathic Consider: • OA • soft tissue
syndromes • FMS
Joint symptoms ? inflammatory ? non-inflammatory
• Pain helped by activity worse with activity
• Stiffness prolonged short-duration
• Restricted movement helped by activity fixed
• Swelling soft tissue hard tissue
Small joint / distal ? objective synovitis • swelling/tenderness • MTP squeeze Consider: • RA • PsA • ReA • CTD • viral • OA • haemochromatosis • vasculitis: HSP / GPA
Large joint / proximal
Limb girdle Consider • PMR • OA shoulders/hips • soft tissue syndromes • statin myopathy • RA
Knee/ankle Consider: •SpA – PsA / ReA •OA knee/ankle •sarcoidosis •polyarticular gout •pseudogout •RA •undifferentiated
A Diagnostic Algorithm
? mechanical ? degenerative ? neuropathic Consider: • OA • soft tissue
syndromes • FMS
Joint symptoms ? inflammatory ? non-inflammatory
• Pain helped by activity worse with activity
• Stiffness prolonged short-duration
• Restricted movement helped by activity fixed
• Swelling soft tissue hard tissue
Small joint / distal ? objective synovitis • swelling/tenderness • MTP squeeze Consider: • RA • PsA • ReA • CTD • viral • OA • haemochromatosis • vasculitis: HSP / GPA
Large joint / proximal Axial ? Inflammatory back pain ? SI / heel / costochondral Consider: • ankylosing spondylitis • psoriatic SpA • enteropathic SpA • Reactive SpA • degenerative spinal
disease • non-specific back pain
Limb girdle Consider • PMR • OA shoulders/hips • soft tissue syndromes • statin myopathy • RA
Knee/ankle Consider: •SpA – PsA / ReA •OA knee/ankle •sarcoidosis •polyarticular gout •pseudogout •RA •undifferentiated
A Diagnostic Algorithm
? mechanical ? degenerative ? neuropathic Consider: • OA • soft tissue
syndromes • FMS
Joint symptoms ? inflammatory ? non-inflammatory
• Pain helped by activity worse with activity
• Stiffness prolonged short-duration
• Restricted movement helped by activity fixed
• Swelling soft tissue hard tissue
Small joint / distal ? objective synovitis • swelling/tenderness • MTP squeeze Consider: • RA • PsA • ReA • CTD • viral • OA • haemochromatosis • vasculitis: HSP / GPA
Large joint / proximal Axial ? Inflammatory back pain ? SI / heel / costochondral Consider: • ankylosing spondylitis • psoriatic SpA • enteropathic SpA • Reactive SpA • degenerative spinal
disease • non-specific back pain
Limb girdle Consider • PMR • OA shoulders/hips • soft tissue syndromes • statin myopathy • RA
Knee/ankle Consider: •SpA – PsA / ReA •OA knee/ankle •sarcoidosis •polyarticular gout •pseudogout •RA •undifferentiated
Effective Use of Investigations
Effective Use of Investigations
Effective Use of Investigations
Effective Use of Investigations
Effective Use of Investigations
Effective Use of Investigations
Effective Use of Investigations
A Diagnostic Algorithm
? mechanical ? degenerative ? neuropathic Consider: • OA • soft tissue
syndromes • FMS
Joint symptoms ? inflammatory ? non-inflammatory
• Pain helped by activity worse with activity
• Stiffness prolonged short-duration
• Restricted movement helped by activity fixed
• Swelling soft tissue hard tissue
Small joint / distal ? objective synovitis • swelling/tenderness • MTP squeeze Consider: • RA • PsA • ReA • CTD • viral • OA • haemochromatosis • vasculitis: HSP / GPA
Large joint / proximal Axial ? Inflammatory back pain ? SI / heel / costochondral Consider: • ankylosing spondylitis • psoriatic SpA • enteropathic SpA • Reactive SpA • degenerative spinal
disease • non-specific back pain
Limb girdle Consider • PMR • OA shoulders/hips • soft tissue syndromes • statin myopathy • RA
Knee/ankle Consider: •SpA – PsA / ReA •OA knee/ankle •sarcoidosis •polyarticular gout •pseudogout •RA •undifferentiated
Effective Use of Investigations
Effective Use of Investigations
Effective Use of Investigations
Effective Use of Investigations
Effective Use of Investigations
Effective Use of Investigations
A Diagnostic Algorithm
? mechanical ? degenerative ? neuropathic Consider: • OA • soft tissue
syndromes • FMS
Joint symptoms ? inflammatory ? non-inflammatory
• Pain helped by activity worse with activity
• Stiffness prolonged short-duration
• Restricted movement helped by activity fixed
• Swelling soft tissue hard tissue
Small joint / distal ? objective synovitis • swelling/tenderness • MTP squeeze Consider: • RA • PsA • ReA • CTD • viral • OA • haemochromatosis • vasculitis: HSP / GPA
Large joint / proximal Axial ? Inflammatory back pain ? SI / heel / costochondral Consider: • ankylosing spondylitis • psoriatic SpA • enteropathic SpA • Reactive SpA • degenerative spinal
disease • non-specific back pain
Limb girdle Consider • PMR • OA shoulders/hips • soft tissue syndromes • statin myopathy • RA
Knee/ankle Consider: •SpA – PsA / ReA •OA knee/ankle •sarcoidosis •polyarticular gout •pseudogout •RA •undifferentiated
Effective Use of Investigations
Effective Use of Investigations
Effective Use of Investigations
Effective Use of Investigations
Effective Use of Investigations
Effective Use of Investigations
Effective Use of Investigations
A Diagnostic Algorithm
? mechanical ? degenerative ? neuropathic Consider: • OA • soft tissue
syndromes • FMS
Joint symptoms ? inflammatory ? non-inflammatory
• Pain helped by activity worse with activity
• Stiffness prolonged short-duration
• Restricted movement helped by activity fixed
• Swelling soft tissue hard tissue
Small joint / distal ? objective synovitis • swelling/tenderness • MTP squeeze Consider: • RA • PsA • ReA • CTD • viral • OA • haemochromatosis • vasculitis: HSP / GPA
Large joint / proximal Axial ? Inflammatory back pain ? SI / heel / costochondral Consider: • ankylosing spondylitis • psoriatic SpA • enteropathic SpA • Reactive SpA • degenerative spinal
disease • non-specific back pain
Limb girdle Consider • PMR • OA shoulders/hips • soft tissue syndromes • statin myopathy • RA
Knee/ankle Consider: •SpA – PsA / ReA •OA knee/ankle •sarcoidosis •polyarticular gout •pseudogout •RA •undifferentiated
Effective Use of Investigations
Effective Use of Investigations
Effective Use of Investigations
Effective Use of Investigations
Effective Use of Investigations - Summary
• Base the choice of tests on the differential diagnosis • Different patterns of presentation require different tests • Avoid requesting irrelevant tests
Determining Urgency
Rationale for early immunomodulatory treatment • In RA, early use of corticoteroids improves long-term outcome • DMARDs
• reduce symptoms • reduce erosive progression • reduce need for NSAIDs and long-term corticosteroids
• Early treatment associated with drug-free remission
Urgency of treatment or referral determined by • prognostic indicators • value of early intervention • potential consequences of delaying treatment • current impact on patient
A Diagnostic Algorithm
? mechanical ? degenerative ? neuropathic Consider: • OA • soft tissue
syndromes • FMS
Joint symptoms ? inflammatory ? non-inflammatory
• Pain helped by activity worse with activity
• Stiffness prolonged short-duration
• Restricted movement helped by activity fixed
• Swelling soft tissue hard tissue
Small joint / distal ? objective synovitis • swelling/tenderness • MTP squeeze Consider: • RA • PsA • ReA • CTD • viral • OA • haemochromatosis • vasculitis: HSP / GPA
Large joint / proximal Axial ? Inflammatory back pain ? SI / heel / costochondral Consider: • ankylosing spondylitis • psoriatic SpA • enteropathic SpA • Reactive SpA • degenerative spinal
disease • non-specific back pain
Limb girdle Consider • PMR • OA shoulders/hips • soft tissue syndromes • statin myopathy • RA
Knee/ankle Consider: •SpA – PsA / ReA •OA knee/ankle •sarcoidosis •polyarticular gout •pseudogout •RA •undifferentiated
Determining Urgency
Small joint / distal inflammatory symptoms poor functional status objective synovitis MCP/MTP squeeze test extra-articular features (including systemic) acute phase response Rheumatoid factor and/or anti-CCP other lab features (e.g. ANA/ENA/dsDNA, ANCA/MPO/PR3)
A Diagnostic Algorithm
? mechanical ? degenerative ? neuropathic Consider: • OA • soft tissue
syndromes • FMS
Joint symptoms ? inflammatory ? non-inflammatory
• Pain helped by activity worse with activity
• Stiffness prolonged short-duration
• Restricted movement helped by activity fixed
• Swelling soft tissue hard tissue
Small joint / distal ? objective synovitis • swelling/tenderness • MTP squeeze Consider: • RA • PsA • ReA • CTD • viral • OA • haemochromatosis • vasculitis: HSP / GPA
Large joint / proximal Axial ? Inflammatory back pain ? SI / heel / costochondral Consider: • ankylosing spondylitis • psoriatic SpA • enteropathic SpA • Reactive SpA • degenerative spinal
disease • non-specific back pain
Limb girdle Consider • PMR • OA shoulders/hips • soft tissue syndromes • statin myopathy • RA
Knee/ankle Consider: •SpA – PsA / ReA •OA knee/ankle •sarcoidosis •polyarticular gout •pseudogout •RA •undifferentiated
Determining Urgency
Large joint / proximal – limb girdle inflammatory symptoms poor functional status extra-articular features (including systemic) GCA symptoms – visual, jaw claudication acute phase response
A Diagnostic Algorithm
? mechanical ? degenerative ? neuropathic Consider: • OA • soft tissue
syndromes • FMS
Joint symptoms ? inflammatory ? non-inflammatory
• Pain helped by activity worse with activity
• Stiffness prolonged short-duration
• Restricted movement helped by activity fixed
• Swelling soft tissue hard tissue
Small joint / distal ? objective synovitis • swelling/tenderness • MTP squeeze Consider: • RA • PsA • ReA • CTD • viral • OA • haemochromatosis • vasculitis: HSP / GPA
Large joint / proximal Axial ? Inflammatory back pain ? SI / heel / costochondral Consider: • ankylosing spondylitis • psoriatic SpA • enteropathic SpA • Reactive SpA • degenerative spinal
disease • non-specific back pain
Limb girdle Consider • PMR • OA shoulders/hips • soft tissue syndromes • statin myopathy • RA
Knee/ankle Consider: •SpA – PsA / ReA •OA knee/ankle •sarcoidosis •polyarticular gout •pseudogout •RA •undifferentiated
Determining Urgency
Large joint / proximal – knee and ankle inflammatory symptoms poor functional status extra-articular features (including systemic) acute phase response (less important) need for arthrocentesis
A Diagnostic Algorithm
? mechanical ? degenerative ? neuropathic Consider: • OA • soft tissue
syndromes • FMS
Joint symptoms ? inflammatory ? non-inflammatory
• Pain helped by activity worse with activity
• Stiffness prolonged short-duration
• Restricted movement helped by activity fixed
• Swelling soft tissue hard tissue
Small joint / distal ? objective synovitis • swelling/tenderness • MTP squeeze Consider: • RA • PsA • ReA • CTD • viral • OA • haemochromatosis • vasculitis: HSP / GPA
Large joint / proximal Axial ? Inflammatory back pain ? SI / heel / costochondral Consider: • ankylosing spondylitis • psoriatic SpA • enteropathic SpA • Reactive SpA • degenerative spinal
disease • non-specific back pain
Limb girdle Consider • PMR • OA shoulders/hips • soft tissue syndromes • statin myopathy • RA
Knee/ankle Consider: •SpA – PsA / ReA •OA knee/ankle •sarcoidosis •polyarticular gout •pseudogout •RA •undifferentiated
Determining Urgency
Axial inflammatory symptoms poor functional status HLA-B27+ acute phase response
Early Interventions
Suspected RA •evidence to support early use of corticosteroids •e.g. prednisone 20 mg daily tapering over 4 – 8 weeks •while awaiting results or assessment for DMARDs
Early Interventions
Suspected RA •evidence to support early use of corticosteroids •e.g. prednisone 20 mg daily tapering over 4 – 8 weeks •while awaiting results or assessment for DMARDs
Can also be applied to •other peripheral inflammatory arthritides, e.g. PsA, ReA, viral
Early Interventions
Suspected vasculitis • multisystem inflammatory disease: neuro, renal, resp, skin joint • discuss with rheumatologist before treating • photographs can help
Early Interventions
Suspected vasculitis • multisystem inflammatory disease: neuro, renal, resp, skin joint • discuss with rheumatologist before treating • photographs can help
Suspected GCA • discuss with rheumatology registrar immediately • if unable to contact, prednisone can be started before biopsy • ideally CRP and ESR before stating treatment • biopsy within 3 weeks of commencement of prednisone
Early Interventions
Suspected vasculitis • multisystem inflammatory disease: neuro, renal, resp, skin joint • discuss with rheumatologist before treating • photographs can help
Suspected GCA • discuss with rheumatology registrar immediately • if unable to contact, prednisone can be started before biopsy • ideally CRP and ESR before stating treatment • biopsy within 3 weeks of commencement of prednisone
Suspected PMR • prednisone 15 mg daily 1/52, then 12.5 mg 1/52, then 10 mg
reducing by 1 mg every 2/52 to 5 mg
Early Interventions
Suspected gout • three options: NSAIDs, colchicine, prednisone • colchicine regimen: 1 g stat and 0.5 mg 1 hour later
Early Interventions
Suspected ankylosing spondylitis / axial spondyloarthritis • Full dose long acting NSAID nocte to bd • refer for confirmation of diagnosis and monitoring • corticosteroids seldom used
Suspected OA • can mimic inflammatory arthritis • NSAIDs now favoured over paracetamol
Summary
• early intervention can reduce the long-term impact of inflammatory arthritis
• different patterns of involvement require different investigations • urgency for intervention determined by clinical and laboratory
features • treatment can be started before diagnosis is confirmed.