Download - First Presentation of Joint Pain - Acurity · First Presentation of Joint Pain ... • ReA • CTD • viral ... • Swelling soft tissue hard tissue Small joint / distal

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?

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


? mechanical ? degenerative ? neuropathic Consider: • OA • soft tissue

syndromes • FMS








syndromes • FMS






Small joint / distal ? objective synovitis • swelling/tenderness • MTP squeeze Consider: • RA • PsA • ReA • CTD • viral • OA • haemochromatosis • vasculitis: HSP / GPA



syndromes • FMS







Large joint / proximal

Limb girdle Consider • PMR • OA shoulders/hips • soft tissue syndromes • statin myopathy • RA



syndromes • FMS







Large joint / proximal


Knee/ankle Consider: •SpA – PsA / ReA •OA knee/ankle •sarcoidosis •polyarticular gout •pseudogout •RA •undifferentiated



syndromes • FMS







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



Effective Use of Investigations



syndromes • FMS











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



syndromes • FMS











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)



syndromes • FMS











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



syndromes • FMS











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



syndromes • FMS











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 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 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.