rheumboardreviewra oa arthropathies

7/28/2019 RheumBoardReviewRA OA Arthropathies

1/38

Osteoarthritis, Rheumatoid

Arthritis, and

Spondylarthropathies

Timothy Niewold, MD

Assistant Professor

Section of Rheumatology


2/38

Question: A 45 yo woman with history of rheumatoid

arthritis presents to the emergency room with a 2

day history of a severely painful, warm, swollen R

knee. Her other joints are not painful, and untilrecently her symptoms were well controlled on

methotrexate and prednisone. The most appropriate

next step in management is:

A. obtain an X-ray of the knee

B. increase prednisone

C. increase methotrexateD. aspirate the knee

E. prescribe physical therapy


3/38

Question: A 54 yo man presents with symmetric

pain and swelling of the small joints in his hands and

wrists progressive over the last 3 months. He has

no fever, weight loss, or constitutional symptoms.Laboratory testing shows high ESR, negative

rheumatoid factor, and a positive anti-CCP antibody

test. The next step in management is:

A. Prescribe methotrexate

B. Check an anti-nuclear antibody test

C. Prescribe a tumor-necrosis factor alphablocker

D. Prescribe a non-steroidal anti-inflammatorydrug and follow up in 6 months

E. Order an MRI of the hand and wrist


4/38

Question: A 59 year old woman is seen in clinic

for a 4 year history of gradually worsening

bilateral hand pain. She has not noted redness,

swelling, or morning stiffness. You suspectosteoarthritis clinically, and would expect to see

all of the following on hand X-ray except:

A. Joint space narrowing in the DIP jointsB. Sclerosis near the articular surface

C. Bony erosions

D. Heberdens and Bouchards nodesE. Hypertrophic changes


5/38

Question: A 23 yo man presents with a 4 year history

of progressive low back pain. He says the pain is

worst in the morning, gradually improving with

activity. X-rays were done and he was told they werenormal at the start of his symptoms four years ago.

Narcotic pain did not relieve his pain. He thinks his

symptoms may have started around the time of a car

accident. He is seeing you in second opinion for hischronic back pain. What should be done next?

A. X-ray of the L-spine and pelvis

B. Referral to PTC. MRI of the L-spine

D. Arrange X-ray guided steroid injection

E. Increase narcotic dose


6/38

Osteoarthritis definition and

prevalence

Definition degenerative joint process

characterized by focal loss of cartilage, new

bone formation (spurring), and subsequent pain

and loss of functionMost common type of arthritis more than half

of individuals over age 55 have radiographic

evidence, goes up to 90% at age 70

Slight female predominance in older age, but

both sexes affected


7/38

Uncertain pathogenesis but:

Genetic factors play a role

Clear environmental or secondarytriggers

injury

history of inflammatory joint condition,

neuropathic (Charcot joint) rare endocrine/metabolic such as

hemochromatosis, acromegaly, Wilsonsdisease

Osteoarthritis pathogenesis


8/38

History is important gradual onset of

symptoms, lack of inflammation, sometimes

history of prior injury or overuse or other

secondary triggerPhysical exam crepitance, hypertrophic

changes, lack of erythema or warmth, usually

not much tenderness

X-ray will confirm diagnosis asymmetric joint

space narrowing, sclerosis near the joint line,

and spurring are characteristic

Osteoarthritis diagnosis

X l i h d t


9/38

X-ray classic changes due to

OA


10/38

Very common

Associated with obesity

Bilateral disease is common althoughone may be worse

Treatment NSAIDs or Tylenol, PT and

weight loss, then steroid injections forknee and potentially X-ray guided forhip, and if these fail total jointreplacement surgery is very effective

Osteoarthritis Hip and Knee


11/38

Heberdens nodes DIP joint bony nodules

Bouchards nodes PIP joint bony nodules

Both nodes are diagnostic for hand OA, 10times more common in women than men, andhave a strong genetic component

Base of thumb (1st CMC joint) very commonly

affected, more likely due to wear-and-tearthan nodes

Treatment NSAIDs or Tylenol, can doinjections particularly for base of thumb,

rarely ever surgery

Osteoarthritis Hands


12/38

Shoulder

uncommon in 40s and 50s, but becomesvery common in 7th and 8th decades of life

Rotator cuff symptoms often accompany

Treatment NSAIDs, infrequent injections.Total replacement is possible, but usedrarely because not as successful as hip +knee

Feet 1stMTP commonly affected (bunion

deformity)

Treatment better shoes, surgery forsevere

Osteoarthritis Shoulder and

Feet


13/38

Joints which are not typically affected by

OA unless injury/secondary cause: MCPs

Wrist

Ankle

Elbow

If these are affected, think

inflammatory!!

OsteoarthritisJoints Not Typically

Affected


14/38

Rheumatoid Arthritis definition

and prevalenceDefinition symmetric inflammatory joint

condition characterized by pannus formation,

joint erosion, and systemic inflammation

Most common inflammatory arthritis, 1% of

the population, 2:1 female to male ratio, peak

incidence between ages 40 to 60

Onset usually insidious over months


15/38

Genetic factors clearly important HLAshared epitope is strongest risk factor,

but also non-HLA genes such asPTPN22, STAT4, TNFAIP3

Environmental factors cigarettesmoking increases both risk of diseaseand severity of disease, also risk in coalminers (Kaplan syndrome)

Rheumatoid Arthritis

Predisposition

C f


16/38

Course of

RA

Reproduced with permission from McInnes IB,

et al. Nat Rev Immunol. 2007;7(6):429-442.

CCP, cyclic citrullinated peptide; CTLA4,

cytotoxic T-lymphocyte antigen 4; GP39,

cartilage glycoprotein 39; PADI4, peptidyl

arginine deiminase, type IV; PTPN22, protein

tyrosine phosphatase, non-receptor type 22.

16


17/38

History and physical are majority of

diagnosis lab not that helpful

Symmetric pain and swelling in small joints

of hands, wrists, feet, ankles most

common, followed by knees, elbows,shoulders

Morning stiffness better with activity

Constitutional symptoms fatigue, evenweight loss are common, but fever is VERY

RARE

Steady, progressive, additive onset is by

far most common presentation

Rheumatoid Arthritis Diagnosis


18/38

Patterns of Onset

Insidious 55%-65% Joint stiffness, swelling,

pain, fatigue

Acute 8%-15% Fever, weight loss, fatigue,joint abnormalities present

but often not prominent

Intermediate 15%-20% Systemic complaints more

noticeable than insidious onset

Harris ED Jr, et al. In: Firestein GS, et al, eds. Kelleys Textbook of Rheumatology, 8th ed. 2008.


19/38

Joints Commonly Involved


20/38

Rheumatoid Arthritis Extra-

articular features

Rheumatoid nodules

Pleural effusions

Atherosclerosis (new, but probablytestable)

Scleritis

Rheumatoid vasculitis (rare)Feltys syndrome (neutropenia,

splenomegaly, recurrent infection)


21/38

High ESR or CRP common but not requiredRheumatoid factor positive in about 50%

RF usually indicates more severe disease, greater

likelihood of extra-articular manifestations

Anti-CCP antibodies - relatively new (but very

clinically useful and testable!!)

Found in about 50% of patients without much

overlap with rheumatoid factor

Highly sensitive positive test almost always

indicates disease (>90% specificity for RA, even in

mixed autoimmune cohorts)

So can rule in, but low sensitivity prevents rule

out

Rheumatoid Arthritis

Laboratory


22/38

Major RA Subsets Based on ACPA

Reproduced with permission from Klareskog L, Catrina AI, Paget S.Lancet. 2009;373(9664):659-672. 22


23/38

Classical findings of inflammatoryarthritis:

Periarticular joint erosions

Periarticular osteopenia Symmetric joint space narrowing

Note that each of these is the oppositeof OA!!

(erosions instead of spurs, osteopeniainstead of sclerosis, and symmetric instead

of asymmetric joint narrowing)

Rheumatoid Arthritis X-ray


24/38

Joint-space narrowing

and erosion are seen in

up to two thirds of

patients within the first 2

to 5 years of disease

Reproduced with permission from Wolfe F, et al.Arthritis Rheum. 1998;41(9):1571-1582.

Early Radiographic Progression


25/38

Rheumatoidarthritis

erosions on

X-ray


26/38

Early RA: RadiographicFindings

High-Detail X-Ray Low-Field MRI

Courtesy of Charles Peterfy, MD.


27/38

Early treatment with a disease modifying drugis standard of care

Non-disease modifying

NSAIDs

Prednisone

Disease modifying

Methotrexate most common first line, usually

around 15-20mg/week with daily folate 1mg/day Sulfasalazine, leflunomide also effective

Biological agents such as TNF-alpha blockers,

abatacept, rituximab, and tocilizumab are all

second or third line

Rheumatoid Arthritis Treatment


28/38

Goal of treatment is clinical remission ifpossible

Control of disease prevents boneerosions and subsequent deformity and

loss of functionAll disease modifying drugs areimmunosuppressive, non-biologics have

risk of GI intolerance and hair loss, TNFblockers are associated with re-activation of tuberculosis and rarely anMS-like disease, other biologics are not

currently in wide use

Rheumatoid Arthritis Treatment


29/38

Spondylarthropathies Definition

and Prevalence

Group of inflammatory conditions

affecting the axial skeletion (spine,

pelvis), may also demonstrateasymmetric oligoarthritis and enthesitis

(inflammation of tendon insertions)

Prevalence about 1 per 1000 in US,

ankylosing spondylitis characterized by

a 3:1 male to female ratio


30/38

Inflammatory spinal involvement is typical,and differentiates from other arthridities

Enthesitis or inflammation of tendoninsertions is classical

Asymmetric oligoarthritis is typical patternof peripheral joint arthritis

Eye involvement (uveitis) is commonAortitis with valvular insufficiency is alsoan important complication

Spondylarthropathies Patterns

of Disease


31/38


Ankylosing Spondylitis

Psoriatic Arthritis

Enteropathic Arthritis and Reactive

Arthritis


32/38

Spondylarthropathies -

Ankylosing Spondylitis

Sacroileitis in all cases, ascending ankylosis of

spine gradually over the years

Symptoms are inflammatory back pain

Can also affect hips and shoulders, rare to affectmore distal joints

HLA-B27 in 90% of European ancestry

Diagnosis Sacroileitis and anklyosis on X-rayTreatment NSAIDs for mild disease,

sulfasalazine or methotrexate, TNF-blockers are

effective second-line therapy


33/38

X-ray of sacroileitis

A k l i d liti l b


34/38

Ankylosing spondylitis: lumbar

vertebrae, bamboo spine


35/38

Spondylarthropathies - Psoriatic

Arthritis

A subset of patients with psoriasis (5-7%) havepsoriatic arthritis

Inflammatory spine disease and peripheral

oligoarthritis common, can affect DIP jointsDiagnosis Psoriasis required, X-rays often showerosive joint disease with little osteopenia,destructive changes such as pencil-in-cup

Treatment Steroids may result in flare of skindisease when tapered, methotrexate andsulfasalazine common, TNF-blockers as secondline therapy


36/38

Psoriatic arthritis: hand



37/38

Spondylarthropathies -

Enteropathic Arthritis and

Reactive ArthritisEnteropathic arthritis spondylarthritis

associated with inflammatory bowel

disease, spine + peripheral joints, rx. forIBD works for arthritis, too

Reactive arthritis spondylarthropathy

following GI or GU infection. Often self-

limited, but can either be recurrent or

persistent


38/38

Questions???

rheumboardreviewra oa arthropathies

Documents