RHEUMATOID ARTHRITIS for the internist... - PowerPoint PPT Presentation

1 / 49
About This Presentation
Title:

RHEUMATOID ARTHRITIS for the internist...

Description:

55 YOF complains of months of bilateral hand pain. ... fibromyalgia. RA - differential diagnosis. Uncommon. hypothyroidism. SBE. hemochromatosis ... – PowerPoint PPT presentation

Number of Views:371
Avg rating:3.0/5.0
Slides: 50
Provided by: Park2
Category:

less

Transcript and Presenter's Notes

Title: RHEUMATOID ARTHRITIS for the internist...


1
RHEUMATOID ARTHRITISfor the internist...
  • Christopher Parker
  • CPT (P), MC, USA
  • Rheumatology Service
  • WRAMC

2
Introduction
  • Interactive format
  • Clinical features
  • Laboratory features
  • Extra-articular features
  • Management considerations and paradigms
  • Prognosis

3
Case
Presentation 55 YOF complains of months of
bilateral hand pain. She describes progressive
morning stiffness lasting 3 hours with wrist,
MCP, and PIP pain and swelling. She has also
noted some discomfort and perhaps swelling in
her wrists, shoulders, knees, and toes. Review
of systems is unremarkable. What historical
features speak for RA?
4
Rheumatoid nodule
5
Rheumatoid Arthritis
6
Case Presentation
  • Physical exam is notable for swelling,
    tenderness, and warmth in the elbows, wrists,
    MCPs, PIPs, knees, and MTPs with non-tender soft
    tissue nodules over the olecronon.
  • What is the difference between arthritis and
    arthralgia?
  • Are there further tests that can be done to
    confirm the diagnosis?

7
(No Transcript)
8
RA Erosion Progression
9
Laboratory Exam
  • WBC 5.2
  • H/H 10/30 with normal RDW
  • PLT 475k
  • ESR 75
  • RF 450
  • ANA positive
  • TSH normal
  • CK normal
  • P1-3 uric acid normal
  • U/A normal

10
Work-up of an inflammatory arthritis
  • CBC, BUN/Cr, calcium, LFTs, uric acid, UA, HIV,
    RF, ANA, CPK, CXR
  • further serologic evaluation and specific tests
    geared toward the presentation and results from
    above tests
  • radiographs have a higher yield with chronic
    symptoms ( 6 weeks)

11
Laboratory abnormalities
  • anemia of chronic disease
  • thrombocytosis in active disease
  • low white cell count in Feltys
  • ESR
  • CRP

12
Rheumatoid factor
  • series of antibodies that recognize the Fc
    portion of an IgG molecule
  • any serotype
  • most IgM
  • many conditions associated with RF positivity -
    chronic inflammation
  • 70 RA positive at onset, overall 85 in first
    two years
  • associated with more severe disease,
    extra-articular manifestations, mortality

13
(No Transcript)
14
DDX of a positive RF
  • normal - 1-4, 10-25 over age 70
  • systemic autoimmune diseases
  • infections
  • malignancy
  • chronic liver disease
  • pulmonary diseases

15
ANA in RA
  • 25 RA are positive for ANA
  • other serologies usually negative
  • ? more severe disease (RA) with worse prognosis

16
(No Transcript)
17
RA - Definition
  • chronic systemic inflammatory disorder
  • unknown etiology
  • diarthroidal joints
  • synovium affected
  • bone, cartilage, ligaments
  • deformity
  • extra-articular manifestations

18
RA - Definition
  • clinical diagnosis
  • symmetric polyarthritis of small joints
  • subacute
  • acute
  • rheumatoid factor positivity
  • erosive disease

19
RA - Epidemiology
  • worldwide distribution
  • all races
  • female male 31
  • 1 adults in U.S.
  • genetic associations
  • HLA-DR4, DR1

20
Case Study
  • 29F presents with 3 weeks of pain and swelling in
    the wrists, MCPs, and PIPs. She has 2 hours of
    morning stiffness. She also complains of extreme
    fatigue and having difficulty keeping up with her
    four year old boy. Her son is well but had a
    rash a few weeks ago. Her exam confirms
    symmetric polyarticular inflammatory arthritis.
  • Could she have something other than RA?

21
Parvo Arthritis
22
(No Transcript)
23
RA - differential diagnosis
  • Common diseases
  • spondyloarthropathies
  • CTDs
  • polyarticular gout
  • CPPD
  • viral infections
  • fibromyalgia

24
RA - differential diagnosis
  • Uncommon
  • hypothyroidism
  • SBE
  • hemochromatosis
  • hypertrophic pulmonary osteoarthropathy
  • hyperlipoproteinemias
  • hemoglobinopathies
  • relapsing polychondritis

25
RA - differential diagnosis
  • Uncommon
  • rheumatic fever
  • sarcoidosis
  • lyme disease
  • amyloid
  • HIV
  • malignancies/paraneoplastic syndromes

26
RA - differential diagnosis
  • Rare
  • familial mediterranean fever
  • multicentric reticulohistiocytosis
  • whipples disease
  • angioimmunoblastic lymphadenopathy

27
Case Study
  • 60WM with RA presents with progressive worsening
    of his joint complaints over the last few months
    with intermittant fever, swelling of his
    glands, and painful lesions on his finger tips.
    ROS notable for 5lb wt loss. Exam confirms
    polyarthritis and small digital infarctions.
  • Could all of his symptoms be explained by RA?

28
Extra-articular manifestations
  • General
  • fever, lymphadenopathy, weight loss, fatigue
  • Dermatologic
  • palmar erythema, nodules, vasculitis
  • Ocular
  • episcleritis/scleritis, scleromalacia perforans,
    choroid and retinal nodules

29
Extra-articular manifestations
  • Cardiac
  • pericarditis, myocarditis, coronary vasculitis,
    nodules on valves
  • Neuromuscular
  • entrapment neuropathy, peripheral neuropathy,
    mononeuritis multiplex
  • Hematologic
  • Feltys syndrome, large granular lymphocyte
    syndrome, lymphomas

30
Extra-articular manifestations
  • Pulmonary
  • pleuritis, nodules, interstitial lung disease,
    bronchiolitis obliterans, arteritis, effusions
  • Others
  • Sjogrens syndrome, amyloidosis

31
Feltys syndrome
  • classic triad
  • RA, splenomegaly, leukopenia
  • generally a neutropenia (
  • thrombocytopenia may occur
  • complications
  • infections, non-healing leg ulcers
  • most require no additional treatment for
    cytopenias
  • splenectomy?

32
Case Study
  • You are tasked to back fill for a small army
    community hospital as a primary care provider
  • GYN exam for perimenopausal 45WF
  • MSK exam
  • On NSAIDs
  • No complaints of pain
  • Are NSAIDs enough?
  • What other medications could you use?

33
(No Transcript)
34
RA - Management
  • Nonpharmacologic
  • rest
  • fatigue, splinting
  • pain relief
  • heat, cold, ultrasound, paraffin, massage
  • physical therapy
  • occupational therapy
  • Patient education

35
RA - Management
  • Pharmacologic
  • analgesics
  • NSAIDs - full dose
  • corticosteroids
  • prednisone at low dose - bridge, burst
  • intra-articular steroids

36
Disease modifying agents
  • every patient should be considered for at least
    one modifying agent
  • limitations
  • may not prevent damage
  • may not have lasting effect
  • may not be tolerated due to toxicity

37
DMARDs
  • hydroxychloroquine
  • mild non-erosive disease
  • combinations
  • 200 mg bid
  • eye exams

38
DMARDs
  • Sulfasalazine
  • 1 gm bid - tid
  • CBC, LFTs
  • onset 1 - 2 months
  • Methotrexate
  • most commonly used drug
  • fast acting (4-6 weeks)
  • po, SQ - weekly
  • CBC, LFTs

39
DMARDs
  • IM Gold
  • slow onset (3-6 months)
  • weekly then monthly injections
  • CBC, UA before each injection
  • Oral Gold
  • less effective
  • slow acting (4-6 months)
  • daily
  • CBC, UA

40
DMARDs
  • Azathioprine
  • 100-200 mg daily
  • CBC, LFTs
  • ?malignancy potential
  • onset 2 - 3 months
  • D-Penicillamine
  • daily
  • slow onset (3-6 months)
  • CBC, UA
  • autoimmune phenomenon

41
DMARDs
  • Cyclosporin A
  • daily
  • BP, UA
  • Cyclophosphamide
  • refractory cases
  • CBC
  • Chlorambucil
  • CBC

42
New Therapies for RA
  • Enbrel
  • Soluble tumor necrosis factor fusion protein
  • Arava
  • Leflunomide

43
Chimeric A2 (cA2) Monoclonal Antibody
Mouse (binding site for TNF-a)
Human (IgG1)
  • Chimeric (mouse/human) IgG1monoclonal antibody
  • Binds to TNF-a with highaffinity and specificity

Knight, et al. Mol Immunol. 1993.
44
DMARDs
  • over the counter remedies
  • report use of vitamins, health aids, unusual
    diets
  • natural does not mean safe

45
Case Study Follow Up
  • During your training you became comfortable with
    the use of prednisone HCQ and begin treatment
    including prophylatic therapy for OP with
    calcium, vitamin D, and discuss ERT. You
    recommend follow up appointment in 4-8 weeks.
  • What objective parameters will you use to
    determine if your therapy is effective?

46
Response to therapy
  • AM stiffness, total number swollen, tender
    joints, (S1T2W)
  • perception of pain
  • perception of overall response
  • health assessment measurement
  • ESR, CRP levels
  • physicians assessment

47
Criteria for Remission (ACR)
  • no fatigue
  • morning stiffness for 15 minutes or less
  • no joint pain
  • no joint tenderness or pain on motion
  • no soft tissue swelling in joints or tendon
    sheath
  • ESR
  • 5 of 6 present for 2 months
  • no vasculitis, pericarditis, pleuritis, myositis,
    weight loss, fever

48
RA - long term prognosis
  • RA shortens survival and produces disability
  • 1/3 leave work force in five years
  • aggressive DMARD TX can reduce disability by 30
    in 10-20 years

49
(No Transcript)
Write a Comment
User Comments (0)
About PowerShow.com