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Osteoarthritis Osteoarthritis Rheumatoid

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Osteoarthritis Osteoarthritis Rheumatoid Powered By Docstoc
					                Osteoarthritis                            Rheumatoid Arthritis
Background      o MC form                                 o More aggressive
                o Over 55yo                               o INFLAMMATION
                o Not part of normal aging process        o 35-50 yo
                o Degen of cartlidge d/t excessive load   o HLA Ag
                o No HLA Ag
Pathogenesis    o ↓ matrix synthesis                      o   IMMUNE system not joint
                o Bad diet habits                             problem
                o Bad collagen gene                       o   IL-1 and TNF-A are the big 2
                o ↓ mucopolysaccaride in JOINTS               pro-inflam mediators
                                                          o   These cause fatigue, malaise,
                                                              stiffness
Pt Hx           o   Pain with USE                         o   AM stiffness >60 mins
                o   Better with rest                      o   Fatigue / malaise
                o   Stiffness > 30 mins                   o   Systemic SSx
                                                          o   Extra-articular SSx
PE findings     o   Bony hypertrophy and tenderness       o   Synovitis (puffiness)
                o   No synovitis                          o   Symmetrical pattern (>3 joints)
                o   Assymetrical weight bearing joints    o   Hands and wrists (MCP)
                o   DIP / PIP                                          Wrist
                o   Wgt bearing joints                                 #2 / #3 MCP
                                                                       #2 / #3 MTP
                                                          o   Non-articular findings
Labs            o   XR good (osteophytes)                 o   XR for monitoring
                o   Synovial fluid with crystals = gout   o   RF
                                                          o   ESR and CRP (best Px)
                                                          o   MHAQ best for monitoring Px
Radiographic    o   Only Dx for OA                        o   Narrowing / erosions
                o   Osteophytes                           o   No osteophytes
                                                          o   MCP joint
Dx criteria     o   Age > 50                              o   Symmetrical joint swelling
                o   No AM stiffness                       o   AM stiffness
                o   Bony changes WITHOUT inflamm          o   Swelling >3 joints
                o   XR: osteophytes                       o   Swelling hands / wrists
                                                          o   (+) RF
                                                          o   Rheumatoid nodules
                                                          o   XR: erosions
                                                          o   4/7 = Dx for RA
Tx              o   Analgesics (DOC)                      o   Analgesic + anti-inflam (NSAIDS
                o   Education                                 as start)
                o   Wgt reduction                                      S/E
                o   Isometric strength                                 >10% dypepsidia
                o   Opioids                                            1-10% GI Bleed
                o   Glucosamine (OA not RA)                            <1% renal insufficiency
                o   Hyaluronic injections                 o   Education
                o   Surgery (joint replacement only       o   DMARDS (DOC)
                    OA)                                                MTX-azithoprine combo
                o   NO Steroids / DMARDS/ bio agents                    (good)
                                                                       MTX-cyclosporine (not
                                                                        good)
                                                          o   Bio agents
                                                                       Inihib cytokines
                                                                       Infliximab
                                                                       CI: (+) PPD (+) TB
                                                                       Yearly TB test
                                                          o   Opioids
                                                          o   Steroid injections (adjunct)
Complications   o                                         o   Mononeuritis multiplex (wrist / foot
                                                              drop)
                                                          o   Rheum. Nodules anywhere
                                                          o   Heart / ulcers / vasculitis



                                       Page 1 of 2
                  JRA                                                      “Still’s Disease”
                  (Packer)                                                 Adult JRA (Kimmel)
Background        Dx of exclusion                                          SSx:
                  UNEXPLAINED Chronic arthritis >6 weeks                   Fever
                  Large joints (“walks funny”                              Arthraligia / arthritis
                  Young females                                            (-) RA (-) ANA
                                                                           Salmon colored rash
                                                                           Same as JRA
                                                                           Complications:
                                                                           Hepatic necrosis
                                                                           DDx: SLE (+) ANA
                                                                           Tx:
                                                                           NSAIDs
                                                                           If liver problems: steroids THEN
                                                                           DMARDs
Characteristics   AM stiffness better with movement
                  Growth abnormalities (mandible hypOtrophic)
Labs              Normocytic anemia                                        Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
                  ↑CRP + ESR + ferritin                                    xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxX
                  ANA and RF (for classify not Dx)
Pauciarticular    Younger:                                                 Older
                  Females <3 yo                                            Males
Forms:            (+) ANA (-) RF                                           (-) RF and (-) ANA
(<5 joint)        Large joints                                             LOWER joints + LOWER back
                  Self-resolves                                            (ankylosing sppondylitis)
                  If (+) ANA → eye problems (iridocyclitis → glaucoma) →   Asymmetric
                  “stuck on cornea”                                        Painful uveitis
                             Tx: steroids / mydriatics                     Weight loss

Polyarticular     RH (-)                                                   RH (+)
                  Females < 10 yo                                          Small joints
forms (>5         (-) ANA                                                  Long term → joint destruction
joints)           LEAST COMMON                                             Kid form of RA
                  Large and small joints + c-spine                         (-) ANA → no eye risk
                  Self-fix in 2 years


Systemic JRA      Etio:
                  Rash / fever / systemic
                  “still disease”
                  MCC: “Fever of unknown origin”
                  SSx:
                  Quotidian fever (BID) with fever bites (BID)
                  Salmon colored RASH
                  Hepatosplenomegaly / anemia / pericarditis / mylagia
                  / pleurisy
                  Complications:
                  25% severe arthritis
                  Rare uveitis
                  Sepsis (hypercoag / cardiac)
                  Heart failure
                  Tx:
                  Preventive
                  If (+) RH → NSAIDs / immunomodulators
                  Influenze vaccine (avoid Reye’s)




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posted:11/3/2011
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