Osteoarthritis Rheumatoid Arthritis and Spondylarthropathies by mikesanye

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									Osteoarthritis, Rheumatoid
      Arthritis, and

     Timothy Niewold, MD
      Assistant Professor
    Section of Rheumatology
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 until
  recently 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 methotrexate
    D. aspirate the knee
    E. prescribe physical therapy
  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 alpha
  D. Prescribe a non-steroidal anti-inflammatory
  drug and follow up in 6 months
  E. Order an MRI of the hand and wrist
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 suspect
osteoarthritis clinically, and would expect to see
     all of the following on hand X-ray except:

 A.   Joint space narrowing in the DIP joints
 B.   Sclerosis near the articular surface
 C.   Bony erosions
 D.   Heberden’s and Bouchard’s nodes
 E.   Hypertrophic changes
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 were
 normal 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 his
   chronic back pain. What should be done next?
   A.   X-ray of the L-spine and pelvis
   B.   Referral to PT
   C.   MRI of the L-spine
   D.   Arrange X-ray guided steroid injection
   E.   Increase narcotic dose
  Osteoarthritis – definition and
Definition – degenerative joint process
characterized by focal loss of cartilage, new
bone formation (spurring), and subsequent pain
and loss of function
Most 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
Osteoarthritis – pathogenesis
 Uncertain pathogenesis but:
 Genetic factors play a role
 Clear environmental or secondary
 – injury
 – history of inflammatory joint condition,
   neuropathic (Charcot joint)
 – rare endocrine/metabolic such as
   hemochromatosis, acromegaly, Wilson’s
   Osteoarthritis – diagnosis
History is important – gradual onset of
symptoms, lack of inflammation, sometimes
history of prior injury or overuse or other
secondary trigger
Physical 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
X-ray – classic changes due to
Osteoarthritis – Hip and Knee

  Very common
  Associated with obesity
  Bilateral disease is common although
  one may be worse
  Treatment – NSAIDs or Tylenol, PT and
  weight loss, then steroid injections for
  knee and potentially X-ray guided for
  hip, and if these fail total joint
  replacement surgery is very effective
 Osteoarthritis – Hands

Heberden’s nodes – DIP joint bony nodules
Bouchard’s nodes – PIP joint bony nodules
Both “nodes” are diagnostic for hand OA, 10
times more common in women than men, and
have a strong genetic component
Base of thumb (1st CMC joint) very commonly
affected, more likely due to wear-and-tear
than nodes
Treatment – NSAIDs or Tylenol, can do
injections particularly for base of thumb,
rarely ever surgery
Osteoarthritis – Shoulder and
– uncommon in 40s and 50s, but becomes
  very common in 7th and 8th decades of life
– Rotator cuff symptoms often accompany
– Treatment – NSAIDs, infrequent injections.
  Total replacement is possible, but used
  rarely because not as successful as hip +
– 1st MTP commonly affected (“bunion”
– Treatment – better shoes, surgery for
Osteoarthritis –Joints Not Typically

    Joints which are not typically affected by
    OA unless injury/secondary cause:
    – MCPs
    – Wrist
    – Ankle
    – Elbow
    If these are affected, think
Rheumatoid Arthritis – definition
      and prevalence
Definition – 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
     Rheumatoid Arthritis –

Genetic factors clearly important – HLA
“shared epitope” is strongest risk factor,
but also non-HLA genes such as

Environmental factors – cigarette
smoking increases both risk of disease
and severity of disease, also risk in coal
miners (Kaplan syndrome)
Course of

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.

Reproduced with permission from McInnes IB,
et al. Nat Rev Immunol. 2007;7(6):429-442.
Rheumatoid Arthritis – Diagnosis
  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,
  – Morning stiffness – better with activity
  – Constitutional symptoms – fatigue, even
    weight loss are common, but fever is VERY
  – Steady, progressive, additive onset is by
    far most common presentation
                        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. Kelley’s Textbook of Rheumatology, 8th ed. 2008.
Joints Commonly Involved
  Rheumatoid Arthritis – Extra-
      articular features
Rheumatoid nodules
Pleural effusions
Atherosclerosis (new, but probably
Rheumatoid vasculitis (rare)
Felty’s syndrome (neutropenia,
splenomegaly, recurrent infection)
      Rheumatoid Arthritis –
High ESR or CRP common but not required
Rheumatoid 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
Major RA Subsets Based on ACPA

Reproduced with permission from Klareskog L, Catrina AI, Paget S.
Lancet. 2009;373(9664):659-672.                                     22
Rheumatoid Arthritis – X-ray
Classical findings of inflammatory
– Periarticular joint erosions
– Periarticular osteopenia
– Symmetric joint space narrowing

Note that each of these is the opposite
of OA!!
– (erosions instead of spurs, osteopenia
  instead of sclerosis, and symmetric instead
  of asymmetric joint narrowing)
        Early Radiographic Progression
                                                        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.
erosions on
               Early RA: Radiographic

       High-Detail X-Ray           Low-Field MRI

Courtesy of Charles Peterfy, MD.
Rheumatoid Arthritis – Treatment
 Early treatment with a disease modifying drug
 is standard of care
 Non-disease modifying
 – 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
 Goal of treatment is clinical remission if
 Control of disease prevents bone
 erosions and subsequent deformity and
 loss of function
 All disease modifying drugs are
 immunosuppressive, non-biologics have
 risk of GI intolerance and hair loss, TNF
 blockers are associated with re-
 activation of tuberculosis and rarely an
 MS-like disease, other biologics are not
 currently in wide use
Spondylarthropathies – Definition
        and Prevalence
 Group of inflammatory conditions
 affecting the axial skeletion (spine,
 pelvis), may also demonstrate
 asymmetric 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
Spondylarthropathies – Patterns
          of Disease
 Inflammatory spinal involvement is typical,
 and differentiates from other arthridities
 Enthesitis or inflammation of tendon
 insertions is classical
 Asymmetric oligoarthritis is typical pattern
 of peripheral joint arthritis
 Eye involvement (uveitis) is common
 Aortitis with valvular insufficiency is also
 an important complication
Ankylosing Spondylitis

Psoriatic Arthritis

Enteropathic Arthritis and Reactive
         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 affect
more distal joints
HLA-B27 in 90% of European ancestry
Diagnosis – Sacroileitis and anklyosis on X-ray
Treatment – NSAIDs for mild disease,
sulfasalazine or methotrexate, TNF-blockers are
effective second-line therapy
X-ray of sacroileitis
Ankylosing spondylitis: lumbar
  vertebrae, bamboo spine
    Spondylarthropathies - Psoriatic
A subset of patients with psoriasis (5-7%) have
psoriatic arthritis
Inflammatory spine disease and peripheral
oligoarthritis common, can affect DIP joints
Diagnosis – Psoriasis required, X-rays often show
erosive joint disease with little osteopenia,
destructive changes such as “pencil-in-cup”
Treatment – Steroids may result in flare of skin
disease when tapered, methotrexate and
sulfasalazine common, TNF-blockers as second
line therapy
Psoriatic arthritis: hand
    Spondylarthropathies -
   Enteropathic Arthritis and
       Reactive Arthritis
Enteropathic arthritis – spondylarthritis
associated with inflammatory bowel
disease, spine + peripheral joints, rx. for
IBD works for arthritis, too

Reactive arthritis – spondylarthropathy
following GI or GU infection. Often self-
limited, but can either be recurrent or

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