Rheumatoid Arthritis VS Osteoarthritis Phong Dao

Rheumatoid ArthritisRheumatoid ArthritisVSVS

OsteoarthritisOsteoarthritis

Phong Dao Phong Dao

DefinitionDefinition

Rheumatoid arthritisRheumatoid arthritis

It is an autoimmune disease that causes chronic inflammation of the joints

Chronic inflammation leads to the destruction of the cartilage, bone and ligaments causing deformity of the joints


It is a joint disease It is a joint disease caused by the breakdown and eventual loss of the cartilage of one or more joints

**Not autoimmuneInflammation may be

present; however, it is usually mild and involves only the periarticular tissues



1. It is more of a systemic illness and therefore can affect other organs in the body


1.1. It It does not affect other organs of the body

2.2. It is a chronic disease that has It is a chronic disease that has NO CURE, so prevention and NO CURE, so prevention and treating the symptoms are the treating the symptoms are the keykey



Extra-articular Manifestations

Heart: pericarditis and myocarditis

Lungs: pleurisy with effusion. Glucose concentration n the effusion are uniquely low (<20-30) while the LDH is elevated (exudate)

Blood: anemia of chronic disease

Renal: Amyloid renal disease occurs late in RA

Who gets it?Who gets it?

RheumatoidRheumatoid1.1. 3X more common in women as 3X more common in women as

in menin men

2.2. The disease can begin at any The disease can begin at any age, but most often starts after age, but most often starts after age forty and before sixtyage forty and before sixty

OsteoarthritisOsteoarthritis1.1. Most often occurs in people over Most often occurs in people over

65, but can develop earlier in life65, but can develop earlier in life2.2. Both men and women get the Both men and women get the

diseasedisease - Before age of 45 more - Before age of 45 more

common in men common in men - After age of 45 more - After age of 45 more

common in women, common in women, usually usually in the hands in the hands

3. People with joints that move or fit 3. People with joints that move or fit together incorrectly, such as together incorrectly, such as bow leg, a dislocated hip, or bow leg, a dislocated hip, or double-jointedness, are more double-jointedness, are more likely to develop OA.likely to develop OA.

Risk FactorsRisk Factors

RheumatoidRheumatoid1.1. 3X more common in women as 3X more common in women as

in menin men

2.2. The disease can begin at any The disease can begin at any age, but most often starts after age, but most often starts after age forty and before sixtyage forty and before sixty

OsteoarthritisOsteoarthritis1.1. Obesity (esp. for knee OA)Obesity (esp. for knee OA)

2.2. History of significant History of significant injury,particularly of the knee injury,particularly of the knee or hip (ligament or meniscal or hip (ligament or meniscal tear)tear)

3.3. History of surgery (a history History of surgery (a history

of menisectomyof menisectomy))4.4. Low dietary intake or serum Low dietary intake or serum

levels of vitamin Dlevels of vitamin D


Symptoms & Signs Symptoms & Signs Rheumatoid ArthritisRheumatoid Arthritis

FatigueFatigue General discomfort, uneasiness, or General discomfort, uneasiness, or malaisemalaise Loss of appetiteLoss of appetite Low-grade Low-grade feverfever Joint painJoint pain, joint stiffness, and , joint stiffness, and joint swellingjoint swelling Often symmetricalOften symmetrical May involve May involve wrist painwrist pain, , knee painknee pain, , elbow painelbow pain, , finger painfinger pain, toe pain, , toe pain, ankle painankle pain, or , or neck painneck pain Limited range of motionLimited range of motion The The spinespine except the atlanto-axial articulation in except the atlanto-axial articulation in late disease late disease is never affectedis never affected Morning stiffness usually Morning stiffness usually lasting more than 30 lasting more than 30 minmin Deformities of hands and feet Deformities of hands and feet Round, painless Round, painless nodulesnodules under the skin under the skin Skin redness or inflammationSkin redness or inflammation PalenessPaleness Swollen glandsSwollen glands Eye burning, itching, and dischargeEye burning, itching, and discharge Numbness and/or tinglingNumbness and/or tingling

SymmetricSymmetric swelling of peripheral joints is the swelling of peripheral joints is the hallmark of the diseasehallmark of the disease

Osteoarthritis

Pain in the affected joint(s) after repetitive useA crunching feeling or sound of bone rubbing on boneStiffness after getting out of bedJoin swelling or tenderness in one or more jointsEarly in the disease the joints may ache after exercise, late in the disease the joints ache even at restMost often occurs in hands, knee, hips, or spine/lower backCan have morning stiffness but usually last less than 30 min

Affected Joints Affected Joints Rheumatoid ArthritisRheumatoid Arthritis Osteoarthritis

Bouchard's node

The localized enlargement seen on the The localized enlargement seen on the proximal interphalangeal (proximal interphalangeal (PIPPIP) joint) joint

May not be painfulMay not be painful

Affected Joints Affected Joints Rheumatoid ArthritisRheumatoid Arthritis

Unlike OA, the distal Unlike OA, the distal interphalangeal (interphalangeal (DIPDIP) ) joints are generally sparedjoints are generally spared

Osteoarthritis

Heberden's Node

The localized enlargement seen on the The localized enlargement seen on the proximal interphalangeal (proximal interphalangeal (DIPDIP) joint) joint

May not be painfulMay not be painful

Nodules Nodules Rheumatoid ArthritisRheumatoid Arthritis Osteoarthritis

Typically does not have skin nodules

Blood WorkBlood Work

RheumatoidRheumatoid

1.1. Chemistries are Chemistries are normalnormal in rheumatoid in rheumatoid arthritis with the exception of a arthritis with the exception of a slight slight decrease in albumindecrease in albumin and and increase in increase in total proteintotal protein reflecting the chronic reflecting the chronic inflammatory process.inflammatory process.

2.2. A mild A mild anemiaanemia with hematocrit with hematocrit values in the range of 30 — values in the range of 30 — 34% occurs in approximately 34% occurs in approximately 25 to 35% of patients with 25 to 35% of patients with rheumatoid arthritisrheumatoid arthritis

(due to chronic disease or (due to chronic disease or even from blood loss from even from blood loss from NSAIDS)NSAIDS)


Most routine blood tests are normal in Most routine blood tests are normal in patients with uncomplicated patients with uncomplicated osteoarthritis. Analysis of osteoarthritis. Analysis of synovial fluid usually reveals a synovial fluid usually reveals a white blood cell count of less white blood cell count of less than 2,000 per mm3 (2.0 3 109 than 2,000 per mm3 (2.0 3 109 per L).per L).



3. The white cell count (3. The white cell count (WBCWBC) is ) is usually normal but can be mildly usually normal but can be mildly elevated secondary to elevated secondary to inflammationinflammation

4.4. PlateletPlatelet count is usually normal but count is usually normal but thrombocytosis occurs in response thrombocytosis occurs in response

to inflammationto inflammation 5. The erythrocyte sedimentation rate 5. The erythrocyte sedimentation rate

((ESRESR) is usually elevated, especially ) is usually elevated, especially in an acute inflammatory state.in an acute inflammatory state.


RheumatoidRheumatoid Rheumatoid factorsRheumatoid factors

- are - are antibodiesantibodies directed against directed against the Fc portion of the Fc portion of immunoglobulin G (IgG) immunoglobulin G (IgG)

- A positive test for rheumatoid - A positive test for rheumatoid factor is by no means factor is by no means pathognomonic of rheumatoid pathognomonic of rheumatoid arthritis, but is present in 70 to arthritis, but is present in 70 to 90% of patients with the disease 90% of patients with the disease

- patients with a high titer - patients with a high titer rheumatoid factor are more rheumatoid factor are more likely to have erosive joint likely to have erosive joint disease, extra-articular disease, extra-articular manifestations, and greater manifestations, and greater functional disability functional disability

- Rheumatoid factors are also - Rheumatoid factors are also detectable in non-rheumatoid detectable in non-rheumatoid patients (endocarditis, TB, HIV, patients (endocarditis, TB, HIV, collagen vascular disease)collagen vascular disease)


RheumatoidRheumatoidRheumatoid factorsRheumatoid factors

Low titers of rheumatoid Low titers of rheumatoid factors may be detected factors may be detected in the serum of in the serum of apparently apparently normal normal peoplepeople, especially over , especially over the age of 70, where its the age of 70, where its prevalence is anywhere prevalence is anywhere from 10 - 25% from 10 - 25%

Anti-nuclear antibody (ANA)Anti-nuclear antibody (ANA) Positive in 20-30% of Positive in 20-30% of patients with rheumatoid patients with rheumatoid arthritis and is more arthritis and is more common in patients with common in patients with extra-articular extra-articular manifestations manifestations

HLA-DR4 antigen HLA-DR4 antigen

It is associated with aggressive RAIt is associated with aggressive RA


RheumatoidRheumatoidRF titersRF titers

A titer is a measure of how much the A titer is a measure of how much the agglutination test blood sample agglutination test blood sample can be diluted before RF can no can be diluted before RF can no longer be detected. A titer of 1 longer be detected. A titer of 1 to 20 (1:20) means that RF can to 20 (1:20) means that RF can be detected when 1 part of the be detected when 1 part of the blood sample is diluted by up to blood sample is diluted by up to 20 parts of a salt solution 20 parts of a salt solution (saline). A larger second (saline). A larger second number means there is more RF number means there is more RF in the blood. Therefore, a titer of in the blood. Therefore, a titer of 1 to 80 indicates more RF in the 1 to 80 indicates more RF in the blood than a titer of 1 to 20 blood than a titer of 1 to 20

Normal value: 1:20 or lessNormal value: 1:20 or less

X-RAYX-RAY



X-RAYX-RAY



DiagnosisDiagnosisRheumatoidRheumatoid

Any 4Any 4 of the following criteria must be present to of the following criteria must be present to classify patients as having RA:classify patients as having RA:

1.1. Morning stiffness for > or = to 1 hour Morning stiffness for > or = to 1 hour **

2.2. Arthritis of 3 or more joints Arthritis of 3 or more joints **

3.3. Arthritis of hand joints (wrist, MCP, or Arthritis of hand joints (wrist, MCP, or PIP)PIP)

4.4. Symmetric arthritis Symmetric arthritis **5.5. Rheumatoid nodulesRheumatoid nodules

6.6. Serum rheumatoid factorSerum rheumatoid factor

7.7. Radiographic changes (hand x-ray film Radiographic changes (hand x-ray film changes typical of RA must include changes typical of RA must include erosions or unequivocal bony erosions or unequivocal bony decalificationdecalification

** Must be present for > or = 6 wks Must be present for > or = 6 wks

OsteoarthritisOsteoarthritisClassification Criteria for Osteoarthritis of the Classification Criteria for Osteoarthritis of the

HandHand

Hand pain, aching, or stiffness and 3 or 4 of the Hand pain, aching, or stiffness and 3 or 4 of the following features: following features:

1. Hard tissue enlargement of 2 or more of 10 1. Hard tissue enlargement of 2 or more of 10 selected jointsselected joints

22. . Hard tissue enlargement of 2 or more DIP Hard tissue enlargement of 2 or more DIP jointsjoints

3. Fewer than 3 swollen MCP joints3. Fewer than 3 swollen MCP joints

4. Deformity of at least 1 of 10 selected joints4. Deformity of at least 1 of 10 selected joints

* The 10 selected joints are the second and third * The 10 selected joints are the second and third distal interphalangeal (DIP), the second distal interphalangeal (DIP), the second and third proximal interphalangeal, and the and third proximal interphalangeal, and the first carpometacarpal joints of both hands. first carpometacarpal joints of both hands. This classification method yields a This classification method yields a sensitivity of 94% and a specificity of 87%. sensitivity of 94% and a specificity of 87%.

DiagnosisDiagnosis

OsteoarthritisOsteoarthritisClassification Criteria for Osteoarthritis Classification Criteria for Osteoarthritis

of the of the HipHip

Hip pain plus at least two of the Hip pain plus at least two of the following: following:

– ESR of less than 20 mm per ESR of less than 20 mm per hourhour

– Femoral or acetabular Femoral or acetabular osteophytes on radiographs osteophytes on radiographs

– Joint space narrowing on Joint space narrowing on radiographs radiographs

DiagnosisDiagnosis

OsteoarthritisOsteoarthritisClassification Criteria for Osteoarthritis Classification Criteria for Osteoarthritis

of the of the KneeKnee

Knee pain plus osteophytes on Knee pain plus osteophytes on radiographs and at least one of the radiographs and at least one of the following: following:

– Patient age older than 50 yearsPatient age older than 50 yearsMorning stiffness lasting 30 Morning stiffness lasting 30 minutes or lessminutes or less

– Crepitus on motionCrepitus on motion

Treatment of RATreatment of RA

NSAIDs:NSAIDs: Usually part of the initial treatment. NSAIDs decrease Usually part of the initial treatment. NSAIDs decrease inflammation and joint swelling but do not alter the course of the diseaseinflammation and joint swelling but do not alter the course of the disease

COX-2 inhibitorsCOX-2 inhibitors: Celebrex 100-200 mg PO BID: Celebrex 100-200 mg PO BID

GlucocorticoidsGlucocorticoids: : low-dose oral prednisone (< 10 mg/d or low-dose oral prednisone (< 10 mg/d or equivalent) and joint injections of glucocorticoids effective for relieving the equivalent) and joint injections of glucocorticoids effective for relieving the symptoms of RA….but does not slow the disease process.symptoms of RA….but does not slow the disease process.

TNF inhibitorsTNF inhibitors:: Infliximab (Remicade) and etanercept (Enbrel) Infliximab (Remicade) and etanercept (Enbrel) inhibit tumor necrosis factor (TNF), an important mediator of the inhibit tumor necrosis factor (TNF), an important mediator of the inflammatory response in RA. They are used alone or with methotrexate for inflammatory response in RA. They are used alone or with methotrexate for moderate-to-severe RA.moderate-to-severe RA.Remicade IV infusion: 3 mg/kg + MethotrexateRemicade IV infusion: 3 mg/kg + MethotrexateEnbrel: 50 mg SQ/wk (25 mg SQ X 2)Enbrel: 50 mg SQ/wk (25 mg SQ X 2)


Disease modifying antirheumatic drugs Disease modifying antirheumatic drugs (DMARDs) – (DMARDs) – have slow onset of action, usually over several have slow onset of action, usually over several months. They have minimal, if any, anti-inflammatory effect so concurrent months. They have minimal, if any, anti-inflammatory effect so concurrent NSAIDs are required during use.NSAIDs are required during use.

Methotrexate (MTX):Methotrexate (MTX): widely used as the initial DMARD, especially for widely used as the initial DMARD, especially for aggressive disease.aggressive disease.

-- best tolerated, so patients tend to take it longerbest tolerated, so patients tend to take it longer

- it is an antifolate agent (contraindicated in renal, liver dz or ETOH abuse)- it is an antifolate agent (contraindicated in renal, liver dz or ETOH abuse) - side effects (nausea, diarrhea, stomatitis, and less often alopecia)- side effects (nausea, diarrhea, stomatitis, and less often alopecia) - cause bone marrow suppression- cause bone marrow suppression - can cause idiopathic pnemonitis- can cause idiopathic pnemonitis - LFTs and CBC should be monitored every 4-8 weeks- LFTs and CBC should be monitored every 4-8 weeks

Dosage: 7.5 mg PO QD or 2.5 mg Q12 hr X 3 doses (Max 20 mg Q/week) w/ folateDosage: 7.5 mg PO QD or 2.5 mg Q12 hr X 3 doses (Max 20 mg Q/week) w/ folate


Disease modifying antirheumatic drugs Disease modifying antirheumatic drugs (DMARDs)(DMARDs)Hydroxychloroquine (HCQ):Hydroxychloroquine (HCQ): need regular eye checks for possible need regular eye checks for possible retinopathy (Plaquenil 400-600 mg QD)retinopathy (Plaquenil 400-600 mg QD)

Sulfasalazine (SSZ):Sulfasalazine (SSZ): side effects N/V, diarrhea, and crampy addominal side effects N/V, diarrhea, and crampy addominal pain, reversible oligospermia, decrease in RBCs, WBCs, and platelets pain, reversible oligospermia, decrease in RBCs, WBCs, and platelets (periodic CBC required) (500 mg PO qd-bid after meals up to 1 gm QD)(periodic CBC required) (500 mg PO qd-bid after meals up to 1 gm QD)

Leflunomide (Arava): 100 mg PO qd X 3 days. Maintenance: 10-20 mg QDLeflunomide (Arava): 100 mg PO qd X 3 days. Maintenance: 10-20 mg QD

These are used for patients with milder disease because of low side These are used for patients with milder disease because of low side effects and low cost.effects and low cost.


Other meds:Other meds:Gold salts:Gold salts: good response. Gold treatment is generally not stopped if the good response. Gold treatment is generally not stopped if the patients gets a nonpruritic rash, mild stomatitis, slight decrease in WBCs, or patients gets a nonpruritic rash, mild stomatitis, slight decrease in WBCs, or slight proteinuria.slight proteinuria.

- IM injection is better than oral- IM injection is better than oral

D-penicillamineD-penicillamine side effects similar to gold.side effects similar to gold.

Treatment of OATreatment of OA

Disease managementDisease managementOA is a condition which progresses slowly over a period of many years and OA is a condition which progresses slowly over a period of many years and

cannot be curedcannot be cured..

Treatment is directed at Treatment is directed at decreasing the symptomsdecreasing the symptoms of the condition, and slowing of the condition, and slowing the progress of the conditionthe progress of the condition

Functional treatment goals:Functional treatment goals:

1. Limit pain1. Limit pain

2. Increase range of motion2. Increase range of motion

3. Increase muscle strength3. Increase muscle strength


Step-wise approachStep-wise approach

Step 1Step 1 (Non-pharmacologic therapy) (Non-pharmacologic therapy)

a.a. Patient educationPatient education

b.b. Programs for aerobic exercisePrograms for aerobic exercise

c.c. If overweight, weight lossIf overweight, weight loss

d.d. Physical therapy or occupational therapyPhysical therapy or occupational therapy

e.e. Walking aidsWalking aids

f.f. Shock absorptionShock absorption

g.g. Re-alignment through orthoticsRe-alignment through orthotics



Step 2Step 2 (Pharmacologic therapy) (Pharmacologic therapy)

Initial approach:Initial approach:

For For mild to moderate painmild to moderate pain can use can use TylenolTylenol, up to 4 gm QD/ 1 mg QID (caution in liver , up to 4 gm QD/ 1 mg QID (caution in liver disease and ETOH abuse); disease and ETOH abuse); NSAIDS NSAIDS (caution GI bleeder/PPI)(caution GI bleeder/PPI)

alternative alternative topical capsaicin cream (Zostrix) or methyl salicylate cream (Ben Gay). topical capsaicin cream (Zostrix) or methyl salicylate cream (Ben Gay).

For For moderate to severe painmoderate to severe pain and swollen joints can do aspiration and injection of and swollen joints can do aspiration and injection of glucocorticoids such as Aristospan (triamcinolone hexacetonide 40 mg ) or glucocorticoids such as Aristospan (triamcinolone hexacetonide 40 mg ) or prednisone 8-20 mg with maximum of 3-4 times per year. (can reduce pain for up prednisone 8-20 mg with maximum of 3-4 times per year. (can reduce pain for up to 4 weeks)to 4 weeks)




When initial therapy is inadequate:When initial therapy is inadequate:

1.1. COX-2 inhibitor (COX-2 inhibitor (CelebrexCelebrex) 200 mg PO qd or 100 mg BID) 200 mg PO qd or 100 mg BID

2.2. If contraindicated to COX-2 inhibitor or NSAIDS, then can try If contraindicated to COX-2 inhibitor or NSAIDS, then can try UltramUltram 200- 200-300 mg divided evenly, QID.300 mg divided evenly, QID.

Other medication:Other medication:

Sodium hyaluronate injection (Synvisc, Sodium hyaluronate injection (Synvisc, HyalganHyalgan) is indicated only for the ) is indicated only for the treatment of patients with treatment of patients with osteoarthritis of the kneeosteoarthritis of the knee. 5 injections (once . 5 injections (once per week of 20 mg)per week of 20 mg)




Alternative medicines: (Glucosamine & Chondroitin)Alternative medicines: (Glucosamine & Chondroitin)

1.1. GGlucosaminelucosamine sulfate- a form of sulfate- a form of amino sugaramino sugar that is believed to play a role in that is believed to play a role in cartilage formation and repair. (crab, lobster, shrimp shells) 1,500 mg QDcartilage formation and repair. (crab, lobster, shrimp shells) 1,500 mg QD

2.2. ChondroitinChondroitin sulfate- part of a large protein molecule (proteoglycan) that gives sulfate- part of a large protein molecule (proteoglycan) that gives cartilage elasticity. (shark cartilage) 1,200 mg QDcartilage elasticity. (shark cartilage) 1,200 mg QD

Side effects: intestinal gas/softened stoolSide effects: intestinal gas/softened stool

Caution: glucosamin-diabetic/Caution: glucosamin-diabetic/

chondroitin (similar to heparin), caution in ASA/coumadin usechondroitin (similar to heparin), caution in ASA/coumadin use



Step 3Step 3 (Surgery) (Surgery)

1.1. Proximal Tibial OsteotomyProximal Tibial Osteotomy

2.2. Total knee replacementTotal knee replacement


Proximal Tibial Osteotomy Proximal Tibial Osteotomy (for younger, (for younger, active patients with 1 side of knee active patients with 1 side of knee affected)affected)

OA usually affects the medial OA usually affects the medial compartments more often than the compartments more often than the lateral compartments lateral compartments Bowlegged Bowlegged

Closing wedge vs. Opening wedgeClosing wedge vs. Opening wedge

Successful operation would last 5-7 years.Successful operation would last 5-7 years.


Total Knee ReplacementTotal Knee Replacement

- - Usually considered in patients over the age of 60Usually considered in patients over the age of 60- Last for about 12 yearsLast for about 12 years

Not recommend in younger patients Not recommend in younger patients because:because:

1. The younger the patient, the more likely the artificial joint will fail1. The younger the patient, the more likely the artificial joint will fail

2. Younger patients are more active and place more stress on thartificial2. Younger patients are more active and place more stress on thartificial

joint, that can lead to loosening and failure earlierjoint, that can lead to loosening and failure earlier

3. Younger patient are more likely to outlive their artificial joint, and will 3. Younger patient are more likely to outlive their artificial joint, and will almost surely require a revision at some point down the roadalmost surely require a revision at some point down the road

4. Replacing the knee the second or third time is much harder and and much 4. Replacing the knee the second or third time is much harder and and much less likely to succeed.less likely to succeed.

Treatment of OATreatment of OATotal knee replacementTotal knee replacement

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Rheumatoid Arthritis VS Osteoarthritis Phong Dao