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7/28/2019 RheumBoardReviewRA OA Arthropathies
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Osteoarthritis, Rheumatoid
Arthritis, and
Spondylarthropathies
Timothy Niewold, MD
Assistant Professor
Section of Rheumatology
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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
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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
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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
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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
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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
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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
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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
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X-ray classic changes due to
OA
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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
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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
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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
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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
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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
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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
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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
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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
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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.
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Joints Commonly Involved
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Rheumatoid Arthritis Extra-
articular features
Rheumatoid nodules
Pleural effusions
Atherosclerosis (new, but probablytestable)
Scleritis
Rheumatoid vasculitis (rare)Feltys syndrome (neutropenia,
splenomegaly, recurrent infection)
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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
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Major RA Subsets Based on ACPA
Reproduced with permission from Klareskog L, Catrina AI, Paget S.Lancet. 2009;373(9664):659-672. 22
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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
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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
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Rheumatoidarthritis
erosions on
X-ray
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Early RA: RadiographicFindings
High-Detail X-Ray Low-Field MRI
Courtesy of Charles Peterfy, MD.
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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
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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
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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
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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
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Spondylarthropathies
Ankylosing Spondylitis
Psoriatic Arthritis
Enteropathic Arthritis and Reactive
Arthritis
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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
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X-ray of sacroileitis
A k l i d liti l b
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Ankylosing spondylitis: lumbar
vertebrae, bamboo spine
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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
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Psoriatic arthritis: hand
Spondylarthropathies
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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
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Questions???