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

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?

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 Felty�s 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

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

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 3:1 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

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 whipple�s 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 Felty�s syndrome, large granular lymphocyte syndrome, lymphomas

30. Extra-articular manifestations Pulmonary pleuritis, nodules, interstitial lung disease, bronchiolitis obliterans, arteritis, effusions Others Sjogren�s syndrome, amyloidosis

31. Felty�s syndrome classic triad RA, splenomegaly, leukopenia generally a neutropenia (<2000/mm3) 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?

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

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 physician�s 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 <30 mm/hr (women) or 20 mm/hr (men) 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