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Rheumatology 101: What you need to know for your ambulatory medicine experience. Kevin Latinis, M.D./Ph.D. Division of Rheumatology Dept. of Internal Medicine [email protected] Rheumatology 101. Arthritis -Inflammatory (RA, spondyloarthropathies) -Mechanical (OA) Lupus Fibromyalgia

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Rheumatology 101:What you need to know for your ambulatory medicine experience

Kevin Latinis, M.D./Ph.D.

Division of Rheumatology

Dept. of Internal Medicine

[email protected]


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Rheumatology 101

  • Arthritis-Inflammatory (RA, spondyloarthropathies)-Mechanical (OA)

  • Lupus

  • Fibromyalgia

  • Low back pain and other peri-articular complaints

  • General musculoskeletal exam (time permitting)


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Mechanical vs. Inflammatory Arthritis

Latinis, K., et al TheWashington Manual Rheumatology Subspecialty Consult., LWW, 2003.


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Osteoarthritis-Background

  • Very common-2nd leading cause for disability in USA-In patients 60 and older: affects 17% of men and 30% of women-Estimated that 59.4 million patients will have OA by the year 2020

  • Etiology-primary idiopathic-secondary


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Osteoarthritis-Distribution

Bouchard’s

Heberden’s

Latinis, K., Dao, K, Shepherd, R, Gutierrez, E, Velazquez, C. TheWashington Manual Rheumatology Subspecialty Consult., LWW, 2003.


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Osteoarthritis-Diagnosis

  • Clinical

  • Supported by X-rays

  • Non-inflammatory lab data, if any


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Osteoarthritis-Treatment

  • Pain relief-Analgesics and NSAIDs/Cox-2 Inhibitors

  • SMOADs (structure modifying osteoarthritis drugs)-Glucosamine Sulfate -see meta-analysis McAlindon et al. JAMA, 283: 3/2000, p. 1469-many under development

  • Non-pharmacologic approaches-Reduce stress/load on joint-Strengthen surrounding muscles-PT/OT-Weight reduction-Patient education

  • Limit disability and improve quality of life


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Osteoarthritis-Treatment

  • Joint Replacement Surgery-Primarily of knee and hip, but also available in hands, shoulders,& elbows-Indications: 1. pain at rest 2. instability-patients benefit from aggressive PT before & after surgery

  • Other surgical procedures


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Clinical Pearl:Arthritis of the DIP joint

Psoriatic Arthritis (inflammatory)

OA (non-inflammatory)


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Inflammatory Arthritis

  • Rheumatoid arthritis

  • Spondyloarthropathies-Undifferentiated-Ankylosing spondylitis-Psoriatic arthritis-Reactive arthritis (formerly Reiter’s syndrome)-Enteropathic arthritis

  • SLE, Sjogrens, Scleroderma, Polymyalgia rheumatica, Vasculitis, Infectious (bacterial, viral, other), Undifferentiated connective tissue disease


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Latinis, K., et al TheWashington Manual Rheumatology Subspecialty Consult., LWW, 2003.


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Rheumatoid Arthritis-Background

  • Symmetric, inflammatory polyarthritis

  • Affects ~1% of our population

  • Occurs in women 3x more than men

  • Etiology-Genetic, class II molecules (HLA-DRB1)-Autoimmune-?Environmental


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Rheumatoid Arthritis-Distribution

Latinis, K., et alTheWashington Manual Rheumatology Subspecialty Consult., LWW, 2003.


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Latinis, K., et al TheWashington Manual Rheumatology Subspecialty Consult., LWW, 2003.


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Systemic Lupus Erythematosus (Lupus)-Background

Definition

-An inflammatory multisystem disease of unknown etiology

with protean clinical and laboratory manifestations and a

variable course and prognosis.

-Immunologic aberrations give rise to excessive autoantibody

production, some of which cause cytotoxic damage, while

others participate in immune complex formation resulting in

immune inflammation.


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Systemic Lupus Erythematosus (Lupus)-Background

Clinical features

-Clinical manifestations may be constitutional or result from

inflammation in various organ systems including skin and

mucous membranes, joints, kidney, brain, serous membranes,

lung, heart and occasionally gastrointestinal tract.

-Organ systems may be involved singly or in any combination.

-Involvement of vital organs, particularly the kidneys and

central nervous system, accounts for significant morbidity

and mortality.

-Morbidity and mortality result from tissue damage due to

the disease process or its therapy.


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1. Serositis: (a) pleuritis, or (b) pericarditis

2. Oral ulcers

3. Arthritis

4. Photosensitivity

10. Malar rash

11. Discoid rash

5. Blood/Hematologic disorder: (a) hemolytic anemia or (b) leukopenia of < 4.0 x 109 (c) lymphopenia of < 1.5 x 109 (d) thrombocytopenia < 100 X 109

6. Renal disorder: (a) proteinuria > 0.5 gm/24 h or 3+ dipstick or (b) cellular casts

7. Antinuclear antibody (positive ANA)

8. Immunologic disorders: (a) raised anti-native DNA antibody binding or (b) anti-Sm antibody or (c) positive anti-phospholipid antibody work-up

9. Neurological disorder: (a) seizures or (b) psychosis

Systemic lupus erythematosus classification criteria(SOAP BRAIN MD)

". ..A person shall be said to have SLE if four or more of the 11 criteria are present, serially or simultaneously, during any interval of observation."


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53 yo BF with severe generalized weakness,

weight loss, and chronic psychosis

Alopecia

Psychosis

Malar rash

Arthritis


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Laboratory Data

139

106

16

7.7

101

298

3.9

4.3

21

1.4

22.3

MCV=83

24 hour urine

Protein=514

Absolute lymph=0.5

ESR=119

CH50=67 (118-226)

C3=31 (83-185)

C4=18 (12-54)

ANA + 1:5280

Anti DNA +

Direct & Indirect Coombs +

Anti-IgG +


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Arthritis, arthralgias, myalgias: NSAIDS, anti-malarials (eg. Plaquenil), Steroids- injections, oral methotrexate

Photosensitivity, dermatitis avoid Sun exposure topical steroids Plaquenil

Weight loss and fatigue steroids

Abortion, fetal loss ASA immunosuppression

Thrombosis anti-coagulants

Glomerulonephritis steroids pulse cytotoxics mycophenylate mofetil

CNS disease anti-coagulants for thrombosis steroids and cytotoxics for vasculitis

Infarction (secondary to vasculitis) steroids cytotoxics prostacyclin

Cytopenias steroids IVIG-short term for thrombocytopenia danazol cytotoxics-if bone marrow status is known

Treatment of SLE


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Steroid responsive Dermatitis (local) (eg. Plaquenil), Steroids- injections, oral methotrexate

Polyarthritis

Serositis

Vasculitis

Hematological

Glomerulonephritis (most)

Myelopathies

Steroid non-responsive Thrombosis Chronic renal damage Hypertension Steroid-induced psychosis Infection

Steroids in Lupus


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ANA-When to order and how to follow up on a positive test (eg. Plaquenil), Steroids- injections, oral methotrexate

Latinis, K., et al TheWashington Manual Rheumatology Subspecialty Consult., LWW, 2003.


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Latinis, K., et al (eg. Plaquenil), Steroids- injections, oral methotrexate TheWashington Manual Rheumatology Subspecialty Consult., LWW, 2003.


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Fibromyalgia-Background (eg. Plaquenil), Steroids- injections, oral methotrexate

  • Chronic musculoskeletal pain syndrome of unknown etiology

  • Characterized by diffuse pain, tender points, fatigue, and sleep disturbances

  • Prevalence is 2-5% with a female to male predominance of 8:1

  • Mean age is 30-60


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Fibromyalgia-Diagnosis (eg. Plaquenil), Steroids- injections, oral methotrexate


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4 (eg. Plaquenil), Steroids- injections, oral methotrexate

3

1

2

6

5

7

8

9


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Fibromyalgia-Treatment (eg. Plaquenil), Steroids- injections, oral methotrexate


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Low back pain and (eg. Plaquenil), Steroids- injections, oral methotrexateother peri-articular complaints-background

  • Very common, one of the most frequent reasons to visit primary care physicians

  • Articular vs peri-articular problems-Articular pain is generally deep or diffuse and worsens with active and passive motion-Periarticular pain usually exibits point tenderness and increased tenderness with active, but NOT passive motion


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Latinis, K., et al (eg. Plaquenil), Steroids- injections, oral methotrexate TheWashington Manual Rheumatology Subspecialty Consult., LWW, 2003.


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Latinis, K., et al (eg. Plaquenil), Steroids- injections, oral methotrexate TheWashington Manual Rheumatology Subspecialty Consult., LWW, 2003.


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Latinis, K., et al (eg. Plaquenil), Steroids- injections, oral methotrexate TheWashington Manual Rheumatology Subspecialty Consult., LWW, 2003.


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Muscles of the rotator cuff: (eg. Plaquenil), Steroids- injections, oral methotrexate

Supraspinatus

Infraspinatus

Subscapularis

Teres Minor


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Low back pain and (eg. Plaquenil), Steroids- injections, oral methotrexateother peri-articular complaints-Treatment

  • RICE-Rest-Ice-Compression-Elevation

  • NSAIDs and analgesics

  • Time

  • Other


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General Musculoskeletal Exam (eg. Plaquenil), Steroids- injections, oral methotrexate

  • Underutilized by primary care providers

  • Should be simple and quick

  • Goal is to recognize signs of rheumatological diseases and determine if it is appropriate to refer to a rheumatologist or manage independently


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Summary (eg. Plaquenil), Steroids- injections, oral methotrexate

  • Arthritis-Inflammatory (RA, spondyloarthropathies)-Mechanical (OA)

  • Lupus

  • Fibromyalgia

  • Low back pain and other peri-articular complaints

  • General musculoskeletal exam (time permitting)


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