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Small Feedings of the Mind: Rheumatology

Small Feedings of the Mind: Rheumatology. Brian J. Keroack, MD, FACP, FACR. Question #1: What do I REALLY need to know ?. English measured concordance rate between Rheumatologist and Internist before and 6 months after spending a day with a Rheumatologist. Before 0.4 (F) after 0.9 (A-)

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Small Feedings of the Mind: Rheumatology

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  1. Small Feedings of the Mind: Rheumatology Brian J. Keroack, MD, FACP, FACR

  2. Question #1: What do I REALLY need to know? • English measured concordance rate between Rheumatologist and Internist before and 6 months after spending a day with a Rheumatologist. • Before 0.4 (F) after 0.9 (A-) • Two things stood out: First can you ask an intelligible question about morning stiffness and Second can you find joint swelling (synovitis) • Inflammatory Arthritis is what you do not want to miss. • 1.5% of the US has Rheumatoid Arthritis, others of note include Psoriatic Arthritis, Ankylosing Spondylitis. • If you are to stand a chance there are certain TOOLS that you will need • NO NOT THE LAB!!!!

  3. Location, Location, Location DIP JOINTS It takes me till 11AM to…or, I just don’t get it I was splitting wood 4 weeks ago now I have trouble brushing my teeth I have all these bumps and I cannot make a fist anymore. If symptomatic; use related Second/third MCP

  4. Progression of Rheumatoid Arthritis Make the diagnosis HERE SYNOVITIS NOT HERE What’s left after the fire

  5. Listen to the patient—they will tell you the diagnosis: William Osler Age <40. Worst in AM. Pain IMPROVED by exercise not relieved by rest. Need to file for disability cannot even lift a gallon of milk. Sharp/Mechanical Symptoms—Please don’t check HLA-B27

  6. Case 27 year old male has had back aching for 3 years. He states that the pain is worst in the morning and occasionally wakes him at night. He takes 600 mg Ibuprofen TID and ‘never misses a pill’. He almost cancelled the appointment because changing jobs from telemarketing to landscaping has improved his symptoms Examination: Decreased side bend cervical spine at 30 degrees. Schober=2.5 cm (what is this?)

  7. Most Psoriasis Patients Don’t have Psoriatic Arthritis, But… Note Asymmetry Tenosynovitis dominates in Dactylitis Nails Dactylitis

  8. Clinical Enthesitis (Spondyloarthropathy) psoriasis Achilles enthesitis

  9. Psoriatic Arthritis “Enthesitis”Gutierrez, Grassi: Clin Rheumatology: (2010) 29: 133-42 Achilles Erosion calcaneus +doppler

  10. Medical Management: Immunosupressives • 80 year old female with Rheumatoid Arthritis on Enbrel. She presents to the ED with nausea having vomited once. Afebrile, no other symptoms. She is alert. Presumed viral gastroenteritis. 24 hours later she is delirious and has a BP of 60/40 with a HR of 121. • Diagnosis • Gram Negative sepsis from Urinary tract infection • I’ve got at least 7 more stories like this • When these patients present they have a greater burden of illness and FEWER symptoms

  11. Plethora of ‘TOOLS” TNF-a Blockade IL-1 RA IL-6 Receptor Blocker IL-12/IL-23 (Stelara) IL-17 (coming soon) This category is associated with standard bacterial infections However, when patients do present they will be further along and will have fewer (more subtle symptoms) ?No Fever, ? No Cough, No Dysuria—makes it much more difficult

  12. HUMIRA + MTX (n=268) 12 HUMIRA (n=274) 10 MTX (n=257) 8 6 4 2 0 0 26 52 78 104 PREMIER Change in Total Sharp Score 10.4 Mean Change From Baseline * 5.5 5.7 * 3.5 3.0 * † 1.9 2.1 † † 1.3 0.8 Weeks OMG—If one is good TWO must be better!!! We see a 25% increase in remissions when we add Methotrexate to ANYTHING---And we add it to EVERYTHING! .

  13. Rituxan ‘Tags’ B-cells NK Cells Macrophages destroy them Another system called complement drills holes in the rest Remember not all antibody producing cells are ‘bad’ So what does THIS mean Vaccine TIMING is everything ‘New’ Infection defenses impared Hyopgammaglobulinemia

  14. Beyond Biologic Response Modifiers XELJANZ Janus Kinase Inhibitor Cytokine hits receptor but how does message get to Nucleus? JAK-STAT System IL-6 (and others) Activates JAK-STAT system Typical Infections

  15. Take Home Message? • Therapeutic ‘revolution’ has occurred in the management of Rheumatoid Arthritis and other inflammatory syndromes • Early diagnosis is the key—we need YOU!!! • Wildly effective; wildly EXPENSIVE • You will hear about some associations: ? Multiple Sclerosis, Lymphoma—These are not relevant and only provide a distraction to the real problems we face in patients on these medications (population based data—no statistical link) • Infection, Infection, Infection

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