Rheumatology: Arthritic Disorders

Basic Concepts

inflammatory vs non-inflammatory
-autoimmune vs OA

signs of inflammation

• warmth

• swelling

• eryhtema

• AM stiffness x 30+ mins

• CRP/ESR→elevated

• synovial fluid/synovium+inflammation

number of joints involved

what joints involved

Rheumatoid Arthritis (RA)

PP: chronic+systemic autoimmune condition→causes joint pain
multiple smaller joints in a symmetric distribution

RF:
genetic

• human leukocyte antigen (HLA) genes

• female

• 40-50y/o

non-genetic

• smoking

• environmental
  -silica
  -dust

• gut health

• diet

CM: symmetric joint pain
-early→small joints
-late→large joints

AM stiffness x 30+ minutes
-reoccur after increased mobility

warmth of joint (inflamed tissue)

joint erythema

loss of range of motion (ROM)

deformities (complications→late dx)

• ulnar deviation/”drift”

• boutonniere

• swan neck

• plantar subluxation

• hallux valgus

other organ involvement

DX: RF
anti-citrullinated peptide antibodies (ACPA/anti-CCP)
HLA-B27

inflammatory markers

• ESR

• CRP

XRay

• osteopenia
  -decreased bone density

• erosions

• soft tissue swelling

• joint space narrowing

US

• soft tissue changes

• swelling

MRI

• bone+soft tissue abnormalities

TX:
prophx

• DMARDS

• bDMARDS

pain relief

• NSAIDS

• glucocorticoids

rheumatology referral

Methotrexate+Folate

MX: DMARDS

MOA: dx-modifying anti-rheumatic drugs

I: RA

AE: GI upset
LFT→increased

DX (x3 months): CBC
CMP
CRP
ESR
-more frequent in beginning

CI: child bearing
hepatitis
alcohol
bactrim
amoxicillin
probenecid

Sulfasalazine

MX: DMARDS

MOA: disease modifying anti-rheumatic drugs

I: RA

AE: GI upset

DX (x3 months): CBC
CMP
CRP
ESR
-more frequent in beginning

CI: ASA
G6PD

Hydrochloroquinolone

MX: DMARDS

MOA: disease modifying anti-rheumatic drugs

I: RA

AE: none
chronic→retina involvement

DX (x3 months): CBC
CMP
CRP
ESR
-more frequent in beginning

CI: retina issue

Leflunomide

MX: DMARDS

MOA: disease modifying anti-rheumatic drugs

I: RA

AE: diarrhea
rash
hair loss

DX (x3 months): CBC
CMP
CRP
ESR
-more frequent in beginning

CI: child bearing

Biologic DMARDS (bDMARDs): MOA+MX

affect epcific pathway of inflammation→decrease active inflammation+prevent joint damage

block cytokine tumor necrosis factor (TNF)

• etanercept

• infliximab

• adalimumab

• golimumab

• certolizumab pegol

suppress t cells

• abatacept

suppress b cells

• rituximab

block cytokin IL-6

• tocilizumab

• sarilumab

JAK inhibitors

• baricitinib

• upadacitinib

• tofacitinib

Biologic DMARDS (bDMARDs): General

ROA: duration→indefinite
-x3-6 months to produce effect
if sick+next dose due→wait

AE: injection site rxn
increased RF of infxn
MS
leukemia

black box warning→JAK

• heart-related events

• cancer

• blood clots

• death

DX:
before tx

• CBC

• CMP

• quantiferon TB gold

• hep B/C

after tx (Q3 months)

• CBC

• CMP

• CRP

• ESR

CI: h/o cancer
MS
hepatitis B
hepatitis C
TB
TNF→HF

Rheumatoid Arthritis (RA): Dx+Tx

DX

• DAS28-ESR

• thorough hx+PE

• good note writing

TX

NP: PT/OT
diet
deformities→surgery

MX: NSAIDS
glucocorticoids
intra-articular steroid injections
omega-3 supplements

Rheumatoid Arthrits (RA): Complications

ulnar deviation

boutonniere

swan neck

plantar subluxation of metatarsal head+hallux valgus

rheumatoid nodules

excessive amount of inflammatory exudate inside synovial cavity

• formation of cysts→drain→fistula

• rupture→spread of inflammation

• baker cyst

rheumatoid nodules
extrasynovial→out

• collection of inflammatory cells

• areas of pressure/trauma→extensor surfaces

• 20-30%

• organ involvement
  -sclera
  -heart
  -lung

Rheumatoid Arthrits (RA): Organ System Complications

opthalmology

• scleritis

• episcleritis

cardiac

• valvular deformities

• pericardial effusion

• pericarditis

• aortitis
  -aortic regurgitation
  -rupture

pulmonary

• fibrosis

• ILD

• pleural effusion

GI

• splenomegaly
  -+neutropenia→felty syndrome

hematology

• lymphadenopathy

• anemia

• vasculitis→thrombosis/nrecrosis
  -MI
  -CVA
  -kidney damage
  -rayndaud phenomenon

MSK

• deformities

• atlantoaxial subluxation→myelopathy
  -spares rest of spine+SI joints

• muscle atrophy

• septic arthritis

neurology

• nerve entrapment

Rheumatoid Arthritis (RA): Prognosis

early+aggresive tx→better outcome

• systemic impact→decreased

• joint damage→decreased

• decreased developement of deformity/disability

control HTN+DM+obesity

no smoking

Oligoarticular Juvenile Idiopathic Arthritis (JIA)

PP: chronic inflammatory dx→causes joint pain in childhood
duration→6+ weeks

RF: genetic susceptibility→HLA

E: m/c form
r/o other dxs
u16 y/o

CM:

• up to 4 joints

• medium-large joints

• asymmetrical

• uveitis

• no systemic sxs

Systematic Juvenile Idiopathic Arthritis (sJIA)

PP: chronic inflammatory dx→causes joint pain in childhood
duration→6+ weeks

RF: genetic susceptibility→HLA

E: r/o other dxs
u16 y/o

CM:

1+ joints+fever+at least 1 of below

• sore thrat

• rash
  -salmon-colored
  -macular
  -nonpruitic
  -chest+abdomen or pressure areas

• serositis

• lymphadenopathy

• hepatomegaly

• splenomegaly

small-large joint involvement
-any #
-can be asx at onset

high fever 2x/day→returns to normal/subnormal

DX: anemia
leukocytosis
ferritin→elevated

Polyarticular Juvenile Idiopathic Arthritis (JIA)

PP: chronic inflammatory dx→causes joint pain in childhood
duration→6+ weeks

RF: genetic susceptibility→HLA

E: 2nd m/c form
r/o other dxs
u16 y/o

CM:

• 5+ joints

• small-large joints

• symmetrical

Ethesitis-Related Juvenile Idiopathic Arthritis (JIA)

PP: chronic inflammatory dx→causes joint pain in childhood
duration→6+ weeks

RF: genetic susceptibility→HLA
male
10+ y/o

E: 2nd m/c form
r/o other dxs
u16 y/o

CM:

• 5+ joints

• large joints→lower extremities
  -low back
  -SI joints

• enthesitis→inflammation at tendon/ligament
  -tibia tubercle
  -heel

Psoriatic Juvenile Idiopathic Arthritis (JIA)

PP: chronic inflammatory dx→causes joint pain in childhood
duration→6+ weeks

RF: genetic susceptibility→HLA
male
10+ y/o

E: 2nd m/c form
r/o other dxs
u16 y/o

CM:
psoriatic:
± psoriasis+2 of the following:

• dactylitis→”sausage digit”

• nail changes

• 1st degree FHx of psoriasis

Undifferentiated Juvenile Idiopathic Arthritis (JIA)

PP: chronic inflammatory dx→causes joint pain in childhood
duration→6+ weeks

RF: genetic susceptibility→HLA
male
10+ y/o

E: 2nd m/c form
r/o other dxs
u16 y/o

CM:
undifferentiated:

• don’t meet criteria of other subgroups

• meet criteria for 2+ subgroups

JIA Dx

labs

• RF

• anti-CCP

• ANA

• HLA-B27

• CRP

• ESR

• CBC

• CMP

synovial fluid

imaging

• XRay

• US

• MRI

JIA NP Tx

PT/OT

shoe lift

diet

eye exam x 4 months post-arthritis onset

• ANA+→slit lamp exam q3 months

• ANA→slit lamp exam q6 months

primary care

• NSAIDS

• pediatric rheumatology referral

JIA Mx Tx

sx relief→NSAIDS

• naproxen

• ibuprofen

• meloxicam

prophx→DMARDS

• methotrexate

• leflunolide

prophx→bDMARDS

• block chemokine tumor necrosis factor (TNF):
  -etanercept
  -infliximab
  -infliximab
  -adalimumab

• block IL-1:
  -anakinra
  -canakinumab

• block IL-6→tocilizumab

• suppress b cells→rituximab

• supresss t cells→abatacept

• janus kinase (JAK) inhibitors

DMARD/bDMARD DX (q3 months):

• CBC

• CMP

• CRP

• ESR

corticosteroids

• IA injections

• opthalmic drops

JIA Complications

blindness

ankylosing spondylitis

leg-length discrepancy

macrophage activation syndrome (MAS)

• coagulopathy

• pancytopenia

• liver dysfxn

JIA Prognosis

varies depending on subgroup

highest rate of remission→oligoarticular JIA+seronegative

highest rate of chronic+erosive dx

• RF+ dx

• systemic sxs last longer than 6m

Psoriatic Arthritis (PsA)+Primary Care Tx

RF: genetics→HLA
non-genetic→environmental trigger
-trauma
-smoking
-infxn
-gut health

E: HLA-B27

CM: asymmetric
larger joint
enthesitis→inflammation at tendon/ligament/joint capsule insertion point
ocular inflammation
finger/toe dactylitis
nail changes
uveitis
IBD/IBD-like sxs

DX:
autoantibodies→absent

• RF

• anti-CCP

HLA-B27 testing
CRP
ESR
uric acid→elevated

XRay

• osteopenia

• ethesophyte

• erosions

• soft tissue swelling

• joint space narrowing→”pencil-in-cup” deformity

US

• soft tissue changes

• swelling

MRI→bone+soft tissue abnormalities

TX:
primary care

• NSAIDS

• glucocorticoids

• rheumatology referral

PsA Mx Tx

sx relief→NSAIDS

• naproxen

• ibuprofen

• meloxicam

glucocorticoids

intra-articular steroid injections

prophx→DMARDS

• methotrexate

• sulfasalazine

prophx→bDMARDS

• block chemokine tumor necrosis factor (TNF):
  -etanercept
  -infliximab
  -infliximab
  -adalimumab
  -golimumab
  -certolizumab

• block IL-12+23→ustekinumab

• block IL-17:
  -secukinumab
  -ixekizumab
  -brodalumab
  -bimekizumab

• block IL-23:
  -guselkumab
  -risankizumab

• phosphodiesterase 4 inhibitors→apremilast

• janus kinase (JAK) inhibitors:
  -tofacitinib
  -upadacitinib

bDMARD DX:
pre-initiation

• CBC

• CMP

• quantiferon TB gold

• hepatitis B+C

post-initiation (q3 months)

• CBC

• CMP

• CRP

• ESR

PsA Tx: bDMARDS

ROA: duration→indefinite
timing→3-6 months for tx

AE: injection site rxn
increased infxn risk
MS
leukemia

DX:
pre-initiation

• CBC

• CMP

• quantiferon TB gold

• hepatitis B+C

post-initiation (q3 months)

• CBC

• CMP

• CRP

• ESR

CI: h/o cancer
MS
hepatitis B
hepatitis C
TB

black box warning→JAK

• heart-related events

• cancer

• blood clots

• death

Pt edu→sick+next dose due→wait

PsA NP Tx

PT/OT

diet

deformities→surgery

PsA Prognosis

earlier+aggressive tx→better outcome

• systemic impact→decreased

• joint damage→decreased

• decreased development of deformities+disabilities

Ankylosing Spondylitis (AS)

PP: HLA-B27 gene mutation→autoimmune axial spine→stiffening→fusion
-intervertebral joints
-facet joints
-sacroiliac joints

RF: HLA-B27
men
u40-45 y/o→20-30 y/o
trauma
smoking
gut health

E: radiographic (AS)
non-radiographic

CM: sacroilitis→inflammation of sacroiliac joints
peripheral joint pain
dactylitis
syndesmophytes→enthesis formed on top of previous enthesis

low back pain+stiffness

• gradual onset

• AM stiffness 1+ hr

• improves with exercise

enthesitis→tendon/ligament insertion point inflammation

• costosternal
  -chest pain
  -restricted chest movement

• ischial tuberosity→pain with sitting

• achilles
  -walking pain
  -limp

• plantar fasciitis→heel pain

• dactylitis

uveitis

DX: HLA-B27
RF
anti-CCP
CRP
ESR

XRay

• “shiny corner sign”→annulus firbosus attaches to vertebra→inflammation+sclerosis

• “bamboo spine”
  -later finding

MRI

• erosion

• sacroilitis/narrowing of joint spaces→joint fusion

AS NP Tx

NSAIDs

corticosteroid injections→not recommended

glucocorticoids

postural training

PT

diet

end-stage dx+deformities→surgery

AS Mx Tx

sx relief

• NSAIDS

• glucocorticoids

prophx

• DMARDS

• bDMARDS

primary care

• NSAIDS

• glucocorticoids

• rheumatology referral

DMARDS

• methotrexate

• sulfasalazine

bDMARDS

block chemokine tumor necrosis factor (TNF):

• etanercept

• infliximab

• adalimumab

• golimumab

• certolizumab pegol

IL-12+23→ustekinumab

IL-17A

• secukinumab

• ixekizumab

IL-23

• guselkumab

• risankizumab

JAK inhibitors

• tofacitinib

• upadacitinib

AS Complications

progressively decreasing back ROM+chest expansion

• posture change→hyperkyphosis

• “bamboo spine”

cardiac

• aortic regurgitation

• AV conduction defects

• aortic root widening

pulmonary fibrosis

neurologic→cauda equina syndrome

mental health→mood disorders

AS Prognosis

early+aggressive tx→decreased development of deformities/disabilities→better outcome

• systemic impact→decreased

• joint damage→decreased

• hips involvement→worse prognosis

Reactive Arthritis (ReA)

PP: infxn→inflammatory arthritis

RF: HLA-B27
young men

GI

• shigella

• salmonella

• yersinia

• campylobacter

GU

• chlamydia

• ureaplasma

CM: post-dysentery/STI
-1-4 weeks prior

beginning→systemic sxs

• fever

• wt loss

oligoarthritis

• 1+ joints

• asymmetric

• lower+larger+wt-bearing joints

conjunctivitis
uveitis
stomatitis
balanitis
keratoderma blennorrhagicum
enthesitis
nail changes
urethritis
cervicitis

DX: clinical
HLA-B27
RF
anti-CCP
infxn→synovial fluid→negative
CBC
CMP
CRP
ESR

ReA Tx

glucocorticoids

DMARDS

• methotrexate

• sulfasalazine

bDMARDS

• TNF inhibitors

• block IL-17s

primary care

• find infxn

• if STI→abx

• NSAIDS

• rheumatology referral

ReA Complications+Prognosis

C: uveitis

cardiac

• carditis

• aortic regurgitation

P: tx x days-weeks
arthritis→persists several months
sxs can reoccur
can become chronic