Rheumatology

Degenerative joint disease

Osteoarthritis is known as ___

Osteoarthritis

What is the most common form of arthritis?

Osteoarthritis

Minimally inflammatory arthropathy that results in cartilage destruction with hypertrophic bony changes

OA

Aging, trauma, obesity, congenital hip dysplasia are all risk factors for developing ____.

Paget's disease

This disease causes ur bones to grow larger and weaker than normal. Increases risk of OA

1. Increase in chondrocyte formation, leading to...

2. Increase in cytokines , causing...

3. Degradation of articular cartilage leading to..

4. Narrow and Reactive bone changes

Explain the pathophysiology behind osteoarthritis

Localized

Is osteoarthritis a localized problem or a systemic problem?

any joint

OA can affect virtually ______

-hypertrophy

-crepitus

-limited ROM

Joints affected by OA demonstrates periarticular bony _____, _____ and _____.

Gel phenomenon

Joint stiffness occurring after long periods of sitting or inactivity (i.e. waking up in the morning)

30 minutes

(recall, RA is > 1 hour)

How long does the gel phenomenon last in a patient with OA in the morning?

OA

RA

Morning stiffness less than 30 minutes is likely to be ___

Morning stiffness greater than 1 hour is likely to be ____

When the atmosphere and water condensation increases, it increases the pressure exerted on the body causing further compression of the joints

Changing barometric pressure (weather) may increase OA symptoms, why?

PIP

Bouchard's nodes affect the ___ joints

Inflammatory Osteoarthritis

Form of osteoarthritis associate with Heberden's nodes and Bouchard's nodes

DIP

Heberden's nodes affect the ___ joints

Heberden's nodes and Bouchard's nodes

Which abnormalities would you expect to see on the hands of a patient with inflammatory OA?

gout or RA

Inflammatory OA may mimic ____ or ___.

1. History

2. Physical Exam

3. X-ray changes

Diagnosis of OA is based on what 3 things?

Osteoarthritis

Which condition is associated with these findings on X-ray...

Decreased joint space

Periarticular sclerosis

Bony cysts

Osteophyte formation

Narrowing of the joint space

Periarticular sclerosis

Osteophyte formation

Bony cysts

What can you expect to find on the X-rays of a patient with OA?

Obesity

What is an important modifiable risk factor for OA?

Physical therapy

What is the first line non-pharmacologic therapy for patients with OA?

Non-weight beating exercise (i.e. swimming)

What kind of exercise regimen should you recommend to your patient with OA?

Localized intra-articular steroid injections are helpful

NO role for systemic steroid treatment

What is the role of steroids in the treatment of OA?

Analgesics and NSAIDs

NO percocets

What is the first line of treatment for a patient who is 9/10 severe pain with OA ?

-Bextra

-Celebrex

-Vioxx (no longer on market, BBW)

(cox 2 selective agents)

What kind of NAIDS would you prescribe to a pt with OA?

Visco-supplementation (Hyaluronic Acid)

Synthetic medication injected into the joint line which serve to act like the normal complex sugars of the joint that have been destroyed. Treatment option for OA. Helps lubricate the joint and restore shock absorption

Knee

Hyaluronic acid (visco supplementation) injections have been FDA approved for OA in which joint?

Rheumatoid arthritis

Progressive autoimmune inflammatory disorder causing a symmetric polyarthritis of diarthrodial (synovial) joints

Rheumatoid arthritis

This type of arthritis is considered a systemic disease and may also affect the cardiovascular, pulmonary, dermatologic, renal, ophthalmologic, gastrointestinal and peripheral neurologic systems.

RA

Type of arthritis with constitutional symptoms such has fever, fatigue, anorexia and malaise are frequent.

RA

Prolonged morning stiffness greater than 1 hour is associated with which condition?

Swann neck deformity

Hyperextension of the PIP and flexion of the DIP joint. Seen in RA

Boutonniere deformity

Fixed flexion deformity of the PIP seen in RA patients

Jaccoud's arthropathy

Swann neck deformity + Boutonniere deformity + ulnar deviation of the MCP joints. Seen in late stage RA and may also be seen in SLE

Swann neck deformity

Boutonniere deformity

Ulnar deviation of the MCP joints

What 3 things make up Jaccoud's arthropathy?

RA

What condition is Jaccoud's arthropathy associated with?

Pericardial effusion

What cardiac complications are RA patients more prone to?

Pleural effusions

Rheumatoid nodules in the lungs

What pulmonary complications are seen with RA?

Thrombocytosis

Anemia

What hematologic abnormalities are common on the CBC of a patient with RA?

Thrombocytosis

Presence of high platelet counts in the blood, associated with active intravascular coagulation. May be seen in patients with RA

RF is only present in less than 40% of patients with early RA

What is the issue with Rheumatoid Factor (RF) in the diagnosis of RA?

Anti-RA33

Anti-CCP

What are the two new antibodies associated with RA that are much more sensitive than Rheumatoid Factor (RF) and are positive in many more patients?

NSAIDs

What is the first line therapy for RA?

Disease Modifying Antirheumatic Drugs (DMARDS)

What is the second line therapy for RA?

Benefit is that DMARDS have the ability to slow the disease progression

Downside is they have many AE

What is the benefit of DMARDS? What is the down side of DMARDS?

Having Some Milk And Little Cookies, Damn Good

Hydroxychloroquine

Sulfasalazine

Methotrexate

Azathioprine

Leflunomide

Cyclosporine

D-penicillamine

Gold (PO, IM)

What are the DMARDS?

Methotrexate

Which of the commonly used DMARDs is associated with an AE of alopecia?

Cyclosporine

Which of the DMARDs is associated with the AE of hirsutism?

D-Penacillamine

Which of the DMARDs can cause drug-induced SLE?

Gold

Which of the DMARDs can cause thrombocytopenia and proteinuria?

Biologic cell modifiers

Which drug class is the newest addition to the treatment regimen for RA?

cytokines

halt or significantly slow

Biologic cell modifiers specifically targets _______. They have the ability to ____ the progression of the disease.

TNF-alpha inhibition

Given as an IV infusion Q4-8 weeks

What is the MOA of Infliximab (Remicade)? How is this drug given?

Adalimumab (Humira)

Recombinant human IgG-1 and TNF-alpha monoclonal antibody given as a self-administered SQ injection every other week

Enbrel

A TNF alpha receptory decoy, a twice weekly self administered SQ injection.

Kineret

A cloned copy of naturally occurring IL-1 receptor antagonist, which competitively inhibits interleukin 1 receptor. Daily self administer SQ injection.

Osteoporosis

Metabolic bone disorder that affects the micro-architecture, resulting in loss of bone mineral density (BMD). Causes decreased bone mass and increase fragility

Post-menopausal osteoporosis

What is the MC metabolic bone disease?

osteopenia

What is the precursor to osteoporosis?

Osteopenia

A condition where bone mineral density is lower than normal. Increases risk of osteoporosis.

Imbalance between bone resorption (osteoclastic) and bone formation (osteoblastic)

What is the underlying mechanism in all cases of osteoporosis?

exceeds

In osteoporosis, the bone resorption _____ bone formation, resulting in a decreased bone density and weaker structure

Increased PTH hormone causes the bones to release calcium into the bloodstream. This causes the bones to lose their density and harness, leading to brittle, weakened bones

Explain how hyperparathyroidism can lead to osteoporosis

Osteoporosis

-Female sex

-Caucasian/Asian

-Advanced age

-Low body weight (<127lbs)

-Cigarette smoking

-Inactivity

-Alcohol

-Low calcium intake

-Estrogen deficiency

These risk factors increase risk of?

-Corticosteroids

-Heparin

-MTX

-Synthroid

What types of medications increase risk of osteoporosis ?

-Hyperparathyroidism

-Hyperthyroidism

What co-morbidities increase risk of osteoporosis ?

silent

Osteoporosis is known as a ____ disease, will only experience pain if a fracture occurs.

negative

A pt with osteoporosis, their physical exam is often ______.

Vertebral fractures

What are the most common osteoporotic fractures?

Tartrate Resistant Acid Phosphatase (TRAP)

Enzyme secreted during bone remodeling. Serum and urinary levels can help determine the relationship between osteoblast and osteoclast activity and can aid in the diagnosis of osteoporosis

Bone Densitometry testing

Assess for osteoporosis

What does BDM testing stand for and what is it used to diagnose?

1. Postmenopausal women under the age of 65 with one or more risk factors

2. All postmenopausal women over the age of 65

Who should be screened for osteoporosis with bone densitometry testing based on the National Osteoporosis Foundation (NOF)?

Central sites, such as the lumbar spine and hips

(Most likely to predict the risk of hip fracture)

What sites are preferred for BDM testing for osteoporosis?

Heel and Finger

Central sites are preferred for BDM but what peripheral site can be tested?

Central dual X-ray absorptiometry (DXA)

-low radiation exposure

What is the most common radiologic technique used for bone densitometry testing? Why?

T score

The number of SDs above or below the mean for a young, healthy population. Used to assess BDM testing results

Z score

Compares the patients BDM to an age and sex matched population and can represent secondary osteoporosis

> -1.0

What is the normal T-score for BDM testing?

< -1.0 and > -2.5

What T-score range is considered osteopenia?

< -2.5

What T-score is considered osteoporosis?

1. adequate Ca2++ & Vit. D intake

2. Weight bearing activity/exercise

3. Avoid excessive amounts of alcohol

4. Avoid cigarette smoking

What is the first line treat osteoporosis ?

Osteoporosis (fall prevention)

-Correct impaired eyesight

-Reduce environmental hazards

-If poor balance or ask abnormalities consider walker or cane to assist with ambulation

These are all recommendation to prevent?

9-18 = 1,300 mg/day

19-50 = 1,000 mg/day

51+ = 1,200 mg/day

(divided doses are recommended for inc. absorption)

What is the recommended daily calcium intake for...

Ages 9-18

Ages 19-50

Ages 51+

600IU-800IU QD

What is the recommended vitamin D intake?

Secondary osteoporosis

- hyperparathyroidism, hyperthyroidism, malignancy, renal disease, medication-induced osteoporosis, osteomalacia (vit. D deficiency)

An abnormal Z-score after BDM testing warrants an additional workup. What can it indicate?

hormone replacement therapy (HRT)

This type of treatment for osteoporosis increases bone density and reduces fracture risk. FDA approved for post-menopausal women with osteoporosis, it is better to begin early in menopause and continued indefinitely. Have an increase risk of DVT's, CAD, Stroke and breast cancer.

Raloxifene

Selective estrogen receptor modulator FDA approved for the prevention and treatment of postmenopausal osteoporosis

DVT and hot flashes

Raloxifene is beneficial over HRT because there is no increased risk in uterine or breast cancer. However, Raloxifene does come with an increased risk of ___ and __

Calcitonin

Anti-resorptive agent that is FDA approved for the treatment of postmenopausal osteoporosis. Has been found to mildly increase spine BMD and decrease new fractures

Reduce osteoclastic activity/bone resorption and increase BMD over time. Reduce both vertebral and non-vertebral fractures

What is the MOA of Bisphosphonates in the treatment of osteoporosis?

Alendronate

Risedronate

What are the two most widely used bisphosphonates?

Contraindicated in hypocalcemia

Not recommended in severe renal impairment

Bisphosphonates are contraindicated in ______ and not recommended in __

Nothing PO for 1 hour

Bisphosphonates are usually tolerated well, however they may cause esophageal irritation, gastric ulcers and dysphagia. How should you instruct ur patient to take?

Increases bone formation by stimulating osteoblasts

What is the MOA of recombinant parathyroid hormone (rPTH)?

-pagets disease

-bone cancer

Recombinant parathyroid hormone should not be given to children/adolescence, individuals with _____ or with a hx of ____.

-nausea

-leg cramps

-dizziness

Recombinant parathyroid hormone is generally well tolerated but may result in?

Gout

A crystal-induced arthropathy that results in episodes of acute arthritis. This is an inflammatory response tp the presence of monosodium urate (MSU) crystals lodging in the joint space

gout

This can results form long term hyperuricemia ?