ARTHRITISAnna JaatinenRotary Doctor Bank Finland, Ilembula Hospital

Today’s topics

Osteoarthritis Rheumatoid arthritis Reactive arthritis Crystal-induced Synovitis Infectious Arthritis HIV-associated arthritis

Rheumatoid arthritis 1

Systemic diseace Unknown etiology

Symmetric inflammatory polyarthritis Extra-articular manifestations

Rheumatoid nodules Pulmonary fibrosis Serositis Vasculitis

Rheumatoid factor up to 80%

Rheumatoid arthritis 2

Clinical Presentation Insidous oncet of the pain, swelling and

morning stiffness in the joints (hands, wrists)Synovitis! Typical places: MCP, PIP, wristRheumatoid nodules on extensor surfacesCourse is often chronic and progressiveErosions!

Rheumatoid arthritis may substatial long-term disability and is associated with increased mortality!

Rheumatoid arthritis 3

American Collece of Rheumatology 1987 Classification Criteria

Morning stiffness (>60 min)Arthritis of three of more jointsArthritis of hand jointsRheumatoid nodulesSerum rheumatoid factorX-ray changes (erosions and decalcification)

4 of the 7 criteria should be met, with criteria 1 to 4 present for more than 6 weeks

Morning stiffness (>60 min)Arthritis of three of more jointsArthritis of hand jointsRheumatoid nodulesSerum rheumatoid factorX-ray changes (erosions and decalcification)

4 of the 7 criteria should be met, with criteria 1 to 4 present for more than 6 weeks

Rheumatoid arthritis 4

TREATMENT NSAID

Ibuprofen 400-800 mg TDS as long as needed

Acetylsalicylic acid Corticosteroids

Prednison 5 to 20 mg OD With long treatments

remember to decrease the dose slowly!

Intra-articulr administration Hydrocortison 25-100

mg i.a.

DMARDs (Diseace-modifying antirheumatic drugs) Methotrexate Hydroxychloroquine Sulfasalazine Leflunomide Biologic DMARDs

Patients with itractable symptoms may require special treatment at spesialist centre!

Patients with itractable symptoms may require special treatment at spesialist centre!

Osteoarthritis 1

= Degenerative joint disease= Arthrosis Most common form of arthritis! Degenerative loss of articular cartilage with

subsequent formation of reactive new bone at the cartilage surface

Most common: PIP, DIP, hips, knees, cervical and lumbar spine

Common in the elderly, but may occur any age especially after joint trauma, chronic inflammatory arthritis or congenital malformation.

Osteoarthritis 2

Clinical PresentationPain!Specific clinical features depend on the

joint involvedKnee: possible hydrops, no signs of infection or

severe inflammationDIP: enlarged joint Bouchard’s nodes

X-ray shows cartilage damage and sometimes even deformity

Osteoarthritis 3

TREATMENT Nonpharmacologic

approaches Prief period of rest Good shoes:

Walkers Crepe bandage or

brace can help Physiotherapy and

exercise to affected joints

Reduction on weight in obese patients

Medications Paracetamol 1 g TID

(QID) NSAID (As low dose

as possible) Ibuprofen 200-600 mg

TID Itra-articular

clucocorticoidShould not be given

more than every 3 to 6 months

Systemic clucocorticoid should be avoided!

Reactive arhtritis 1

Inflammatory arthritis, which occasionally follows certain GI or genitourinary infectionsReiter sdr = arthritis + conjuctivitis + urethritis

Most common afterChlamydia trachomatis, Shigella flexneri,

Salmonella species, Yersinia enterocolitica, Campylobacter jejuni

Genetic predispositionHLA-27 positive 60-80%

Reactive arthritis 2

Clinical PresentationAsymmetric oligoarthritisUrethritisConjuctivitisSkin and mucous lesionsUsually transient, lastin one to several

monthsSome patients develope chronic arthritis

Reactive arthritis 3

TREATMENT Control of pain and

inflammation! NSAIDs Severe cases short

glucocorticoid therapy

Ophthalmologic referral if you suspect iritis

Remember and search for infection!Clamydia tr

Antibiotic treatment if still neededProlonged

antiobiotic therapy has NOT been showed to be beneficial

Crystal-Induced Arthritis 1

Gout (Urate crystals) Pseudogout (Calcium pyrophosphate dihydrate

crystals) Apatite disease

Gout arthritis developes when urate crystals deposites in the joints Primary: hyperuricemia due to undersecretion of

uric acid Secondary: Renal disease, diuretic therapy, low-

dose aspirin, ethanol, starvation, lactic asidosis, dehydration, pre-eclampsia, diabetic ketoasidosis

Crystal Induced Arthritis 2

Clinical PresentationExcruciating painUsually in single joint in foot or ankle

Occasionally a polyarthritic oncet can mimic rheumatoid arthritis

Joint is swollen, skin erythema, warm/hotChronic gout: With time acute gouty attacs

more often, even chronic joint deformity may appear

Lab: Uric acid levels with 70%, Crystals seen in the joint fluid examined with microscope

Crystal Induced Arthritis 3

TREATMENT Acute gout

NSAID high dose Indomethacin 75 mg start

then 50 mg every 6 hours 24 hrs, 50 mg TDS 24 h, 25 mg TDS 24 h

Diclofenac 75 mg BDS Ibuprofen 400-800 mg TDS

Glucocorticoids (especcially when NSAID is contraindicated) Intra-articular injection Prednison 40 mg OD 3-5

days Colchisine

1 mg stat followed 0,5 mg every 2 hours orally until patient improves or ad 10 mg

Prevention Anti-hyperuricaemic

therapy; Allopurinol Goal serum uric acid

below 8 mg/dl (0.48 mmol/l)

Avoid precipitants (alcohol, small fish, diuretics)

Reduce weight in obese patients

Remember that allopurinol can make acute gout even worse! Start after clinical improvement!

Remember that allopurinol can make acute gout even worse! Start after clinical improvement!

Infectious Arthritis 1

Septic infection! Non-conococcal: Staphylococcus Aureus,

Streptococci Conococcal arthritis Occasionally: M Tuberculosis, Brucella,

Fungi

Non-bacterial infectious arthritisViral infections: Hepatitis B, Rubella, Mumps,

Mononucleosis, parvovirus, enterovirus, adenovirus

Infectious Arthritis 2

Clinical Presentation Non-gonococcal infectious arthritis

FeverAcute monoarticular arthritis

Multiple joint may be affected by hematogenous spread of pathogens

Gonococcal arthritisMigratory or additive polyarthralgias

followed by tenosynovitis or arthritis of wrist, ankle or knee and vesicopustular skin lesions

Infectious Arthritis 3

TREATMENT Immediate antibiotic therapy

Cover S. Aureus, Streptococcus, Neisseria gonorrhoeae

IV-antibiotics are recommended for at least 2 weeks, followed by oral antibiotics 2(-4) weeks

When definite gonococcal arthritis Ceftriaxone i.v. For 3 days followin 7-14 days treatment with cefixime or Amoxicillin/clavulanate

Surgical drainage especcially if there is big joint (shoulder, hip), lobulation of pus, osteomyelitis or delay with response to treatment

Supportive treatment for septic infection! NSAID

HIV-infection and arthritis 1

HIV-associated arthralgiaAny stage of HIV infectionMild to moderate, involves usually large

joints (shoulders, elbows, knees)No synovitis!Treatment: Pain medication, support

HIV-infection and arthritis 2

Reactive arthritis Psoriatic arthritis HIV-assosiated arthritis

Virus is directly involving joint synovium Oligoarticular, occurs predominantly in the lower

extremities Self-limiting course, lasting <6 weeks X-ray: no erosion in the joints

Also HIV-associated polyarthritis is possible, resembles rhematoid arthritis

Synovitis abates when CD4 is declining, but joint destruction continues

Diagnose with intra-articular punctureMain principles Clear synovial fluid: Osteoarthritis,

Rheumatoid arthritisLeukocyte amount

Thick, fuzzy: Crystal-induced ArthritisCrystals seen in microscope

Purulent: Infectious arthritisCulture, Gram stain

Assure that your technique is clean!Assure that your technique is clean!

Take Home Message

Osteoarthritis is the most common reason for joint pain; treat the pain and educate the patient

Treat with antibiotics when… It’s infectious arthritis!Reactive arthritis if there still is infection

If you suspect Rheumatoid arthritis, treat aggressively, consider refferal for specialist

Asante, Thank you!