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Arthritis In Primary Care

Presentation: St. Anselm Conference

Samuel Poon, MD

Staff Rheumatologist

Manchester VA Medical Center

September 7, 2018

General Outline

• Clinical Characteristics of Common Arthritic Conditions

• Degenerative Arthritis

• Common Inflammatory Arthritis

• Early Recognition

• Potential Risks of Immunosuppressive Therapy

PRE-CONFERENCE

1. Pre-test Clinical Suspicion

2. Should I consider a rheumatology referral?

PRE-CONFERENCE

A 55 yo woman with h/o anxiety, chronic low back

pain due to prior lumbar disc herniation on low dose

oxycodone, who reports fatigue for last 3 months

working the night shift at Walmart and reports hand

pain in the wrists, knuckles, and the balls of the feet.

She wakes up in the afternoon. She finds it hard to

get going but she typically gets through her shift

okay. She “muscles” through it, but she is real tired

afterwards and in a bit of pain.

PRE-CONFERENCE

1. Pre-test Clinical Suspicion

2. Should I consider a rheumatology referral?

PRE-CONFERENCE

A 68 yo man with history of chronic low back pain, history of

L3-L5 laminectomy, previously on OTC ibuprofen 600mg TID

who had been hospitalized 9 months ago due to UGIB now on

PPI.

Six months ago, he had noticed right shoulder pain which he

thought he “pulled” playing with his grandson, which

dissipated. Then he noticed left ankle pain, which is still there,

and now persistent left shoulder pain. He denies seeing any

joint swelling. He states: “I can deal with the pain.”

Relevant medical history: Interstitial lung disease

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PRE-CONFERENCE

1. Pre-test Clinical Suspicion

2. Should I consider a rheumatology referral?

PRE-CONFERENCE

A 19 yo woman who was an avid runner in high school

presents with back pain for 18 months. She reports that her

pain medicine specialist diagnosed her with fibromyalgia.

They have tried facet joint injections and epidural steroid

injections. She seeks your opinion on fibromyalgia

medications.

She reports pain that wakes her up at 3AM in the lower gluteal

regions. She is tearful that she cannot run ½ mile now.

PRE-CONFERENCE

1. Pre-test Clinical Suspicion

2. Should I consider a rheumatology referral?

Your Clinical Encounter: Thought Questions

Your Clinical Encounter: Thought Questions

• Is this an arthritic condition, OR infectious, neoplastic,

endocrine, dermatologic, neurologic, orthopedic/ traumatic?

• Is the primary pathology an arthritis? As opposed to soft

tissue, bursitis, vascular, lymphatics, tendinous, or

ligamentous derangements?

• If it is arthritic, is this process acute, subacute, or chronic?

• If it is arthritic, is this process degenerative in nature or

inflammatory or infectious in nature?

• Is the arthritis symmetric, polyarticular, oligoarticular (3-5),

monoarticular, palindromic, additive, migratory, recurrent,

axial, peripheral, entheses predominant?

Clinical Case

• Acute monoarthritis and Fever +/- leukocytosis

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Clinical Pearl

• Acute monoarthritis or oligoarthritis and Fever +/-

leukocytosis

• ddx: Septic arthritis, (septic bursitis)

• ddx: Crystal arthritis, gout, pseudogout (CPPD)*

• Mechanism: Direct trauma; most common

hematogenous spread

Clinical Pearl

• Acute monoarthritis or oligoarthritis and Fever +/-

leukocytosis

• Top Ddx: Septic arthritis, (septic bursitis)

• Mechanism: Direct trauma; most common

hematogenous spread

• Risk:

• Total joint arthroplasty, recent or past

• Diabetes, Frequent skin infections, Alcoholism

• Indwelling device, IVDU

• Recent intraarticular procedure

• Age <40yo, sexual promiscuity (maybe afebrile)

Septic Arthritis, Gonococcus Septic Arthritis, Gonococcus

• “Arthritis-Dermatitis Syndrome”

• These patients are ill, fevers

• Preceded by GU infection 2-3 weeks ago

• Tenosynovitis, polyarthritis, dermatitis

• Pustular

• Blood cultures are Positive

• Purulent Arthritis

• Maybe Afebrile

• Synovial fluid is suggestive, > 50,000 cells

• Swab mucosal surfaces, U GC/Chlamydia

• Inform the laboratory you suspect GC

(Chocolate Agar, Thayer-Martin Agar)Klausner, J, Bloom, A. Disseminated gonococcal infection. Uptodate.com

Arthritis-Dermatitis Syndrome

Klausner, J, Bloom, A. Disseminated gonococcal infection.

Uptodate.com

Outpatient Rheumatology

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Copyright © 1972-2004 American

College of Rheumatology Slide

Collection. All rights reserved. https://www.rheumatology.org/Learning-Center/Educational-

Activities/Rheumatology-Image-Library

Copyright © 1972-2004 American

College of Rheumatology Slide

Collection. All rights reserved.

Osteoarthritis

MCP

PIP

DIP

CMC

Copyright © 1972-2004 American

College of Rheumatology Slide

Collection. All rights reserved.

Osteoarthritis

HEBERDEN’S

BOUCHARD’S

Osteoarthritis

• Degenerative joint disease, cervical/lumbar spondylosis

• Epidemiology: By 1973, >65 yo: incident OA: 97%

➢ Incident OA was 9.4% in age 15-24 years old

• Risk factors:

➢ Age

➢ Obesity

➢ Occupation

➢ Sports Activity

➢ Previous Injury

➢ Muscle weakness

➢ Neurologic deficits

➢ Genetics, Polygenic

Lawrence, J. S., J. M. Bremner, and F. Bier. 1966. “Osteo-Arthrosis. Prevalence

in the Population and Relationship between Symptoms and x-Ray Changes.”

Annals of the Rheumatic Diseases 25 (1): 1–24.

OSTEOARTHRITIS

• Symptoms

➢ Chronic, slowly progressive, polyarticular, non-inflammatory

in general

➢ Exertional pain

➢ Morning stiffness < 30 minutes

➢ Worse at end of the day

➢ Joint swelling, sometimes

• Signs

➢ Antalgic gait

➢ Joint effusion, non-inflammatory

➢ Joint deformity (eg. Heberden’s, Bouchard’s)

➢ Joint crepitus, joint line tenderness

➢ Reduced passive ROM on examination

➢ Active ROM reduced to similar degrees as passive ROM

OSTEOARTHRITIS - CASE

CC: “Hand Pain”

HPI: 80 yo woman with history of atrial fibrillation, she reports

that she likes to do knitting and crocheting. She has a history

of right total hip replacement after a fall. She uses a walker for

balance when she is outside, and a cane at home.

She reports pain in the hands for many years. Lately the

fingers had gotten more noticeable, especially the third finger.

This interferes with her knitting.

Medications: Tylenol OTC which helps the knee pain but not

the hands.

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ACR Image Library https://www.rheumatology.org/Learning-

Center/Educational-Activities/Rheumatology-Image-Library

Differential Diagnosis

Differential Diagnosis

• Gout

• Psoriatic arthritis

• (Inflammatory) erosive osteoarthritis

• Multicentric reticulohistiocytosis

• Pigmented villonodular synovitis, PVNS

• Giant cell tumor of the tendon sheath, synovial sarcoma

• Thorn synovitis

• Consider non-rheumatologic causes: paronychia

Differential Diagnosis

• Gout

• Psoriatic arthritis

• (Inflammatory) erosive osteoarthritis

• Multicentric reticulohistiocytosis

• Pigmented villonodular synovitis, PVNS

• Giant cell tumor of the tendon sheath, synovial sarcoma

• Thorn synovitis

• Consider non-rheumatologic causes: paronychia

Multicentric reticulohistiocytosis

(Inflammatory) Erosive Osteoarthritis

• NOT a systemic

inflammatory arthritis

• Joints “look” inflammatory

• Subacute or insidious onset

• Progressive, erosive,

ankylosis

• Female > Male

• Post-menopausal women

• Onset: 40-50 yo

• PIP and DIP joints

• Radiographs:

Seagull or Gull- wing “T”

(Inflammatory) Erosive Osteoarthritis

• Wave “Z-shaped” fingers

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CC: One month of “REAL pain”

HPI: 67 yo veteran with hyperlipidemia, who presents with

increased pain in the joints, particularly ankles, wrists, and the

knees. He had been taking “a lot of Advil” for the joints lately.

He reports that he was fine in the summer time, and “last

winter he was fine.”

Past month, he was so bad that he could not move, until he

increased his daily Advil.

He felt Advil reduced pain from 8/10 to 3/10, but it does not

last.

Case

ROS:

No fevers, chills, malaise, weight loss, gain

No recent travels, no illness. ++ fatigue

No headaches, no dry mouth, dry eyes

No eye pain, redness, no nasal condition, hearing loss

No shortness of breath, no dyspnea on exertion, no cough

No chest pain, palpation, dizziness

No abdominal pain, constipation, diarrhea, no blood in stool

No skin rash, no finger lesion

No depression, no mental health conditions

Case

PAST MEDICAL HISTORY:

Hyperlipidemia

Leg edema, left sided unknown cause

Looking Back….

4 years ago: “Generalized aches and pains for 1 week”

MD: “I cannot tell if… in joints, but patient describes muscle

aches in thighs and legs… Rx = Ibuprofen

3 years ago: “… has pain in the right foot..”

Clinician: “… perhaps podiatry appointment if it is

persistent”

Case

FAMILY HISTORY:

One brother with lower back pain

One daughter, healthy

SOCIAL HISTORY

Retired concrete work, used to drive bulldozer

No cigarettes,

+ EtOH, beer ~ 2 a day

No recreational drugs

MEDICATIONS:

ASA 81 mg Daily

Advil OTC 200mg 3 tabs four times a day

Multivitamin

Case

EXAMINATION:

BP 127/84 P 85 RR 12 Pain 2/10

GEN: NAD, well appearing, gait is antalgic

HEENT: No icterus, EOMI, + dentures, some cavities, mmm

Neck: No LAD

CV: RRR no m/r/g

PULM: CTA B/L No w/w/r

ABD: NDNT, no HSM

DERM: no lesions, no periungal erythema

NEURO: A&O x 3, CN II- XII intact grossly

VASC: 2+ PT/DP. Left leg generalized swelling

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CaseMSK EXAMINATION:

C/T/L spine: Mild reduced ROM of L-S spine. No pain

Hands: Right 3rd/4th tender, Left 2nd-4th tender, synovitis noted

Wrists: Bilateral wrists are tender, Mild swelling in the Right

Elbows: Full A/P ROM

Shoulders: Reduced forward flexion AROM. Mild pain noted L

PROM

Hips: Reduced PROM. No pain

Knees: R knee swelling with active small effusion. L calf is

swollen, chronically

Ankles: Right and Left ankles are swollen, and painful PROM

Feet: MTP tenderness are noted, hammer toes

Rheumatoid Arthritis

• 1% of the population (3.26 million, from 325.7million in 2017)

➢ (NOT) The most common inflammatory arthritis in the US

• Female Predominance

• RF and anti-citrullinated peptide (CCP) antibodies

• Chronic, symmetric, polyarthritis of >= 3 months

• Erosive, deforming arthritis

Rheumatoid arthritis: Why Does

it Occur

◼ Environment factors

◼ Smoking – bad

◼ Olive oil / fish oil – may reduce chance of RA

◼ Your genes

◼ Identical twins have high risk 3X compared to fraternal

twins

Rheumatoid Arthritis

MCP

PIP

DIP

CMC

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Rheumatoid Arthritis

• Systemic inflammatory arthritis

1987 ACR criteria 4/7

• AM stiffness > 60 minutes for more than 6 weeks

• Swelling in 3> joints for more than 6 weeks

• Swelling in hand joints for more than 6 weeks

• Symmetric joint swelling for more than 6 weeks

• Erosions on hand Xrays

• Rheumatoid nodules

• Abnormal Rheumatoid Factor

Rheumatoid Arthritis

2010 ACR/EULAR criteria

• Synovitis in at least one joint

• NO OTHER DIAGNOSIS is LIKELY + 6/10 score OR

• Erosive disease in RA pattern, or those with longstanding

disease historically fulfilling 6/10 scores

• Score 6 out of 10

• 2 - 10 large joints = 1 pt

• 1 – 3 small joints = 2 pts

• 4 – 10 small joints = 3 pts

• > 10 joints = 5 pts

• Low positive RF OR CCP = 2 pts

• High positive (3x ULN) RF OR CCP = 3 pts

• High ESR or C-RP

• Duration >= 6 weeks

Changes In 2010 Rheumatoid Arthritis Criteria

• “Early” or “recent-onset” Rheumatoid arthritis

➢ Symptom duration less than 2 yrs

➢ Early Intervention = less deforming disease or chronic

damage

• Seronegative rheumatoid arthritis is captured

➢ RF negative, anti-CCP negative

➢ Generally better prognosis

➢ May seroconvert later in course (Clinical experience)

• Overdiagnosis and overtreatment in rheumatology

➢ Is a recognized problem

➢ Diagnosis requires EXCLUSION of other diagnoses

• Occurs PRECISELY because emphasis FOR early RA

✓ Value of advanced imaging, MRI or MSK Ultrasound

• Advances in Effective treatments

✓ Early treatment also is coupled with aggressive treatment

✓ Despite trials in RA (COBRA and BeST) showing “go-low-go

slow approach” works, the paradigm has shifted to

aggressive treatments

✓ Miss the segment who benefits from traditional DMARDs

• Drive for Clinical Remission

✓ Logical for those with high / aggressive disease

✓ Value is questionable for those low/ indolent disease

Rheumatoid Arthritis

“Practice of Medicine is an ART OR a SCIENCE?”

Rheumatoid Arthritis

“Practice of Medicine is an ART OR a SCIENCE?”

The more we try to quantify RA, opportunities for over-

interpretation / mis-interpretation (in both directions) occurs.

Does not mean we should stop trying to characterize RA.

Does mean that “prior authorization” bodies should allow clinicians

to practice the art AND the science of medicine.

Because… back in the day….. Speaking of ART

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Saint Peter and

Saint John Healing

a Cripple at Gate of

Temple, 1513

Copper engraving

by Albrecht Dürer

Last scene of the

Engraved Passion.

Depicts a New

Testament episode

in the Acts of the

Apostles (3:1-10), in

which Peter and

John heal a cripple,

who was begging.

Systemic

Disease

Cachectic

Systemic

Disease

Cachectic

Rheumatoid Arthritis Before DMARD/Biologics Rheumatoid Arthritis: CASE

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Rheumatoid arthritis: Why Does

it Occur

◼ Environment factors

◼ Smoking – bad

◼ Olive oil / fish oil – may reduce chance of RA

◼ Your genes

◼ Identical twins have high risk 3X compared to fraternal

twins

Outline

• Current Treatment Approach and Options

in 1987

in 2012

I Was Diagnosed with Rheumatoid Arthritis

• POINT : Deep breath & Relax

• POINT: Listen to your doctor closely

• POINT: Keep an open mind

I Was Diagnosed with Rheumatoid Arthritis

• POINT : Deep breath & Relax

Joint damage happens slowly, but it happens

• POINT: Listen to your doctor closely

He/she will navigate the complicated treatment plans

He/she should give you options as to why one is better

than another

• POINT: Keep an open mind

While some newer medications are very useful

you may not need them…

Don’t worry if you are not given the “Latest” therapy

especially if you are feeling better **

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I Was Diagnosed with Rheumatoid Arthritis

• ** Tell your doctor if you are not feeling >90% well also.

• Do not under-report your joint symptoms

Older Anchor Therapy – True and Tried

• Plaquenil (Hydroxychloroquine)

• Methotrexate

• Arava (Leflunomide)

• Sulfasalazine

• Azathioprine

• Prednisone

New Therapy from Last Decade… Tumor Necrosis Factor Inhibitors

Others

B cell inhibitor

T cell inhibitor

IL-6 inhibitor

IL-1 inhibitor

Rheumatoid Arthritis

2012: “Biologic” Medications or “Infusions/ Injections”

Remicade Intravenous q6wk to 8wk

Enbrel Subcutaneous qwk

Humira Subcutaneous q2wk

Simponi Subcutaneous q4wk

Cimzia Subcutaneous q4wk

Rituxan Intravenous q6 mo

Orencia Intravenous or Subcutaneous q4wk

Actemra Intravenous q4wk

Anakinra Subcutaneous

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Outline: Stopping Biologic

• Can I stop my biologic therapy?

Outline: Stopping Biologic

• Traditional answer:

• “No. You will relapse. Worse… you will lose effect to the

medications… “

• ATTRACT trial (remicade)

“Anti-Tumor Necrosis Factor Trial in Rheumatoid Arthritis with

Concomitant Therapy”

References◼ Doherty, Michael, Abhisheck, A. Uptodate.com “Clinical Manifestations and Diagnosis of Osteoarthritsi”

◼ Banks, Sharon E. “Erosive Osteoarthritis: A Current Review of a Clinical Challenge.” Clinical Rheumatology 29, no. 7 (July

2010): 697–706. https://doi.org/10.1007/s10067-009-1369-7.

◼ Wade, Ryckie G., Sachin Daivajna, Peter Chapman, Joseph G. Murphy, and Damodar Makkuni. “Hand Surgery for

Multicentric Reticulohistiocytosis: A New Avenue of Treatment and Review of the Literature.” International Journal of Surgery

Case Reports 4, no. 8 (2013): 744–47. https://doi.org/10.1016/j.ijscr.2013.04.039.

◼ The National Collaborating Centre for Chronic Conditions. Rheumatoid Arthritis. National Institute for Health and Care

Excellence: Clinical Guidelines. London: Royal College of Physicians (UK), 2018.

http://www.ncbi.nlm.nih.gov/books/NBK519103/.

◼ Landewé, Robert B M. “Overdiagnosis and Overtreatment in Rheumatology: A Little Caution Is in Order.” Annals of the

Rheumatic Diseases, July 4, 2018, annrheumdis-2018-213700. https://doi.org/10.1136/annrheumdis-2018-213700. Thank You