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110 Identification and Treatment of Rheumatologic Diseases

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110 Identification and Treatment of Rheumatologic Diseases 4/2/2021 Describe common rheumatologic diseases Identification • Kristine M. Lohr, MD, MS and Treatment • Professor of Medicine and Chief of Determine routine diagnostic of Rheumatology Division Objectives evaluations for rheumatologic • University of Kentucky College of Medicine diseases prior to referral Rheumatologic • April 20, 2021 Diseases Describe new treatment modalities and alternative therapies for rheumatologic diseases 1 2 Prevalence Rates of Common Rheumatic Diseases • Osteoarthritis • Rheumatoid arthritis Most common • Gout rheumatologic • Lupus diseases • Fibromyalgia • Psoriatic arthritis • Ankylosing spondylitis Centers for Disease Control and Prevention March 2017 Vital Signs https://nccd.cdc.gov/cdi/rdPage.aspx?rdReport=DPH_CDI.ExploreByTopic&islTopic=ART&islYear=9999&go=GO 3 4 Arthritis among Adults Aged >18 yr. in Kentucky Age-adjusted Prevalence (%) Rheumatic Joint Disorders: History Male Female Survey Year Inflammatory Non-inflammatory (Mechanical) All adults aged > 18 yr. 27.8 33.3 2018 Joint pain In the AM, at rest, & with use With use, improved with rest With obesity 32.9 40.0 2018 Stiffness Prolonged morning (>1 hr.) Short-lived after inactivity With diabetes 64.7 40.6 2018 Fatigue Significant Minimal With heart disease 47.2 53.9 2018 Activity May improve stiffness May worsen symptoms Activity limitation due to doctor-diagnosed arthritis 49.5 64.0 2015 Rest May cause gelling May improve symptoms Severe joint pain due to doctor-diagnosed arthritis 35.3 38.3 2017 Instability Buckling, give-way Work limitation due to doctor-diagnosed arthritis 57.2 57.7 2017 Systemic involvement Yes No Physical inactivity 36.2 39.0 2018 Corticosteroid responsiveness Yes No CDC Behavioral Risk Factor Surveillance System (health survey) 5 6 1 4/2/2021 Rheumatic Joint Disorders: Exam Findings Rheumatic Joint Disorders: Exam Findings Feature Rheumatoid Arthritis Osteoarthritis (Mechanical) Rheumatoid arthritis Osteoarthritis (Mechanical) Joint involvement Almost any Predominantly weight-bearing joints & Symmetry Yes Occasional hands, mid-cervical, mid-lumbar Synovitis Yes Rarely (may occur in erosive OA) Swelling Distended joint capsule Bony (“stony”) hypertrophy • Distal interphalangeal No Heberden nodes Firm, rubbery Irregular • Proximal interphalangeal Yes Bouchard nodes Spindle-shaped Nodular • Thumb carpometacarpal No Yes • Wrist Yes No Crepitus None or fine Rough Deformities Swan neck DIP or PIP angulation Range of motion Limited Limited Boutonniere Nodules (subcutaneous) Yes No Subluxation Extraarticular signs Yes No Ulnar drift 7 8 • Most generalized rheumatic disorders • E.g., rheumatoid arthritis, systemic lupus erythematosus • Weight loss • Fibromyalgia • Fever • Poor sleep Contributors • Color changes (e.g., black, dark purple) or • Related to pain coldness of digits or limbs to Fatigue & • Poor-quality Red Flags • Temple headache, pain with scalp Malaise • Heartburn, nocturia, CHF, neurologic tenderness, visual disturbance disorders, hyperthyroidism, OSA • • Medications, alcohol, caffeine Loss of sensation or motor function • • Depression & other mental health problems Difficulties with urination or defecation 9 10 • CBC • Lymphopenia in active SLE or with Acute Phase Reactants immunosuppressive drug treatment • Thrombocytosis (inflammation) or Elevated Westergren ESR Elevated C-reactive Protein Screening tests thrombocytopenia (active SLE) • Infection • Infection • Anemia (inflammation/chronic disease) • Rheumatic disease • Rheumatic disease prior to • Renal function & urinalysis • Higher in women • Higher in women • rheumatologic Aminotransferases • Increased with age • Increased with age referral • Serum uric acid • Obesity • Obesity • • Metabolic stress, e.g., insulin Acute-phase reactants • Malignancy • ESR (higher in women; increased with resistance age) • Renal disease • Race • CRP (higher in obese patients) • Anemia • Tissue injury/ischemia 11 12 2 4/2/2021 • High specificity & moderate sensitivity for RA • Can be present up to a decade before clinical • Hepatitis C & B, bacterial endocarditis, TB, Autoantibodies: disease chronic bronchitis Anti- • Can be positive in Autoantibodies: • 5-6% of older adults in normal population • ~25% of RF-negative RA citrullinated Rheumatoid • Specificity increases with higher titer • With erosive disease in SLE, primary Sjogren, Peptide psoriatic arthritis Factor • Suspicion of RA or Sjogren syndrome • Active TB • 20-30% of RA patients are Antibodies • Rare in hepatitis C seronegative (ACPAs) or CCP • Rare in alpha-1 antitrypsin deficiency and in COPD 13 14 Autoimmune Disease Sensitivity (%) Systemic lupus erythematosus 95-100 ANA 1:40: 20-30% Systemic sclerosis 60-80 Mixed connective tissue disease 100 Poly/dermatomyositis 60 ANA 1:80: 10-15% Rheumatoid arthritis 50 Autoantibodies: Can a positive Rheumatoid vasculitis 30-50 Anti-nuclear Sjogren syndrome 40-70 ANA occur in ANA 1:160: 5% Antibodies Drug-induced lupus 15 a normal Pauciarticular juvenile idiopathic 70 (ANAs) arthritis healthy ANA 1:320: 3% Nonrheumatic Disease Sensitivity (%) Frequency of Hashimoto thyroiditis 45 ANAs person? Healthy relative of an SLE patient: 5-25% (usually low titer) Graves disease 50 Autoimmune hepatitis 50 Primary pulmonary hypertension 40 Age >70 years: up to 70% positive at ANA titer 1:40 15 16 Rheumatoid Arthritis: Pharmacologic Therapy Conventional DMARDS Biologic DMARDs Targeted Synthetic DMARDs • Methotrexate TNF-alpha inhibitors Janus kinase inhibitors • Leflunomide • Etanercept • Tofacitinib • Sulfasalazine • Infliximab • Baricitinib • Hydroxychloroquine • Adalimumab • Upadacitinib • Golimumab • Certolizumab pegol IL-6 receptor antagonist • Tocilizumab • Sarilumab T-cell costimulation blocker • Abatacept (CTLA4-Ig) Anti-CD20 B-cell depleting monoclonal antibody • Rituximab 17 18 3 4/2/2021 Management of Osteoarthritis: Management of Osteoarthritis Recommended Physical, Psychosocial & Mind-Body Approaches Recommended Pharmacologic Approaches Modality Hand Knee Hip Drug Hand Knee Hip Exercise Strong Strong Strong Oral NSAIDs Strong Strong Strong Self-efficacy & Self- Strong Strong Topical NSAIDs Conditional Strong Management Programs Intra-articular Steroids Conditional Strong Strong (imaging-guidance) Weight loss, Tai Chi, Cane Strong Strong Acetaminophen Conditional Conditional Conditional st Assistive device Strong: 1 CMC Orthosis Strong: Tibiofemoral Knee Brace Tramadol Conditional Conditional Conditional Duloxetine Conditional Conditional Conditional Conditional: Heat, therapeutic cooling, cognitive behavioral therapy, acupuncture, kinesiotaping, balance training, other hand orthoses, patellofemoral knee brace, paraffin, yoga, radiofrequency ablation Chondroitin Conditional Topical capsaicin Conditional Kolasinski SL et al: 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Kolasinski SL et al: 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis Osteoarthritis of the Hand, Hip, and Knee. Arthritis Care Res 2020 Feb;72(2):149-62. of the Hand, Hip, and Knee. Arthritis Care Res 2020 Feb;72(2):149-62. 19 20 • The epitome of a red, hot, swollen joint • But acute monoarthritis = infection Triggers of acute gout till proven otherwise! • Rare in men aged < 25 years & in • Alcohol ingestion • Trauma Acute premenopausal women • Initiation of urate-lowering therapy • Radiation or chemotherapy Monoarthritis: • Diagnosis: tap the joint • • • Needle-shaped negatively Dietary excess of purines Fructose ingestion Gout birefringent crystals + leukocytes • Acute medical illness (e.g., infection) • Postoperative days 3-5 (20,000-100,000/cu mm) • Exercise • Dehydration • Serum uric acid can be normal during • Drugs an attack 21 22 Drugs that decrease renal excretion of urate Drugs that • Amlodipine • Cyclosporine • Ethambutol • Atorvastatin • Alcohol • Low dose ASA mildly • Fenofibrate • Nicotinic acid • Pyrazinamide increase renal • Leflunomide • Thiazides • Levodopa • Losartan • Tacrolimus • Theophylline excretion of • Rosuvastatin • Furosemide & loop diuretics • Didanosine urate • High-dose salicylates 23 24 4 4/2/2021 • Moderate intake of purine-rich food • Asparagus, cauliflower, spinach, mushrooms • Typically decreases serum uric acid by <1 mg/dL • Nuts • Weight loss • Legumes (beans, peas, lentils) Can diet & • Can diet & Complex carbs (fruits, vegetables, whole grains) • Proteins: lifestyle alone • Hydrate with water lifestyle alone • Lean meat & poultry • Limit • Low-fat dairy (milk, yogurt) manage • Saturated fats (red & organ meats, fatty poultry, manage • May reduce risk of gout high-fat dairy products) • Coffee in moderation, especially regular caffeinated symptomatic • symptomatic Seafood (shellfish, sardines, anchovies) • Vitamin C 500 mg/day • gout? Fructose (soda, fruit juice, energy drinks) gout? • Tart cherries • Moderate consumption of wine https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/gout-diet/art-20048524 https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/gout-diet/art-20048524 25 26 Treatment of Acute Gout Options Dosage Comments NSAIDs Indomethacin 50 mg po qid 24-48 hr., then Contraindicated in moderate/severe CKD • Frequent attacks (>2-3 over 1-yr. period) TID x 48 hr., taper off after attack subsides NSAIDs w/ short half-lives OK When do you Oral colchicine 1.2 mg po followed by 0.6 mg po 1 hr. later Within 36 hr. of onset initiate urate- • Renal stones (urate or calcium) Avoid in elderly, renal
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