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Joint Pain and Swelling Common Rheumatologic Concerns ROBERT VALENTE MD ARTHRITIS CENTER of NEBRASKA LINCOLN, NE

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Joint Pain and Swelling Common Rheumatologic Concerns ROBERT VALENTE MD ARTHRITIS CENTER of NEBRASKA LINCOLN, NE Joint Pain And Swelling Common Rheumatologic Concerns ROBERT VALENTE MD ARTHRITIS CENTER OF NEBRASKA LINCOLN, NE I have no financial disclosures or conflicts of interest to report 1/3rd of All Primary Care Visits Involve a Musculoskeletal Complaint. Do You See Patients with Joint and Muscle Aches and Pains? DO YOU ALWAYS FEEL COMFORTABLE TRIAGING THESE PATIENTS? Common Arthritis Questions • Is it inflammatory arthritis ? • Distinguishing RA from OA • What does this + ANA mean? • Distinguishing CTD from chronic pain and fibromyalgia Case 1 DISTINGUISHING INFLAMMATORY ARTHRITIS FROM OSTEOARTHRITIS Case 1: The Reluctant Contractor 67 yo Male Contractor • Previous hx of LBP, neck pain chronic plantar fasciitis • 2 yrs previous, pneumonia, Rx included prednisone. Joints felt wonderful. • 2+ yrs of polyarthralgia, 3 ibuprofen QID, otherwise too stiff to get out of bed • No F/C/S, no wt loss. No rash or sun sensitivity, no dry eyes, eye inflammation, pleurisy, SOB, Cough, or GI distress. No numbness, Raynauds. No hx STD, kidney stones or gout. No hx of cancer, recent infection. • Dad with seropositive RA • Pain score 6, AM stiff 10 min What features of the Patient History suggest inflammatory polyarthritis? A. 10 min of morning stiffness B. Hx of Back pain and plantar fasciitis? C. Trial of prednisone made everything better D. Needs 12 ibuprofen a day, or too stiff to get out of bed and dad had rheumatoid arthritis DDx of Polyarticular Pain • Polyarthritis: Chronic and Acute (viral) • Reactive arthritis • Fibromyalgia • Multiple site Bursitis/Tendonitis • Hypothyroidism • Metastasis • Depression “The evaluation of the adult with polyarticular pain” • Neuropathic pain Shmerling RH, ed Wolters Kluwer, May 2018 • Metabolic/inherited bone diseases (osteomalacia, osteogenesis imperfecta) Can you tell if a joint is swollen? Case 1 • Yes • No Physical Exam • Rapid 3 = 7.5 • Moderate OA hands, 1st and 3rd MCPS, 1st CMCs, AC joints, L knee, B PF joints, toes • Bilateral Rotator cuff dysfunction • Normal Achilles, No sausage digits • Normal L-spine motion (finger to floor distance 2 inches) • 17 swollen, 20 tender joints Case 1 LAB AND X-RAY RESULTS • Normal: CBC, ESR, CRP, Chemistries, urine • -RF, -CCP, - ANA • X-ray hands C/W osteoarthritis, Moderate (nodal pattern) Rheumatoid Arthritis: Radiographic Abnormalities • Soft tissue swelling • Symmetric joint involvement • Peri-articular osteoporosis • Symmetric joint space narrowing • Marginal erosions • Deformity – Fibrous ankylosis Question Does this 67 yo Male Contractor have inflammatory Arthritis? A. Yes B. No The Case for Inflammatory Arthritis • SX > 6 weeks • Prolonged AM stiffness • SX better with ibuprofen • + family hx of Sero+ RA • 17 Swollen joints on PE The Case Against Inflammatory Arthritis • Patient is 67 yo, and a laborer with lots of OA • No CTD disease features • No inflammatory bowel sx • No psoriasis • No STD risks, no Gout/stone • Normal ESR, CRP • Negative ANA, RF, CCP • X-rays show osteoarthritis without erosions, Ca++, etc Does Negative RF, CCP, Normal ESR Affect Your Decision A. YES B. NO The Key: SYNOVITIS Rheumatoid Arthritis Osteoarthritis Laboratory Testing to Discriminate Between RA and Non-RA in Patients With Early Arthritis Sensitivity (%) Specificity (%) PPV (%) NPV (%) Anti-CCP * 48 96 84 81 IgM RF * 54 91 74 81 Anti-CCP or RF 63 88 72 83 Anti-CCP and 39 98 91 78 RF Elevated ESR had a PPV of only 17% for RA *Anti-CCP and IgM RF were determined by enzyme-linked immunosorbent assay (ELISA). CCP = cyclic citrullinated protein; PPV = positive predictive value; NPV = negative predictive value. Visser H, et al. Best Pract Res Clin Rheum. 2005;19:52–72. II.14 Early Undifferentiated Polyarthritis: What Matters? Synovitis (especially @ 3 Mo) % Patients Receiving DMARDs at 12 Months Characteristics at Baseline RF + ↑ CRP ↑ CRP RF + RF - SE + RF + Synovitis 70 43 Synovitis 60 Synovitis 62 80 No No No 40 15 0 033 synovitis synovitis synovitis Characteristics at Month 3 RF + ↑ CRP ↑ CRP RF + RF - SE + RF + Synovitis 75 70 Synovitis 60 Synovitis 69 100 No No No 02 0 00 synovitis synovitis synovitis What Trumps What? SE = possession of ≥ 1 allele of shared epitope (HLA-DR1,4,10); UPA = undifferentiated polyarthropathy. CRP = C-reactive protein level ≥ 10 mg/L. SYNOVITIS ! Quinn MA, et al. Arthritis Rheum. 2003;48:3039–3045. 2010 ACR/EULAR RA Classification Criteria ≥ 6 points = RA • 1 med or large joint swelling = 0 points • 2 – 10 med or large joints swollen = 1 point • 1 – 3 small joints swollen = 2 points • 4 – 10 small joints swollen = 3 points • > 10 small joints swollen = 4 points • -RF, -CCP = 0 points • + RF or + CCP (low titer 2-3 x normal) = 2 points • +RF or + CCP high titer = 3 points • Duration of synovitis > 6 weeks = 1 point • Abnormal CRP or ESR = 1 point A & R, Aug 2010 Case 1: Dx = Seronegative RA • Treatment Goals • Make the patient feel as normal as possible • Prevent bony damage/disability • Avoid toxicity • Cost effectiveness • Use standardized scoring to measure RA disease activity • Treat to Target (low disease activity) 2015 ACR Guideline for the Treatment of Rheumatoid Arthritis, Arthritis Rheumatol. 2016 Jan;68(1):1-26 The Progression of RA - Why Do We Need To Dx Early? Early Intermediate Late Inflammation Disability Joint Damage Severity (arbitrary units) 0 51015202530 Window of Duration of Disease (years) Graph: Adapted from Kirwan JR. J Rheumatol. 2001;28:881–886. Opportunity Photo: Copyright © American College of Rheumatology. Very Early RA (VERA) vs Late Early RA (LERA) Impact of DMARD Therapy on ACR Response Rates 80 3 months 36 months 70 70 65 60 60 55 VERA patients 50 50 LERA patients 40 40 * * 35 * 30 * 25 20 20 20 15 * 10 % of Patients of % 0 0 ACR-20 ACR-50 ACR-70 ACR-20 ACR-50 ACR-70 *P < 0.05 for LERA vs VERA. VERA = patients presented within 3 mo of symptom onset; LERA = patients presented between 9 months and 3.5 years after symptom onset (median of 12 months). All patients were naive to treatment with DMARDs. II.22 Nell, VPK et al. Rheumatology. 2004;43:906–914. Case1: Treatment • Problems with dysphagia • Initially did not use / continue NSAID • Upper endoscopy negative This Photo by Unknown Author is • Started back on Ibuprofen 600 mg TID licensed under CC BY-NC-ND • Prednisone 5 mg Q AM (with taper beginning at 8 wks • Methotrexate, increasing dose to 20 mg po Q week • Folic acid • @ 2 mo Rapid 3 was 4, down from 7.5, AM stiff 15 min • Swollen joint count 11, down from 17 Case 2 WHEN DOES A POSITIVE ANA MEAN SOMETHING?? WHEN TO AVOID CHECKING AN ANA! Case 2: The Stiff Daycare Provider • 23-year-old nonsmoking female daycare provider • Onset of pain and stiffness and swelling in her hands and wrists beginning February 2017. Compromised activities of daily living. • Morning stiffness that would last up to 4 hours • Primary care evaluation documented new onset hypothyroidism. No improvement in joint symptoms with T4 • Trial of prednisone with prompt but temporary benefit. Minimal benefit with diclofenac • Mother notices puffy fingers • At the same time, patient’s develops classic white attacks/Raynaud’s phenomenon. No other formal CTD sx. (No SOB, swallowing difficulty, Dry eyes, oral ulcers, numbness, rash) What historical features suggest inflammatory arthritis? A. Pain and stiffness in the hands B. Prednisone helped temporarily, diclofenac without benefit C. Puffy, swollen fingers noted by mom D. Raynaud’s phenomenon E. New onset hypothyroidism F. All of the above Fibromyalgia • Muscle attachment pain • Hurt all over (Large > small joints) • All day stiffness • No swollen joints • Normal inflammatory markers • Other complaints • Fatigue, cognitive problems, • Paresthesia, headache • Irritable bowel and bladder +ANA ≠ inflammatory arthritis Predicting Pain in OA pts after TKA and THA Fibromyalgia-ness (FM-ness) Calculated with the • Outcomes Polysymptomatic Distress Scale • Post op opioid consumption • Pain relief @ 6mo • 9 mg > Morphine requirements for each point higher “FM-ness” • 20% less likely to reach 50% less pain after arthroplasty with each point higher “FM-ness” Brummett, etal. Anesthesiology, 2013 DDx of Polyarticular Pain • Polyarthritis: Chronic and Acute (viral) • Reactive arthritis • Fibromyalgia • Multiple site Bursitis/Tendonitis BUT… • Hypothyroidism • Metastasis • Depression “The evaluation of the adult with polyarticular pain” • Neuropathic pain Shmerling RH, ed Wolters Kluwer, May 2018 • Metabolic/inherited bone diseases (osteomalacia, osteogenesis imperfecta) This is Polyarthralgia/itis + Something ELSE FORMAL CTD / SLE SPONDY / IBD/ VASCULITIS HEPATITIS PSORIATIC • Polyarthritis + • Polyarthritis + • Raynauds • Polyarthritis + • Inflammatory back • New HA, visual changes • Polyserositis pain • Claudication • Rash • Iritis • Nephritis • Sun sensitivity • Psoriasis • • Dry Eyes • Inflammatory Bowel Pulmonary infiltrates • Multiple Miscarriages disease • Pulmonary hemorrhage • DVT • Hx of dysentery or • Neuropathy STD • Seizures • Purpura / ulcers • Renal disease • Cytopenias Case 2: Physical Exam • Wt 134#, BP 96/65, Pain 8.5 • Skin: puffy fingers +++ nailfold capillary changes - telangiectasia, scleroderma -psoriasis, Nodules • CV: no murmur, 4+ pulses, - Allen’s test bilaterally • Lungs, Abd, Neuro, Extremities all normal. No edema • Raynaud’s phenomenon • 18 swollen and tender joints Case 2: Lab and X-ray • Lab from home • Normal ESR, CRP, TSH, Lyme titer, B12, Vit D 26.8 • CXR normal • Lab after Rheum Visit • Hand x-ray normal except • Normal Hepatitis profile B,C for soft tissue swelling • Normal
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