polyarticular disease

Polyarticular disease

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Publisher: OxfordUniversityPress PrintPublicationDate: Oct2013PrintISBN-13: 9780199642489 Publishedonline: Oct2013DOI: 10.1093/med/9780199642489.001.0001

Chapter: PolyarticulardiseaseAuthor(s): AdeAdebajoandLisaDunkleyDOI: 10.1093/med/9780199642489.003.0009

OxfordMedicine

OxfordTextbookofRheumatology(4ed.)EditedbyRichardAWatts,PhilipConaghan,ChrisDenton,HelenFoster,JohnIsaacs,andUlfMüller-Ladner

Polyarticulardisease

Introduction

Whenpresentedwithapatientwhohasjointdisease,itisimportanttohaveaclinicalstrategyformakingadiagnosisandeffectinganappropriatemanagementplan.Thefirstquestionthattheclinicianshouldaskis‘Isthisajointproblem?’,asoneneedstomakesurethepatientdoesnothavebonypain,musclepain/weakness,oratendonorothersofttissueproblem(Table9.1).Ifitisajointproblem,oneshouldask,‘Doesthisaffectonejoint(monoarthritis),afewjoints(oligoarthritis),ormultiplejoints(polyarthritis)’?Withthesebasicfirststeps,theclinicianisalreadybeginningtoformulateadifferentialdiagnosis.


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Table9.1Examplesofmimicsofjointdisease

Symptom Possiblecauses

Bonepain Osteomalacia,Paget’s,bonymetastases,hypertrophicpulmonaryosteoarthropathy(HPOA)

Musclepain/weakness

Polymyalgiarheumatica,vitaminDdeficiency,polymyositis

Thepresentationofmonoarthritidesisconsideredelsewhere(Chapter7).Hereweconsideraclinicalapproachtopolyarticulardisease.

Generalinformationfromclinicalhistoryandexamination

Allclinicalassessmentbeginswithaclinicalhistoryandexamination.Specificinformationrelatingtoindividualdiagnoseswillbeconsideredinlatersections,butthefollowingareusefulgenericpointstoconsiderwhenassessingapatientwithpolyarticulardisease.

Age

Inflammatoryjointdiseasemayoccuratanyagefromchildhoodtoveryoldage,butdegenerativediseaseismuchmorecommonaswegetolder.Goutisuncommonbeforethefifthdecadeandcalciumpyrophosphatediseasetypicallydevelopsfromtheseventhdecade.

Gender

Goutismorecommoninmen,buttheautoimmunediseasesaremorecommoninwomenwithfemale:maleratiosof3–5:1(rheumatoidarthritis,RA)and9:1(systemiclupuserythematosus,SLE).

Lifestylefactors

SmokingisassociatedwithRA,whichisthreetimesmorecommoninsmokersthaninnon-smokers.Alcoholisassociatedwithgoutandpsoriasis.Obesityisassociatedwithosteoarthritis(OA)ofthekneesandfeet,butequally,patientswithahistoryofhigh-levelsportsactivityarealsoatriskofearlyOA(e.g.inthekneesoffootballersortheshouldersofcricketersorracquetsportsplayers).Occupationalhistoryisalsoimportant;physicaljobscansimilarlyleadtoearlyOA,e.g.ofthekneeinplumbers,andclassicallyofthehipinfarmers.High-riskbehaviourforcontractionofblood-bornediseasesraisesthepossibilityofarthritisrelatedtochronicinfections,suchashepatitisBandC.

Familyhistory/personalmedicalhistory

Patientswithoneautoimmunediseaseoftendevelopanother,orhavefamilymemberswithautoimmunity.Askaboutthyroiddisorders,vitiligo,andperniciousanaemia.Alsoaskaboutunderlyingconditionsthatmightbedirectlyassociatedwithjointdisease—Crohn’sdisease.ulcerativecolitis,skinpsoriasis,uveitis.Patientswiththe‘metabolicsyndrome’(central


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obesity,type2diabetes,hypertriglyceridaemia,andhypertension)areathighriskofdevelopinggout(orviceversa)andthereisoftenapositivefamilyhistory.Patientswithrenalimpairmentarealsoatriskofgout.Metabolicconditionscanbeassociatedwithcalciumpyrophosphatedisease(CPPD),mostcommonlyprimaryhyperparathyroidism,butrarerassociationsincludehypomagnesaemia,Wilson’sdisease,andacromegaly.

Honingthediagnosis:inflammatoryversusnon-inflammatorydisease

Therearemanyapproachestoformulatingadifferentialdiagnosis.Consideringwhetherapatientpresentswithinflammatoryornon-inflammatorysymptomsisoftenhelpful(seeTable9.2).

Table9.2Comparisonofinflammatoryanddegenerativejointsymptoms

Symptoms Inflammatory Degenerative

Pain Easeswithuse IncreaseswithuseOftenclicks/clunksheard

Stiffness Significant(＞60min)Earlymorning/atrest(evening)

Notprolonged(＜30min)Morning/evening

Swelling Synovial±bony Noneorbony

Inflammation Hotandred? Notclinicallyinflamed

Patientdemographics

E.g.young,psoriasis,familyhistory

E.g.older,prioroccupation/sport

Jointdistribution E.g.handsandfeet E.g.1stCMCJ,DIPJ,knees

RespondstoNSAIDs

Positiveresponse Lessconvincingresponse

CMCJ,carpometacarpophalangealjoint;DIPJ,distalinterphalangealjoint;NSAIDs,non-steroidalanti-inflammatorydrugs.

Inflammatoryjointpain

Patientstypicallydescribepainandstiffnesswithintheaffectedjoints,thatisoftenworstfirstthinginthemorning(aftertheinactivityofbeingasleepallnight)andagainafteraperiodofrest(oftenlaterintheeveningastheyrelaxbeforebed).Moderatemovementtypicallyeasesthisstiffnessandpain—‘OnceIgetgoingagainI’mfine’.Generallyearlymorningstiffnessisconsideredsignificantandindicativeofinflammatorypathology,ifitlastsatleast30–60minutes.Non-steroidalanti-inflammatorydrugs(NSAIDs)maybeofsignificantbenefit,moreso


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thanparacetamolorcodeine-basedsimpleanalgesia,butthisisnotubiquitouslytrue.Ifsteroidshavebeenadministered,usuallyeitherorallyorintramuscularly,thesewouldbeexpectedtobringaboutasubstantialbuttemporaryreliefofsymptoms.

Non-inflammatoryjointpain

Patientsalsodescribepainandstiffness,butthestiffnessisusuallylesspersistentthanininflammatorydisease.Bothofthesesymptomsareattheirworstintheevenings,andtypicallymovementofajointmakesthepainworse.Earlymorningstiffnessmaybepresent,especiallyinosteoarthritisofthehands,butthedurationandintensityofstiffnessisnotasmarkedasininflammatorydisease.NSAIDsareoftenofnoadditionalbenefittosimplecodeine/paracetamol-basedanalgesia.

Jointdistribution

Thedistributionofaffectedjointscanhelpdifferentiatenotonlybetweeninflammatoryandnon-inflammatorydisease,butalsobetweenspecifictypesofinflammatorydisease(Figure9.1).

Fig.9.1Usualjointdistributionofcommonarthritides.

Involvementofthefirstcarpometacarpal(CMC)jointisalmostalwaysduetoosteoarthritis;RArarelyinvolvesthedistalinterphalangeal(DIP)jointsofthehands,andneverinisolation.Thecommonestjointstobeaffectedbygoutarethefirstmetatarsophalangeal(MTP)joints(classicalpodagra),ankles,andknees.

Appearanceofthejoints

Ared,hot,swollenjointclassicallyoccurswiththeveryacutehistoryofgout/pseuogout.Asepticjointcanalsopresentinthisway.Bothmaypresentwithsystemicfever.ThechronicinflammatoryarthritidesofRAandpsoriaticarthritistypicallypresentwithamoresubacutepictureofswellingandwarmth,butnotclassicallymarkedlyerythematousjoints.

Chronicityofsymptoms


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TypicaltimelinesofvariouspolyarticularconditionsareillustratedinFigure9.2.Crystaldiseaseandinfectionareusuallyacuteconditions;RAandpsoriaticarthritismayevolveslowlyovermanymonths,waxingandwaninginthattimeframe,butforasmallproportionofpatients,thesetoocanbe‘explosive’andrapidlyprogressive.

Fig.9.2Typicalchronicityofsymptomsincommonarthritides.

Inflammatoryversusnon-inflammatorydisease

Theclinicianhasnowestablishedwhetherthepatienthasinflammatoryornon-inflammatoryjointsymptoms.ConsideringthejointpainparadigmasshowninFigure9.3,itisnowpossibletoexplorethenon-inflammatoryversustheinflammatoryarmsandbegintoworktowardsaspecificdiagnosis.

Fig.9.3Aparadigmfordiagnosisofpolyarticularjointpain.CWPS=chronicwidespreadmusculoskeletalpainsyndrome.

Non-inflammatorypolyarticulardiseases

Degenerativedisease:osteoarthritis

OAisaconditionofdegradationwithinthejoint,usuallyinvolvingcartilagelossanddamagetosubchondralbone.Itmayalsoinvolveanexaggeratedrepairresponsetotheinitial

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degradativestimulus. Itisthecommonestformofarthritisworldwide.

DifferentpatternsofOAexist.Itmayaffectthespine,thelargejoints,isolatedsmalljoints(e.g.thefirstMTPjoint)ormultiplesmalljoints(typically‘nodalOA’ofthehands).ThislattersubsetofOAcanmimicinflammatoryarthritisintermsoftheinflammatorynatureofthejointpain,butthepresenceofHeberden’sandBouchard’snodesandinvolvementofthefirstCMCjointareusuallyenoughtoconfirmthediagnosis.

TherearealsofurtherpolyarticularsubsetsofOA,oftenreferredtoas‘inflammatoryOA’or‘erosiveOA’.Thesepatientshaveinflammatorysymptoms,typicallyinvolvingthesmalljointsofthehandsasdescribedabove.Thekeydifferenceisthattheirradiographsshowerosivechange.

Inonesubset,patientshaveerosivediseaseoftheproximalanddistalinterphalangealjointsofthefingers,andsymptomsareoftenpoorlyresponsivetoconventionaltreatments.TypicalradiographsareshowninFigure9.4.

Fig.9.4Erosiveosteoarthritisinvolvingproximalanddistalinterphalangealjoints.

ThesecondsubsetofpatientsarethosewhohavearthritisassociatedwithCPPD.Thisisalsooftenreferredtoas‘inflammatoryOA’buthasapropensitytoinvolvethesecondandthirdMCPjointsinisolation.SecondarycausesofCPPD,suchashaemochromatosis,diabetes,hypomagnesaemia,andhyperparathyroidismshowthissamepatternofjointinvolvement(seealsosection‘Pseudogout:calciumpyrophosphatedisease’).

Non-degenerativedisorders

Benignjointhypermobilitysyndrome

Approximately10%oftheadultpopulationarehypermobile. Jointhypermobilityinitselfisnotpathological,butmaybeconsideredsoifassociatedwithpersistentpainandjointdysfunction.Diagnosisofbenignjointhypermobilitysyndrome(BJHS)ismadeusingtheBrightoncriteriawhichidentifythecombinationofjointhypermobilityandpatientsymptoms.Jointhypermobility

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maybeassociatedwithchronicnon-inflammatoryjointpain.Thepainmightberestrictedtooneortwo(oftenweight-bearing)joints,butcanpresentasasymmetricalpolyarticularcondition.Thecluetodiagnosisisoftentheinitialexamination.

Chronicwidespreadmusculoskeletalpain

Chronicwidespreadmusculoskeletalpainsyndrome(CWPS)isalsoreferredtobymanyas‘fibromyalgia’.Theseoverarchingtermsencompassasyndromeofwidespreadjointandmusclepainthatisaccompaniedbymultipleassociatedsymptoms,includingfatigue,poorsleep,andmooddisturbance.Takingacarefulhistorytoelicittheseassociatedsymptoms,andestablishingthepresenceofwidespreadbutnon-inflammatorypain,helpsconfirmthediagnosis.

Inflammatorypolyarticulardiseases

Autoimmuneconditions

Rheumatoidarthritis

RAisasymmetrical,erosivepolyarthritisthattypicallyaffectsthesmalljointsofthehandsandfeet.Thekeyfeaturesofthehistoryareinflammatorypainandstiffness,usuallyprogressiveoverseveralmonths,andadescriptionofjointswelling.Patientsmayalsodescribefatigueorgeneralmalaise.Asdescribedabove,theremayoftenbeafamilyhistoryofRAorotherautoimmunedisease.Symptomsandsignscanbequitesubtle,butsomepatientspresentwithrapidlyprogressivesynovitisandgrosslyswollen‘boxingglove’hands.

Examinationtypicallydemonstratesswellingand/ortendernessinthewrists,MCPandPIPjointsofthehandsandMTPjointsofthefeet.Lookforcallusonthesolesofthefeet,andrheumatoidnoduleswhichtypicallyoccurontheextensorsurfacesoftheelbow,hands,andtheAchillestendon.Somepatients,however,havelargejointpredominantdisease,soitisimportanttoexaminethesejointstoo.

Spondyloarthropathy

The‘spondyloarthropathies’encompassabroadrangeofrelatedarthritidesthatarevariouslyassociatedwiththetissuetypeHLAB27(seeTable9.3).Theclinicalpresentationvarieswidelybetweenandwithinthem.Aswellasinflammatoryarthritis,thehallmarkoftheseconditionsisthepresenceofanenthesopathy.Thearthritisitselfmaybeasymmetricalsmalljointpolyarthropathy(typicallypsoriaticarthritis)butmayberestrictedtothespineonly(ankylosingspondylitis),orpresentasaperipherallargejointoligoarthritis(psoriaticarthritis,reactivearthritis,enteropathicarthritis).Thereismuchoverlapbetweentheindividualspondyloarthropathies,andapatientmayevolvebetweendiagnosesovertime.


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Table9.3TheHLAassociationofspondyloarthropathies

Diagnosis HLAB27positivity(%ofpatients)

Ankylosingspondylitis

90–95%

Psoriaticarthritis 50%overall(10–20%peripheraldisease;60–70%ifspinalinvolvement)

Reactivearthritis 70–85%

Enteropathicarthritis 50%

Isolatedanterioruveitis

50%

Spinalinvolvementisindicatedbyinflammatorybackpain—stiffnessafteraperiodofrest,paindirectlyoverthesacroiliacjoints(i.e.mid-buttock),thoracicandanteriorchestwallpain,andsignificantearlymorningstiffnessinthespine.Apatientmaynotknowthathe/shehaspsoriasis.Itisworthaskingforahistoryofitchy,scalyskinpatches,rememberingthe‘hidden’sitesforpsoriasis—thescalp,behindtheears,umbilicus,natalcleft,palmsandsoles,nails.Dystrophictoenailsmaybepsoriaticratherthanfungal,andnailclippingsareworthsendingifindoubt.Thepatientmaynothavepsoriasis(yet)buttheremaybeafamilyhistory.

Enquireaboutbowelsymptomsanduveitis—bothcurrentandhistorical.Takeasexualhistory,butbesuretomaketherelevanceofthisclear‘somearthritisconditionscanbetriggeredbysexuallytransmittedinfections’.Thismayrequireasecondvisit,atelephonecall,oradiscreetquestioninaseparateexaminationroomifthepatientisaccompaniedbyapartner.Evenifthehistoryis‘negative’,ifreactivearthritisisapossibility,invitethepatienttoself-refertothegenitourinarymedicineclinic.

Examineforperipheralarthritis,enthesitis(commonlyAchillestendonwithassociatedplantarfasciitis,and/orepicondylitisattheelbow),chestwallinvolvement(sternoclavicularjoint,costochondraljoints)andspinalrestriction.

Juvenileidiopathicarthritis

Theabovesectionsaddressinflammatoryjointdiseaseinadults.Childrenandyoungpeoplemayalsodevelopinflammatoryarthritides,buttheclinicalpresentation,naturaldiseasehistory,andmanagementcanbeverydifferent.Aseparateclassificationofdiseasesisused(Table9.4)anditiscriticalthatthesepatientsaremanagedbymultidisciplinary,multiagencyteamsthathavespecificexpertiseinmanagingallaspectsoftheircare.30–50%continuewiththeirarthritisintoadulthoodsoitisimportantthatclinicalpathwaysexisttomanagethistransitionproperly.

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Table9.4ILARclassificationofjuvenileidiopathicarthritis(JIA)

JIAsubtype Keyfeatures

Systemiconset(SOJIA)

10–20%patients;usuallypolyarticular,quotidian(daily)fever,evanescentrash,lymphadenopathy.Differentialdiagnosisincludesinfection/malignancy

Oligoarthritis MostcommonformofJIA.1–4jointsin1st6months;ageusually＜6yrs.May‘extend’to＞4joints—‘extendedoligoarticular’—after1st6months;worstprognosisandoftenmissedatonset

PolyarticularRF(−)

Typicallyyoungchildren,girls＞boys,ANA(+)=highriskofanterioruveitis

PolyarticularRF(+)

Typicallyteenagegirls;muchlikeadultRA

Psoriaticarthritis

Dactylitiscommon

Enthesitis-related

Oftenboys＞6yrs.ResemblesadultAS,butperipheralinvolvementgreater

Undifferentiated Doesnotfitintoanyofthecategoriesabove

Foralltheabove,arthritisofunknownaetiologyoccurringbeforethe16thbirthdayandpersistingfor＞6weeks.Allotherknownconditionsexcluded.

Allpatientswithjuvenileidiopathicarthritis(JIA),particularlythoseundertheageof11andthosewithpositiveanti-nuclearantibodies,musthaveophthalmicscreening.Anterioruveitisiscommon;itisanimportantreversiblecauseofchildhoodblindnessintheUK,andisoftenasymptomaticinchildren.

Connectivetissuedisease/vasculitis

Connectivetissuediseasesandvasculitidesoriginallybecamethedomainoftherheumatologistastheycanpresentwitharthritis(andlatterlybecausetheyarealsoimmunologicallydriven).Theseconditionscanbeassociatedwithlife-threateningorganinvolvement,sorememberthatwhatmightappeartobea‘simple(unclassified)inflammatoryarthritis’mayheraldamoreseveresystemicdisease.

Remembertoothatconnectivetissuediseasesmayoccurasoverlapsyndromes:apatientwithlimitedcutaneoussystemicsclerosismayhavetrueerosiveRAalongsidethescleroderma.

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AselectionofdiagnosesisconsideredinTable9.5.

Table9.5Clinicalpresentationsofcommonconnectivetissuediseases/vasculitides

Diagnosis Associatedarthritis Non-articularfeatures

SLE ‘Jaccoud’sarthritis’—symmetrical,correctiblepolyarthritis—phenotypicallylikeRAbuttypicallynon-erosive

Photosensitivity,malarrash,mouthulcers,hairfall,fatigue,abnormalnailfoldcapillaries

MCTD Arthralgia/symmetricalerosivearthritis—75%ofpatientshavetrueRAoverlap

Raynaud’s,sclerodactyly,myositis,pulmonaryhypertension,pleuritis/pericarditis

PSS Non-erosiveinflammatoryarthralgia/arthritis

Siccacomplex(dryeyes/drymouthandmucousmembranes),fatigue,peripheralandcentralnervoussysteminvolvement.Riskoflymphoma(NHL)

Large-vesselvasculitis

Myalgiaandstiffness(polymyalgiarheumatica);nottypicallytruearthralgia

Temporalarteritis/vascularbruits/systemicmalaise/jaw,tongue,calfclaudication

ANCA-associatedvasculitis

Inflammatory,erosive(trueRA?)ornon-erosive

Respiratory/renal/cardiac/ENT/neurologicalinvolvementofvasculitis+systemicmalaise

ANCA,anti-neutrophilcytoplasmicantibodies;MCTD,mixedconnectivetissuedisease;NHL,non-Hodgkin’slymphoma;PSS,primarySjögren’ssyndrome;RA,rheumatoidarthritis;SLE,systemiclupuserythematosus.

Crystalarthritis

Bothgoutandpseudogoutshowacuteandchronicforms.Ingeneral,theacutediseaseisamono-oroligoarthritis,whilstthechronicdiseaseispolyarticular.

Gout

Goutispainful.Patientsoftendescribewakingintheearlyhourswithjointpain,andbythemorningbeingunabletoputtheirfoottothefloor.Theaffectedjointistypicallyhot,red,andswollen.Thepatientmaybesystemicallyunwell.Jointdistributionhasbeendescribedearlier(firstMTPjoint,knees,ankles).Diffuseinvolvementofthemidfootisalsocommon.Itcanalsopresentasatrulypolyarticulardisease,especiallyifthereisamorechronichistoryofjoint


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pain.Inthislatterscenario,whenyouexplorethepatient’shistoryyouwillusuallyelicitthetypicalacutemonoarthritishistoryofgoutfromseveralyearsorevendecadesearlier.Inthissituation,examineforgoutytophi—ifpresent,thesewillhelpconfirmthediagnosis.

Serumuricacidmaybeelevated,butcanbenormalorlowduringanacuteattack.Thegoldstandardfordiagnosisispolarizedmicroscopyofsynovialfluidfromanacutelyaffectedjoint,demonstratingtheclassicalnegativelybirefringentneedle-shapedcrystalsofuricacid.Radiographsmayshow‘punchedout’periarticularerosions.

Pseudogout:calciumpyrophosphatedisease

Pseudogoutorcalciumpyrophosphatediseaseiscommoninelderlypeople.Itoftenoccursduringorfollowinganintercurrentillnessandpresents,likegout,withahot,swollen,redjoint.Wristsandkneesareclassicallyaffectedinacutedisease.Synovialfluidexaminationrevealspositivelybirefringentrhomboidcrystalsofcalciumpyrophosphate.Radiographsmayshowchondrocalcinosis(linearcalcificationofthecartilage),typicallyinthemenisciofthekneesorthetriangularligamentofthewrist.Iflookedfor,chondrocalcinosismayalsobepresentinthesymphysispubis.

Themorechronicpolyarticularformofcalciumpyrophosphatediseasecanaffectanyjoint,butoftenthesecondandthirdMCPjoints,wrists,elbows,shoulders,andknees.Thisclinicalpictureisoftendescribedsynonymouslywith‘inflammatoryOA’andisalludedtointheearliersectiononOA.Radiographsmayshowhookosteophytes,usuallyatthesecondandthirdMCPjoints(Figure9.5).

Fig.9.5TypicalhookosteophytesandnarrowingatMCPJ2&3inCPPD—inthiscaseassociatedwithhaemochromatosis.

Othercrystaldepositiondiseases

Calciumhydroxyapatiteandcalciumoxalatecrystalsmayalsocausecrystal-associatedarthritis.Aswithgoutandpseudogout,presentationmaybeacute/mono-oroligoarticular,or


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chronic/polyarticular.Patientsmayhaveassociatedrenalstonedisease.

Infection

Theclassicalhistoryofjointsepsisisthatofasinglehot,redswollenjointinapatientwhomaybesystemicallyunwell.Jointsepsiscan,however,bepolyarticularinupto20%ofcasesandmayinvolvethespine/intervertebraldiscs/sacroiliacjointsaswellasperipheraljoints.Mortalityismuchhigher,at30%comparedwith4–8%formonarticularsepsis.RiskfactorsforpolyarticulardiseaseincludeRA,diabetes,SLE,malignancy,alcoholism,andimmunosuppression,butitcanoccurinpatientswithnoneofthese.Theclinicianmustmaintainahighindexofsuspicionforsepsisinpolyarticularpresentations.Diagnosisisconfirmedbyjointaspiration,andifnecessaryradiologicallyguidedaspirationshouldbeundertaken.

Rarities

Thischapterhasdeliberatelyconcentratedoncommonclinicalpresentations.Thereare,however,rarercausesofpolyarticularjointdisease.Mostofthesearesystemicconditionsassociatedwithinflammatoryjointpainbut,withtheexceptionofsarcoidosisandSAPHOsyndrome,usuallycauseanon-erosivearthritis.SomeexamplesarelistedinBox9.1.

Box9.1Systemicconditionsknowntobeassociatedwithinflammatoryjointsymptoms

◆Coeliacdisease◆Whipple’sdisease◆Lymphocyticcolitis◆Primarybiliarycirrhosis/chronicactivehepatitis◆Infectioushepatitis/HIV◆Sarcoidosis◆SAPHO(synovitis,acne,pustolosis,hyperostosis,osteitis)◆Infections—poststrep/postviral/parvovirus/Lymedisease/tropicalarthritis◆Inflammatory—Behçet’s,familialMediterraneanfever

Genericmanagementofpolyarticulardisease

Confirmingthediagnosis

Thefirststep,afterclinicalassessmentofthepatient,istoconfirmthediagnosis.Forsomeconditionsthiswillrelyontheclinicalassessmentalone,butoftenwecansupplementthiswithadditionalinvestigations.

Bloodtestsmayconfirminflammation(orsepsis)withraisedwhitecellcount,thrombocytosis,elevatedinflammatorymarkers(ESRandCRP)andoftenelevatedalkalinephosphatasetoo.

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Specificautoimmunediagnosesmaybesupportedbythepresenceofantibodiessuchasrheumatoidfactor,anti-CCP,ANA,andENA.Elevateduricacidmaybepresentingout.Synovialfluidexaminationforcrystalsorinfectionmaybeimportant.Imagingwithplainfilms,ultrasound,andMRIisoftenuseful.Isotopebonescanningisusedlessthesedays.

Responsetoaone-offdoseofintramuscularsteroid(usuallydepomedroneortriamcinolone)isoftenusedtoconfirmthepresenceofinflammatoryvsnon-inflammatorypathology.Reliefofsymptomsisindicativeofunderlyinginflammatorydisease.

Managingthe‘non-inflammatory’patient

Managementofnon-inflammatoryjointpainisoftensupportive;toreducepainandoptimizefunctionwhilstattemptingtominimizefuturejointdamage.Thisrequirestheinputofamultidisciplinaryteam.

Medicalmanagementincludessimpleanalgesiaandanti-inflammatories(NSAIDs)ifrequired,withalltheusualprecautionsaboutprescriptionofthelatter.ForselectedpatientswithOA,intra-articularinjectionofsteroidsmaybeappropriate.

Patientswith‘inflammatoryOA’associatedwithcalciumpyrophosphatedepositionmaybenefitfromNSAIDs,low-dosecolchicine,low-doseoralsteroidorevenmethotrexateandhydroxychloroquine.

Inputfromothermembersofthemultidisciplinaryteamshouldincludephysiotherapy,occupationaltherapy,podiatry,andoftenpainmanagementspecialists.Principlesoftherapyincludemaintenanceofappropriatemusclestrengthandflexibility,maximizingfunctiondespitejointdisease/pain,jointprotection,pacingofactivities,andconsiderationoftheimpactofoccupationalandrecreationalactivitiesonjointsandviceversa.

Surgicalmanagementisreservedforpatientswheremedicalandconservativetherapyhasfailed.Theusualindicationforjointsurgeryisintractablepainand/orinstability.

Managingthe‘inflammatory’patient

Thegenericmultidisciplinarymanagementdescribedfor‘non-inflammatory’jointpainappliesequallytopatientswithinflammatorydisease.Inaddition,thesepatientsrequirespecifictherapytotreattheunderlyinginflammatoryprocess.

Managementofindividualconditionswillbeaddressedindetailinlaterchaptersofthisbook.Whatfollowsisanoverviewoftheprinciplesoftreatment.

Erosive/organ-threateningdisease

Inmostcases,wherejointdiseaseisdrivenbyinflammation,theearlierwetreat,thebettertheoutcome.Modernmanagementoferosive/organ-threateningdiseasetakesazerotoleranceapproachtoinflammation.Treatearlyandtreathard,usingcombinationsofdrugswhereappropriatetoinducediseaseremission.Maintenanceofdiseaseremissionmaybeachievedatalaterdatewithlessaggressivetherapy.

Non-erosivedisease

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Inthecaseofnon-erosivedisease,westillwanttocontrolinflammationbutcanusethepatient’ssymptomsasanindicatorofseverity,ratherthanworryingaboutunderlyingjoint/organdamage.Incertainconditions,treatmentoftheunderlyingdisease,e.g.agluten-freedietincoeliacdiseaseorviraleradicationtherapyinhepatitisB/C,willbethemosthelpfulstrategyincontrollingjointsymptoms.

Managingthechronicdisease

Mostofourpatientswithinflammatorydiseasehavechronicdisease.Weneedtomanagenotonlytheiracutepresentations/relapsesbuttheirongoingdisease,evenwhenitiswellcontrolled.Weusedrugsthatrequiremonitoringastheycancausetoxicityandcomplications.Wenowknowthatpatientswithchronicinflammatorydiseaseareathigherriskofcardiovasculareventsandosteoporosis.

Box9.2describesthecomponentsrequiredforchronicdiseasemanagement,andgivesagenericchecklistoftopicstocoverinaroutinepatientreview.

Box9.2Managementprinciplesforchronicinflammatoryjointdisease

Managementofchronicpolyarticulardisease –

◆Assessmentofdiseaseactivity(DAS,PsARC,BASDAI,SLEDAI,etc.)◆Drugtoxicity?(bloods,CXR/PFTs,bloodpressure)◆Multidisciplinaryteamaccessibletopatient◆Helpline/counselling/rapidaccessforflares◆SharedcarewithGP◆Patientinformationandeducation/modificationlifestylefactors/acceptanceofchronicdisease

Checklistforroutinereview

◆Diseaseactivity◆Drugmonitoring◆Extra-articularfeaturesdisease/newsymptoms◆Osteoporosisassessment/DEXA◆Cardiovascularriskfactors◆Vaccinations(inpatientsonimmunosuppressivedrugs)◆Specialconsiderations,e.g.pregnancy

Thefuture

Withtheadventofbiologicaldrugs,thelastdecadehasseenaperiodofimmensechangeinthemanagementofrheumatologicaldisease.Infuturewemaywellseemoretargetedtherapy,

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hopefullyguidedbyindividualpatientbiomarkers/geneticpredictors,sothatthemostaggressivetherapyisappropriatelytargetedtothepatientsthatreallyneedit.Regardless,webelievethattheneedforacomprehensivehistory,thoroughclinicalexamination,andappropriateinvestigationswillcontinuetobeprecursorstoanaccuratediagnosisandaneffectivemanagementofpolyarticulardisease.

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