rheumatoid arthritis case presented at orthopedic rheumatology rounds at physical medicine and...
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7/27/2019 Rheumatoid Arthritis Case presented at Orthopedic Rheumatology Rounds at Physical Medicine and Rehabilitation Grand Rounds
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Mr. T (no, the other Mr. T)
46 y/o RHD AA male professional furnituremover for ~ 30 years
Decreased hand strength and pain for ~ 3years
Concerned about not being able to continueto move furniture due to pain and weakness
(concern for possible injury to himself orco-workers)
Also, intermittent pain in the right instep
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Mr. T continued
Originally evaluated by his PCP and wasreferred to NRH based on his Xray.
Initially seen in MSK outpatient clinic,diagnosed with an inflammatory arthritis Office Xrays showed moderate to marked erosive
changes in the osseous structures of the wrists,distal radius, ulna carpal bones and metacarpal
bases, right hand > left hand
Treated at that time with Dose Pack, Feldeneand referred to Rheumatology
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Mr. T continued
PMH:
HTN
Medications: IB or Naprosyn prn
Allergies:
NKDA
Social History:
Denies EtOH
16 pack year history (quit 1 year ago)
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Mr. T Fam Hx
No FH of gout
2 healthy brothers
Mother: DM
Spine disease
Arthritis in hands and fingers
Father: unsure of history, possible stroke andHTN
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Mr. T, ROS
Stiffness in the mornings Could not quantify time
OTC NSAIDS do help some
Occasional nonproductive cough Denied any back pain
Appetite normal
Lost ~ 15 pounds in 2 months Denied fevers, chills, sweats, h/o infections, tick
bite exposure, psoriasis, podagra, infectiousdiarrhea, or chlamydia exposure
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Mr T. Physical Exam
Healthy appearing muscular male in NAD
Neck, Heart, Lungs, Abdomen and Skin wereunremarkable
Extremities: Pain and swelling in his bilateral hands, wrists and
MCP joints.
Dorsal subluxation, warmth, tenderness anddorsal wrist swelling
Separation of his fingernails from the plate
Clubbing of the fingernails
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Mr. T, Physical Exam
continued Mild tenderness over his right instep.
Functional range of motion in all joints
+ evidence of fingernail and toenail fungalinfection
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Mr. T, right wrist 2007
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Mr. T, January 2012
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Mr. T, January 2012
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Mr. T, January 2012
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Mr. T, January 2012
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Labs
WNL except: ALT: 62
HCT: 36
RF: 113 Anticitrullinated protein antibody (ACPA ) or Anti
Cyclic Citrullinated Peptide (Anti-CCP) antibody: > 250
19 Units or less: Negative
20-39 Units: Weak positive 40-59 Units: Moderate positive
60 Units or Greater: Strong positive
Uric Acid: elevated
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Diagnosis and Treatment
Diagnosis Rheumatoid Arthritis
Possible superimposed gout
Treatment Methotrexate
Obtain Hepatitis screening to R/O Viral hepatitisprior to starting Methotrexate
Anti-TNF Therapy
PPD prior to TNF therapy
Allopurinol
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RA Classic manifestations
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RA hand deformities
A: Pt with early RA. No jointdeformities, but the soft tissuesynovial swelling around the 3rdand 5th PIP joints is easily seen.
B: A patient with advanced RAwith severe joint deformitiesincluding subluxation at the MCP
joints and swan-neck deformities(hyperextension at the PIP joints).
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Progressive destruction of
an MCP joint by RASequential radiographs ofthe same 2nd MCP joint.A: The joint is normal 1 yearprior to the development ofRA.B: 6 months following theonset RA, there is a bonyerosion adjacent to the
joint and joint spacenarrowing.C: After 3 years of disease,diffuse loss of articularcartilage has led to marked
joint space narrowing.
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Keys to Optimize Outcome
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Medication
DMARDs
BRMs
Passive treatments Cold/heat
Compression andelevation
Massage TENS
Acupuncture
Orthosis
Surgery
Synovectomy
Arthrodesis
Tendon reconstruction
BRM, Biologic responsemodifier;
DMARD, disease-
modifying antirheumaticdrug;
TENS, transcutaneouselectrical nervestimulation.
Treatment Options for RA
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Exercise, Equipment, and Education
Treatment Options in Rheumatoid Arthritis
Exercise, Equipment, andEducation Treatment Options inRheumatoid Arthritis
Exercises
LE strengthening
Walking
Whole-body physical activity
Jogging in water
Combined LE strengthening,flexibility, and mobility
Aerobic exercises LE range of motion, mobility, or
flexibility
Manual therapy with exercises
Equipment
Adaptive for ADL
Assistive for ambulation
Appropriate footwear or insoles
Education
Self-management
Weight loss (if obese)
Activity management or jointprotection
Social support Stress management/relaxation
ADL, activities of daily living; LE,Lower extremity.
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Old ACR criteria
The previous criteria (revised 1987)
Provided the benchmark in defining RA
Helped discriminate patients with established RAfrom those with a combination of otherrheumatologic diagnoses.
Was somewhat limited because they did not
identify patients who would benefit from earlyeffective intervention
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1987 ACR Criteria
Criterion Definition
1. Morning stiffness Morning stiffness in and around the joints, lasting at least 1hour before maximal improvement
2. Arthritis of 3 or more joint areas At least 3 joint areas simultaneously have had soft tissueswelling or fluid (not bony overgrowth alone) observed by
a physician. The 14 possible areas are right or left PIP,
MCP, wrist, elbow, knee, ankle, and MTP joints
3. Arthritis of hand joints At least 1 area swollen (as defined above) in a wrist, MCP, or PIPjoint
4. Symmetric arthritis Simultaneous involvement of the same joint areas (as definedin 2) on both sides fo the body (bilateral involvement of PIPs,MCPs, or MTPs is acceptable without absolute symmetry)
5. Rheumatoid nodules Subcutaneous nodules, over bony prominences, or extensorsurfaces, or in juxtaarticular regions, observed by a physician
6. Serum rheumatoid factor Demonstration of abnormal amounts of serum rheumatoidfactor by any method for which the result has been positive in
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Misc
Smoking increases the risk of RA 20-40 fold
In pre-RA, anti-citrullinated proteinantibodies and other auto-antibodies like RFs
can appear more than 10 years before clinicalarthritis.
Rheumatoid synovium has many
characteristics of locally invasive malignancy But never becomes completely unresponsive to
anti-inflammatory and anti-proliferative factors
In 2010, things changed a bit
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New (2010) Criteria Goals
Prevent a chronic, erosive disease state (asexemplified by the 1987 criteria) by earlytreatment
Set of rules to be applied to newly presentingpatients with undifferentiated synovitis thatwould 1) identify the subset at high risk of chronicity and
erosive damage;
2) be used as a basis for initiating disease- modifyingtherapy; 3) not exclude the capture of patients later in the
disease course.
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The New ACR/EULAR
classification Helps identify patients with a relatively short
duration of symptoms
Helps those that may benefit from entry intoclinical trials of promising new agents
By initiating these new medications, may haltthe development of the disease that currently
fulfills the 1987 ACR criteria.
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Who can the criteria be
applied to? The classification criteria can be applied to:
any patient or otherwise healthy individual, aslong as 2 mandatory requirements are met:
First, there must be evidence of currently activeclinical synovitis (i.e., swelling) in at least 1 joint
Second, the observed synovitis is not betterexplained by another diagnosis
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The New Classification
Criteria Jointly published by the American College of
Rheumatology (ACR) and the European LeagueAgainst Rheumatism (EULAR)
Uses a point value between 0 and 10. 6 is unequivocally classified as an RA patient
provided he has synovitis in at least one joint andgiven that there is no other diagnosis better explaining
the synovitis. Addresses 4 areas: Joint involvement,
Serological Parameters, Acute phase reactantsand arthritis duration
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2010 Classification Tree Criteria for
Rheumatoid Arthritis (RA)
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Joint Involvement
Joint involvement refers to any swollen ortender joint on examination, which may beconfirmed by imaging evidence of synovitis.
DIP joints, 1st CMC joints, and 1st MTP jointsare excluded from assessment because theyare commonly found in OA.
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Small joints
MCP
PIP
thumb IP
2nd-5th MTP
Wrist
Large joints
Elbows
Hips
knees
Whats in a joint?
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Joint Involvement and
scoringType of Joint Points applied
1 large joint 0 points
2-10 joints 1 point
1-3 small joints (+ or large joints) 2 points
4-10 small joints (+ or large joints) 3 points
> 10 joints (w/ at least 1 small joint) 1 joint must be a small joint; the
other joints can include any combo oflarge and additional small joints, aswell as other joints not specifically
listed elsewhere (e.g., TMJ, AC SCJ, etc)
5 points
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Serologic
Serology criteria:
at least 1 test result is needed for classification
i.e., Anti-Citrullinated Peptide Antibodies or
Rheumatoid Factor
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Serologic
Serologic Marker Points
Negative RF and negative ACPA 0 points
Low-positive RF or low-positive ACPA 2 points
High-positive RF and/or high-positive
ACPA
3 points
Neg test ULN
Low positive > ULN ULN X 3
High Positive > ULN X 3
ULN = upper limit of normalRF = rheumatoid FactorACPA = anticitrullinated protein antibody
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What is CCP
The cyclic citrullinated peptide antibody (CCP)test is an assay that detects the presence ofcitrulline antibodies in the blood.
These autoantibodies are proteins produced by theimmune system in response to a perceived threat fromcitrulline.
Citrulline is an unusual amino acid produced when theamino acid arginine is altered
There is speculation that the conversion of arginine tocitrulline may play a role in the autoimmuneinflammatory process seen in the joints of those withRA
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Why CCP/ACPA?
2nd generation CCP antibody testing:
sensitivity of 80% and a specificity of 98% for RA
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Robust Rheumatoid Arthritis
Cohort of patients that had:
robust personality
Practically infinite capacity for work
Substantial subcutaneous nodules (often thereason for the referral)
High titer on the Rose test
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ROM was unaffected and unguarded
Joints were at sometime painful, but rarely hadto stop working
Shoulder joints affected in all patients Subcutaneous nodules at the elbows and the
fingers in 3 patients Pathology confirmed RA histology
Function: Decreased grip strength
Most were on maintenance Gold Therapy
Robust Rheumatoid Arthritis
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Psychologically the Robust patient scoredmore closely to normals, with regard to:
exploitation of disease-induced dependence
Neuroticism
Robust RA scores normal, in contrast to most RApatients who tended to have higher scores
Robust Rheumatoid Arthritis
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Robust type rheumatoid arthritis represents aspecial reaction to the disease of a strongbody supported by a tough mind, but is in no
other way a separate clinical entity.
Robust Rheumatoid Arthritis
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They had the prognostically unfavorablesymptoms of subcutaneous nodules and a hightiter of the Rose test
However the were robust, felt well and workednormally.
Additional sthentic (i.e., strong, vigorous, oractive) properties included:
Athletic build, good grip strength, high pain thresholdin the finger joints, mental stolidity and independence
Raised question of possibility of mental attitudeon disease and disability
Robust Rheumatoid Arthritis
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Outcome Measures and
Treatment Efficacy counts of the number of tender and swollen
joints;
patient and physician global assessment ofdisease activity;
pain assessment using a visual analoguescale;
a validated measure of disability; and
an acute phase reactant (e.g., erythrocytesedimentation rate or C-reactive protein).
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Commonly Used Outcome Measures For
The Rheumatic Diseases
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Treatment to Target Schema
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Treatment to Target
Recommendations
Treating rheumatoid arthritis to target:recommendations of an international taskforce
http://ard.bmj.com/content/69/4/631.short
http://ard.bmj.com/content/69/4/631.shorthttp://ard.bmj.com/content/69/4/631.short -
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Treatment to Target
Treatment of RA must be based on a shared decisionbetween the patient and the rheumatologist
The primary goal of treating the patient with RA is tomaximize long-term health-related quality of life
through control of symptoms, prevention ofstructural damage and normalization of function andsocial participation
Abrogation of inflammation is the most importantway to achieve these goals
Treatment to target by measuring disease activityand adjusting therapy accordingly optimizesoutcomes in RA
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Medication Options
NSAIDS
Glucocorticoids
DMARDS Biological DMARDS
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Medication Options - DMARDS
Conventional (synthetic) DMARDs:
methotrexate
sulfasalazine
gold no longer commonly used
antimalarials
leflunomide
azathioprine penicillamine
minocycline.
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Biological DMARDS
Biological DMARDs:
Biological therapies have had a significant impacton the treatment of patients with RA.
It is now clear that proinflammatory cytokines,most notably tumor necrosis factor- (TNF- ) andinterleukin-1, play a central role in thepathophysiology of RA
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Biological DMARDS
Anti TNF
Etanercept (Enbrel)
Infliximab (Remicade)
Adalimumab (Humira)
Interleukin-1 (anakinra)
Block T-cell co-stimulation
Abatacept (Orencia)
Target B-cells Rituximab (Rituxan)
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References
Aletaha, D., et al.:2010 Rheumatoid Arthritis Classification Criteria, Arthritis &Rheumatism Vol. 62, No. 9, September 2010, pp 25692581
http://www.rheumatology.org/practice/clinical/classification/ra/ratree_2010.asp
Schur, PH, et al.: Pathogenesis of rheumatoid arthritis; www.uptodate.com
De Haas, WH, et al: Rheumatoid arthritis of the robust reaction type.;
Annals of Rheum Disease. 1974 January; 33(1): 8185. Atzeni, F, et: Anti-cyclic citrullinated peptide antibodies in primary Sjgren
syndrome may be associated with non-erosive synovitis.; http://arthritis-research.com/content/10/3/R51,Arthritis Research & Therapy 2008, 10:R51
Vossenaar, ER: Citrullinated proteins: sparks that may ignite the fire inrheumatoid arthritis.; Arthritis Research and Ther 2004, 6:107-111 (DOI10.1186/ar1184).
Braddom, Physical Medicine and Rehabilitation 3rd Edition Current Rheumatology Diagnosis & Treatment, 2nd edition
http://www.rheumatology.org/practice/clinical/classification/ra/ratree_2010.asphttp://www.uptodate.com/http://arthritis-research.com/content/10/3/R51http://arthritis-research.com/content/10/3/R51http://arthritis-research.com/content/10/3/R51http://arthritis-research.com/content/10/3/R51http://accessmedicine.com/resourceTOC.aspx?resourceID=38http://accessmedicine.com/resourceTOC.aspx?resourceID=38http://accessmedicine.com/resourceTOC.aspx?resourceID=38http://accessmedicine.com/resourceTOC.aspx?resourceID=38http://arthritis-research.com/content/10/3/R51http://arthritis-research.com/content/10/3/R51http://arthritis-research.com/content/10/3/R51http://www.uptodate.com/http://www.rheumatology.org/practice/clinical/classification/ra/ratree_2010.asp