Rheumatology PA

Heike Franziska Obreja Rheumatology PA December 2020
NSAIDs
Definition
• Weak organic acids that bind to serum proteins
• Inhibition of prostaglandin synthesis
• > 70 million prescription in USA
History
• 1760s Willow bark – antipyretic
• 1829 Salicylic acid willow bark
• 1860 Aspirin synthesized (Hoffman)
• 1899 Aspirin in USA (Bayer)
• 1949 Phenylbutazone first alternative to ASA
• 1970 J.R. Vane COX inhibition
• 1990 specific COX 2 inhibitors
Effects
• Analgesia – equivalent reduction in acute pain compared with narcotics
• Antipyresis – inhibit PG in CNS
• Antiinflammatory
• Antiplatelet – inhibiting COX 1, TXA2
Classification
• Carboxylic acids
o Salicylates
o Acetic acid → Indomethacin, Diclofenac, Etodolac
o Propionic acids → Ibuprofen, Naproxen, Ketoprofen
o Fenamic acids → Mefenamic acids
o Pyrolizine carboxylic acids → Ketorolac
• Nonacidic (Nabumetone)
• COX 2 inhibitors
• Enolic acids
o Oxicams → Prixocam, Meloxicam
o Pyrazolones → Phenylbutazone (BM suppression)
COX1/COX2 inhibition
• COX1
o Selective: Low dose aspirin
o Nonselective: Ibuprofen, Naproxen, Indomethacin, Meclomen
• COX2
o Selective: Etodolac, Diclofenac, Meloxicam
o Highly selective: Celecoxib, Etoricoxib
Side effects
• Hypersensitivity
o Patients with severe asthma with nasal polyps
o Isolated asthma, nasal polyps, chronic urticaria
o Sensitivity, not allergy!
• Hepatotoxicity
o Clearance is predominantly by hepatic metabolism → inactive metabolites – urine
o Elevation of liver enzymes (Diclofenac)
o Severe hepatitis, fatal hepatotoxicity in children, cholestasis
1
• Gastrointestinal
o Dyspepsia, indigestion, vomiting
o GE reflux, esophagitis
o GD ulcers
o GI hemorrhage and perforation
o Small + large bowel ulceration
o Small bowel webs
o Colonic diverticular perforation
o Diarrhea
• Nephrotoxicity
o Vasoconstriction
o Increased sodium retention and BV
o Papillary necrosis
o Hyperkalemia
o Hyponatremia
o Interstitial nephritis
• Cardiovascular
o Sodium and fluid retention
o Loss of hypotensive effect of BP medications
o COX2 – increase the risk of nonfatal MI and stroke
• Rare adverse reactions
o Febrile reactions (Ibuprofen)
o Mediastinal lymphadenopathy
o Hematologic – aplastic anemia pure red cell aplasia, thrombocytopenia, neutropenia
o Stomatitis
o Cutaneous effect
o Aspetic meningitis
o Kidney stone (Sulindac)
o Reversible infertility
Who is at risk?
• Older patients
• Multiple NSAID
• History of peptic ulcer
• Higher dose, prolonged use of NSAID
• Chronic disease → RA, COPD, coronary disease, diabetes
• Corticosteroid, warfarin, clopidogrel, ASA
• Tobacco, alcohol, H. pylori
Decrease the incidence of GI side effects

• Topical NSAID formulation
• Use the lowest dose
• Use NSAID with gastric protective agent
• Treating of existing H. Pylori
Strategies to reduce CV risk

• Control BP
• Not use extended release preparation
• Not use for 3-6 months after CV event or procedure
2
Formulations
• Enteric coated tablet
• Liquid formulation
• Slow release
• Topical formulations
• Combination medications
o Diclofenac/Misoprostol
o Naproxen/Esomeprazole
o Ibuprofen/Famotidine
Drug interactions
• Warfarin
• Sulfonylurea
• BBs
• Hydralazine, prazosin, ACEIs
• Diuretics
• Phenytoin
• Lithium
• Digoxin
• Aminoglycosides
• MTX
Treatment
• Rheumatoid arthritis
o NSAID + MTX not recommended!
o Diclofenac 150 mg/day
o Ibuprofen max. 2.4g/day
o Naproxen 3 x 250 mg/day
• Psoriatic arthritis
• Reactive arthritis
• Infectious arthritis
• Sjörgen’s syndrome – arthralgia
• Gout
o Ibuprofen up to 2.4g/day
o Celecoxib 120 mg/day
• Systemic lupus erythematosus
o Ibuprofen 3 x 400-800 mg/day
3
Glucocorticoids
• Potent medication
• Suppression of the inflammatory cascade
• Modification of the immune response
Effects on innate immune system

• Decreasing swelling and pain
• Suppress production of PG
• Interfere with phagocytosis and cytokine production
• Neutrophilia
• Decrease release of eosinophils
Effects on adaptive immune response

• Dendritic cells undergo increased apoptosis
• Lymphopenia
• B cells less affected than T cells
• Monocytopenia
Administration routes
• Parenteral: IM, IV
• Oral
• Intrasynovial (joint, bursa, tendon sheath)
Potential complications
• Chronic infections
• Increase glucose intolerance
• Risk for osteoporosis
• Gastrointestinal erosive disease
• CV, BP
• Mental status examination
Doses
• Low dose ≤ 7.5 mg/day
• Medium dose 7.5-40 mg/day
• High dose 40-100 mg/day
• Very high dose > 100 mg/day
4
Biologic activity
Side effects
• Glucose intolerance
• Growth suppression
• Osteonecrosis
• Glaucoma
• Skin disorder
• Peptic ulcer disease
• Weight gain
• Infection
• Hypertension
• Abnormal menstruation
• Mental disturbance
• Muscle weakness
• Osteoporosis
• Response to vaccines
Measures for less adverse reaction

• Lower possible dose
• Encourage physical activities
• Fall prevention program
• Supplemental calcium
• Vitamin D
• Bisphosphonate therapy implementation
5
Indication for injection therapy

• Monoarthritis
• Recurrent joint inflammation
• Tendon sheath inflammation
• Bursitis or tendinitis refractory to NSAID
Volume injected into a joint

• Large (knees, ankle, shoulders) → 1-2 ml
• Medium (elbow, wrist) → 0.5-1 ml
• Small (IPH, MPH) → 0.1-0.5 ml
Dose injected into a joint

• Bursa → 10-20 mg
• Tendon sheath → 10-20 mg
• Small joint of hand or feet → 5-15 mg
• Medium size joint (wrist, elbow) → 15-25 mg
• Large size joint (knee, shoulder, ankle) → 20-50 mg
Problems/sequelae
• Infection
• Skin hypopigmentation
• Steroid crystal-induced synovitis
• Subcutaneous tissue atrophy
• Tendon rupture (never inject Achilles tendon)
• Osteonecrosis
• Erythroderma
6
SLE
• GC provide rapid symptom relief
• 7.5 mg/day
Sjörgen’s syndrome (SS)

• 1 mg/kg/day
• 5-20 mg/day
• In initial stage of SS associated with edema, ILD, CV, MSK
• Long term GC can determine renal crisis
7
Other indications
• Polymyositis/dermatomyositis
• Vasculitis disorders (initial stage)
• Crystalline disease flares
• Polymyalgia rheumatica
8
Disease Modifying Anti Rheumatic Drugs (DMARDs)

Definition
• Category of drugs who put rheumatic disease in remission
• Sustained improvement in physical function
• Decreased inflammatory synovitis
• Slowing/preventing structural joint damage
HCQ
• Least toxic DMARD
• Effective in early treatment or add-on therapy
• Dosage: 200-400 mg/day
• Indications
o RA
o Juvenile idiopathic arthritis
o SLE
o Discoid lupus, skin rash of dermatomyositis
o Antiphospholipid antibody syndrome
o Palindromic rheumatism
o Psoriatic rheumatism
o Sjögren’s syndrome
o Sarcoidosis
o Erosive osteoarthritis
• Side effects
o Nausea, vomiting
o Headache, dizziness
o Myopathy
o Cardiomyopathy
o Aplastic anemia, hemolysis
o Rash, hyperpigmentation
o Retinal toxicity
o Monitoring: ophthalmologic examination every 12 months
• Complications
o Corneal deposits
o Retinopathy
o Renal dysfunction
o Liver dysfunction
Sulfasalazine
• Early, mild disease
• Act quickly (4 weeks); lower toxicity
• Dosage:
o 1-3 g/day
o Start at 500 mg and increase by 500 mg each week
• Indication
o RA
o Reactive arthritis
o Psoriatic arthritis
o AS
o Enteropathic arthritis
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• Side effects
o Nausea, vomiting
o Rash
o Headache and dizziness
o Azoospermia
o Neutropenia
o Hemolysis
o Pulmonary infiltrate with eosinophilia
o Hepatic enzyme elevation
o Monitoring: CBC, liver enzyme (monthly)
MTX
• Most effective DMARD for RA
• 30% of patients achieve low disease activity on monotherapy
• Can be used in combination with HCQ or sulfasalazine
• Dose
o 7.5-25 mg/week
o Per os, SC or IM
o Folic acid 5mg always be given with MTX at 24-72h!
• Indications
o RA
o Psoriatic/reactive arthritis
o AS
o Polymyositis/dermatomyositis
o Adult still’s disease
o SLE
o Polymyalgia rheumatica
o Sarcoidosis
o Uveitis
• Side effects
o Oral ulcers, photosensitivity
o Nausea, vomiting, anorexia, migraine
o Hepatic & hematologic toxicity
o Pneumonitis
o Flu-like symptoms → nausea, fever, chills, myalgias
o Worsening nodules
o Leukocytoclastic vasculitis
o Lymphomas
• Monitoring
o Before starting: CBC + Plt, Hep B+C, AST/ALT, ALP, Alb, Cr, CrCl, Chest Xray
o Follow up: 4 and 12 weeks
• Precautions
o CrCl < 30ml/min
o Renal insufficiency
o Avoid alcohol
o Contraindication in pregnancy → stop 3 months before
o Used with caution in patients with Hep B + C
10
Leflunomide
• Inhibits pyrimidine synthesis
• Efficacy comparable to MTX and sulfasalazine
• Slow radiographic progression in RA
• Used when MTX is contraindicated or to reduce dose of MTX
• Dosage: 10-20 mg/day
• Indications: same as MTX
• Side effects
o Nausea, vomiting, diarrhea
o Skin rash
o Allergic reaction
o Neutropenia, thrombocytopenia
o Alopecia
o Hepatic enzyme elevation
o Hypertension
o Teratogenicity
o Pneumonitis
• Monitoring
o Hepatitis B + C
o AST/ALT
o Creatinine
o Follow up: 8-12 weeks
o Drug interactions:
§ Rifampin: increases serum level of leflunomide
§ Warfarin: can be potentiated by leflunomide
• Precautions
o Not to be used in patients with…
§ Hepatic impairment
§ Pregnancy
o Caution in renal impairment
o Long half-life → up to 2 years of undetectable plasma concentration
Azathioprine
• Dosage: 50-200mg
• Indications
o RA
o SLE
o Polymyositis/dermatomyositis
o Behcet disease
o ANCA-associated vasculitis
• Follow up:
o CBC weekly in first 3-4 months
o Liver enzyme within 2 weeks of a dosage change
o CBC every 1-3 months and liver enzyme every 3 months once on stable dose
• Precautions
o Avoid in pregnancy
o Avoid living vaccine
o Reduce dose with allopurinol or febuxostat
o Sulfasalazine increases risk of leukopenia
o Causes warfarin resistance
o Risk of rash on ampicillin
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• Side effects
o BM suppression
o Nausea, vomiting, skin rash
o Malignancy
o Hepatotoxicity
o Infections → Herpes Zoster, CMV
o Pancreatitis
o Hypersensitivity syndrome → rash, fever, hepatitis, renal failure
Mycophenolate mofetil
• Dosage: 500-1500 mg 2x/day
• Capsule, oral suspension and IV
• Indications
o Lupus nephritis
o Cutaneous lupus (discoid and subacute)
o Systemic sclerosis
o Myositis
o Uveitis
o Vasculitis
o Interstitial lung disease
• Follow-up:
o CBC, liver enzyme weekly with dose change
o CBC every 1-3 months
• Side effects
o Gastrointestinal
o Leukopenia
o Anemia
o Hepatotoxicity
o Infection
o Malignancy
• Precautions
o Avoid in pregnancy + lactation
o Avoid live vaccine
o Cholestyramine and administration with food or antacids decrease bioavailability
Cyclophosphamide
• Dosage:
o 50-200 mg/day oral
o Monthly 0.5-1 g/m2 or 15 mg/kg
o 500 mg IV every 2 weeks for 6 doses
• Indications:
o SLE
o GPA (former Wegener’s granulomatosis)
o Interstitial lung disease
o Other systemic vasculitis syndromes
o Rheumatic disease refractory to conventional therapy
• Follow-up:
o Daily dose: CBC every week, then monthly; urinanalysis monthly
o Monthly dosing: CBC, urinanalysis before each dose
• Precautions:
o Avoid pregnancy + live vaccine
o Use lower dose in elderly
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o Cimetidine and allopurinol increase frequency of leukopenia

• Toxicity
o BM suppression
o Infection
o Hemorrhagic cystitis + bladder cancer
o Malignancy
o Infertility
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Lab tests in Rheumatology

Common laboratory tests
• Acute phase reactants
• Anti-nuclear antibodies
• Rheumatoid factor
• Anti-cyclic citrullinated peptide antibodies (CCP) → RA, TB, Alpha 1-AT deficiency
• Anti-neutrophil cytoplasmic antibodies (ANCA)
• Antiphospholipid antibodies → LA; aCL, anti-beta-2GP1
• Complement
• Cryoglobulins
Acute Phase Reactants

• Positive reactants
o CRP
§ Non-inflammatory causes of mild CRP elevation
• Periodontitis
• Smoking
• Uremia
• Aging, obesity, DM, HT, sedentary lifestyle
• Oral hormone replacement therapy
• Alcohol consumption
• Chronic fatigue, depression
o Ceruloplasmin
o Alpha-1 antitrypsin
o Complement
o Ferritin
o Fibrinogen
o Haptoglobin
o Serum amyloid A
• Negative reactants
o Albumin
o Transferrin
o Transthyretin
Antinuclear antibodies
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ANA patterns
• Nuclear/homogenous
• Homogenous nucleolar
• Speckled
• Centromere
• Nuclear fine speckled
• Nuclear large speckled
• Multiple nuclear dots
15
Positive ANA in diseases other than systemic autoimmune disease

• Hep C
• HIV infection, TB
• Graves disease
• Hashimoto thyroiditis
• Primary biliary cirrhosis, primary autoimmune cholangitis
• Crohn’s disease
• Lymphoproliferative disorders
• Infectious mononucleosis
• Subacute bacterial endocarditis
• Idiopathic pulmonary hypertension
Diseases with positive dsDNA antibody

• SLE, RA
• Sjörgen’s syndrome
• Scleroderma
• Drug-induced lupus, discoid lupus
• Raynaud’s phenomenon
• Mixed connective tissue disease
• Myositis
• Uveitis
• Chronic active hepatitis
• Graves disease
• Women with silicone breast implants
Special antibodies
• Anti-smith and anti-U1RNP antibodies
• Anti-SSA/anti-SSB antibodies
• Anti-histone antibodies
• Antiribosomal P protein antibodies
• Anti-Scl 70, anti-centromere, anti-U3RNP antibodies
Antibodies in inflammatory myopathies
Rheumatoid factor (RF)
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ANCA
ANCA positivity in non-vasculitic conditions
17
Physical examination
Inspection
• At rest
o Swelling over/near the joint
o Contours
o Atrophy/muscle bulk
o Redness/erythema
o Deformity
o Posture
o Nodules (Heberden – DIP, Bouchard -PIP)
o Rashes
• With motion
o Active ROM
§ Fingers: formation of fist, flexion, extension
§ Wrists: dorsiflexion, palmar flexion
§ Elbow: flexion, extension, supination, pronation
§ Shoulders: elevation, back scratch
§ Neck: flexion, extension, lateral bending, rotation
§ Hips: flexion, extension, internal/external rotation
§ Knees: flexion extension
§ Ankles: plantar flexion, dorsiflexion, inversion, eversino
§ Toes: flexion, extension
Palpation
• Heat
• Tenderness
• Texture of a joint
• Subcutaneous nodules
• Crepitus → crunching sensation felt when the joint is moved through it range – fingers in
contact with joint
• Instability
• Range of motion
• Muscle strength
• Effusion: soft tissue swelling
• Joint line tenderness: synovitis
• Passive ROM – determine pain, tenderness, limits of motion
Percussion
• Spinous processes
• Tinel’s sign
o Strike median nerve as it passes through carpal tunnel
o Tingling sensation from wrist to hand
Auscultation
• Temporomandibular joint: for crepitus
• Achilles tendon: for tendon rubs (scleroderma)
18
Upper extremity examination

• Hand
o Presence of nodules
o Interosseous muscle atrophy
o Fist formation
o Gaenslen’s maneuver: (pic I)
§ Application of pressure on the MCF joints → to evoke pain
• Wrist
o Dorsiflexion, palmar flexion
o Tinel sign
o Swollen joint (?)
o Tenosynovitis – 1st dorsal compartment – APL and EPB tendons
o Finkelstein’s test – ulnar deviation of the wrist, thumb in fist (pic II)
• Elbow
o Determine active + passive ROM
o Palpate lateral and medial epicondyle (extensor and flexor muscle origins)
o Palpate the extensor surface of the forearm for nodules
o Tennis elbow (lateral epicondylitis) (pic III)
§ Extensor tendinopathy – ECRB
§ Recurrences common
• Shoulder
o Determine active ROM
o Inspect general contour
o Inspect muscle atrophy
19
Spine
• Determine ROM
• Look for gross deformities
• Visible muscle spasm
• Percussion of spinous processes for pain & palpate for general alignment and tenderness
• Kyphosis
• Scoliosis
• Schober’s test → detect reduced flexion
• Sacroiliac tenderness test → downward pressure on the sacrum
20
Lower extremity examination

• Hip
• Knee
o Assess integrity of ligaments
§ Lachman test → ACL
§ Sag test → PCL
o Assess integrity of meniscus → McMurray test
• Ankle
o Determine ROM
o Inspect for gross deformity or swelling
o Palpate for tenderness
• Foot
o Look for obvious deformities and swelling
o Inspect toes for deformities and calluses
o Palpate for points of tenderness indicating inflammation of bursae or joints
o MTP joints:
§ Palpate for tenderness, synovial thickening
§ Squeeze test
21
Low back pain

• Most common pathology in outpatient care specializing in pain therapy
Categories
• Mechanical
• Radicular
• Inflammatory
• Infiltrative
• Referred
Approaching
• P → provocative and palliative factors: sitting, walking, supine, Valsalva maneuver, lumbar
extension, flexion
• Q → quality of pain
• R → radiation of pain
• S → severity of pain or systemic symptoms
• T → timing of pain
Mechanical low back pain

• Suddenly starts, usually after physical effort (after lifting weights with fledged spine, sudden
torsional movements of the body)
• Pain occurs during the effort or a few hours after
• Affects people of all ages
• Probability of recurrence of painful episode: HIGH
• Painful episode lasts up to 2 weeks
• Improved by rest
• Pain is felt in the lumbar/lower lumbar region
• Therapeutic approach:
o Multimodal – physical + drugs
o NSAID + pain reliever
o Non-drug therapy or kinetotherapy applies the principle to stay active
o Rest is contraindicated
Sciatica
• Back pain radiated to lower limb
• Pain is sharp or burning
• Valsalva maneuvers (flexion and extension of lumbosacral spine)
• Nerve root irritation
22
Emergencies – RED FLAGS

• Cauda equina syndrome → urinary/intestinal incontinence/retention, progressive loss of
sensitivity, major motor and sensory deficit
• Bone fracture → posttraumatic, chronic use of steroids, low and painful mobility of the
lumbar spine
• Infections → history of lumbar spine surgery in the last year
• Cancer → bone metastases, cancer history, weight loss, fever
• Age over 50
• Inflammatory nature of pain → augmentation of pain night and at rest
Yellow flags
• “Yellow flags” → chronic disease
• Belief that activity is contraindicated during painful periods
• “bed” addiction
• Depression
• Burn-out syndrome
• Lack of support from the family
• Lack of satisfaction at work
• Stress
Objectives of the evaluation

• Exclusion of “red flags”
• Identifying of any neurological deficit
• Assessing functional limitations caused by pain
• Determining the appropriate therapeutic options
Maneuvers on physical exam

• Femoral nerve stretch test (pic I)
• Lasegue’s sign → Straight leg raise test
• Crossed straight leg test
• Slump test
• Schober’s test
23
Treatment
• Hygiene-Dietetic: Hyposodic regimen, avoiding efforts, a torsion at the level of the spine,
nocturnal rest on a rough plane or ventral decubitus with cushion under the abdomen, which
presses on solar plexus
• Drug treatment: NSAID + pain reliever
• Physical treatment
o Objectives
§ I. General nervous and muscular relaxation
§ II. Ensuring root protection
§ III. Controlling pain and inflammation
o Exercises for mechanical LBP
§ Williams exercise
§ MacKenzie’s
§ Spine stabilization
2017 Guidelines
24
ACP 2017 guidelines – Warnings
Prognosis
• 80% will develop LBP during their life
• Prognosis is good
o 50% improvement in 1 week
o 75% improvement in 1 month
o 85% improvement in 3 months
o 25% recurrent pain in 1 year
o 7% chronic LBP
25
Rheumatoid arthritis
• Chronic, systemic, inflammatory
• Unknown etiology
• Diarthrodial joint involvement, pannus, damage and deformities
Etiology
• Unknown
• Multifactorial
• Genetic factors HLA DR4
• Environmental factors: smoking, bacteria, viruses
Differential diagnosis
• Common disease
o AS
o Calcium pyrophosphate deposition disease
o Connective tissue disease
o Osteoarthritis
o Viral infection
o Polyarticular gout
o Fibromyalgia
o Reactive arthritis
• Uncommon disease
o Hypothyroidism
o Subacute bacterial endocarditis
o Rheumatic fever
o Sarcoidosis
o Lyme disease
o Behcet disease
Epidemiologic characteristics
• Race
• Sex distribution: F:M = 2-3:1
• Age
• 1% of all population
26
Patterns
• 1. Typical:
o Insidious: joint pain, swelling, stiffness
o Subacute: more systemic symptoms
o Acute: severe onset with fever
• 2. Palindromic:
o Insidious onset of elderly
o Arthritis robustus
o Rheumatoid nodulosis
Clinical predictors
• Higher number of joint involved
• Positive anti-CCP antibodies
• Positive RF
• Older age, female sex
• Morning stiffness > 90min
• Elevated CRP
Hand deformities
• Fusiform swelling
• Boutonniere deformity
• Swan neck deformity
• Ulnar deviation of fingers
• Hitchhiker thumb
• “Piano key” ulnar head
Radiographic features
• A – Alignment: abnormal
• B – Bones: Periarticular osteoporosis
• C – Cartilage: uniform joint space loss
• D – Deformities: symmetrical distributions
• E – Erosions: marginal
• S – Soft tissue swelling: nodules without calcifications
27
Cervical spine
• Involved in 30-50% of RA patients
• Can lead to instability & impingement
• C1-C2 subluxation
• C1-C2 impaction
• Subaxial involvement
Laboratory findings
• CBC
• Chemistries
• Urinanalysis
• ESR, CRP, RF
• Anti-CCP, ANA, Complement: C3, C4, CH50
Rheumatoid nodules
• Subcutaneous nodules
• Central area of fibrinoid necrosis, palisade of elongated histiocytes, peripheral layer of
cellular connective tissue
• 20-35% of RA patients
• Severe disease
• Surface of forearm, olecranon bursa, over joint, sacrum, occiput, heel
• MTX can increase nodulosis
Extraarticular manifestation
• Ocular
• Pulmonary
o Pleural disease
o Nodules
o Interstitial pulmonary fibrosis
o Bronchiolitis obliterans
o Cryptogenic organizing pneumonia
o Nonspecific interstitial pneumonitis
• Cardiac
o Pericarditis
o Nodules
o Coronary arteritis
o Myocarditis
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• Vasculitis
o Leukocytoclastic vasculitis
o Small arteriolar vasculitis
o Medium vessel vasculitis
o Pyoderma gangrenosum
• Felty’s syndrome
o RA + splenomegaly + leukopenia
o Subcutaneous nodules, extraarticular manifestation
o Complications
§ Bacterial infections
§ Chronic non-healing ulcers
§ Non-Hodgkin’s lymphoma
o Treatment:
§ Same as for RA ± G-CSF
§ Splenectomy for severe cases
Clinical problems
• Atherosclerosis
• Sjögren’s syndrome
• Amyloidosis
• Osteoporosis
• Entrapment neuropathy
• Laryngeal manifestations
• Ossicles of ear
• Renal, GI
• Large granular lymphocyte syndrome
Markers for severe disease

• RF, anti-CCP
• Generalized polyarthritis for both small and large joints
• Extraarticular disease
• Elevated ESR, CRP
• ANA positivity
• Radiographic erosions within 2 years
• HLA-DR4
• Education level
Treatment
29
Instruments to measure RA disease activity
Mortality in RA
• Cardiovascular
• Infectious
• Cancer
30

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Rheumatology PA

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Heike Franziska Obreja Rheumatology PA December 2020

Decrease the incidence of GI side effects

Strategies to reduce CV risk

Effects on innate immune system

Effects on adaptive immune response

Measures for less adverse reaction

Indication for injection therapy

Volume injected into a joint

Dose injected into a joint

Sjörgen’s syndrome (SS)

Disease Modifying Anti Rheumatic Drugs (DMARDs)

o Cimetidine and allopurinol increase frequency of leukopenia

Lab tests in Rheumatology

Acute Phase Reactants

• Nuclear fine speckled

• Nuclear large speckled

• Multiple nuclear dots

Positive ANA in diseases other than systemic autoimmune disease

Diseases with positive dsDNA antibody

Antibodies in inflammatory myopathies

Rheumatoid factor (RF)

ANCA positivity in non-vasculitic conditions

Upper extremity examination

Lower extremity examination

Low back pain

Mechanical low back pain

Emergencies – RED FLAGS

Objectives of the evaluation

Maneuvers on physical exam

ACP 2017 guidelines – Warnings

Markers for severe disease

Instruments to measure RA disease activity

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