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Osteoarthritis, Rheumatoid Arthritis, and Spondylarthropathies

Timothy Niewold, MD Assistant Professor Section of Rheumatology

Question: A 45 yo woman with history of rheumatoid arthritis presents to the emergency room with a 2 day history of a severely painful, warm, swollen R knee. Her other joints are not painful, and until recently her symptoms were well controlled on methotrexate and prednisone. The most appropriate next step in management is:

A. obtain an X-ray of the knee B. increase prednisone C. increase methotrexate D. aspirate the knee E. prescribe physical therapy

Question: A 54 yo man presents with symmetric pain and swelling of the small joints in his hands and wrists progressive over the last 3 months. He has no fever, weight loss, or constitutional symptoms. Laboratory testing shows high ESR, negative rheumatoid factor, and a positive anti-CCP antibody test. The next step in management is: A. Prescribe methotrexate B. Check an anti-nuclear antibody test C. Prescribe a tumor-necrosis factor alpha blocker D. Prescribe a non-steroidal anti-inflammatory drug and follow up in 6 months E. Order an MRI of the hand and wrist

swelling. Joint space narrowing in the DIP joints Sclerosis near the articular surface Bony erosions Heberden’s and Bouchard’s nodes Hypertrophic changes . or morning stiffness. You suspect osteoarthritis clinically. D. B. E. C. and would expect to see all of the following on hand X-ray except: A.Question: A 59 year old woman is seen in clinic for a 4 year history of gradually worsening bilateral hand pain. She has not noted redness.

X-rays were done and he was told they were normal at the start of his symptoms four years ago. C. What should be done next? A. gradually improving with activity. D.Question: A 23 yo man presents with a 4 year history of progressive low back pain. E. B. He is seeing you in second opinion for his chronic back pain. He thinks his symptoms may have started around the time of a car accident. Narcotic pain did not relieve his pain. X-ray of the L-spine and pelvis Referral to PT MRI of the L-spine Arrange X-ray guided steroid injection Increase narcotic dose . He says the pain is worst in the morning.

new bone formation (spurring). goes up to 90% at age 70 Slight female predominance in older age. but both sexes affected .Osteoarthritis – definition and prevalence Definition – degenerative joint process characterized by focal loss of cartilage. and subsequent pain and loss of function Most common type of arthritis – more than half of individuals over age 55 have radiographic evidence.

Wilson’s disease . acromegaly.Osteoarthritis – pathogenesis Uncertain pathogenesis but: Genetic factors play a role Clear environmental or secondary triggers – injury – history of inflammatory joint condition. neuropathic (Charcot joint) – rare endocrine/metabolic such as hemochromatosis.

lack of erythema or warmth. usually not much tenderness X-ray will confirm diagnosis – asymmetric joint space narrowing. sclerosis near the joint line. sometimes history of prior injury or overuse or other secondary trigger Physical exam – crepitance. and spurring are characteristic .Osteoarthritis – diagnosis History is important – gradual onset of symptoms. hypertrophic changes. lack of inflammation.

X-ray – classic changes due to OA .

and if these fail total joint replacement surgery is very effective . PT and weight loss.Osteoarthritis – Hip and Knee Very common Associated with obesity Bilateral disease is common although one may be worse Treatment – NSAIDs or Tylenol. then steroid injections for knee and potentially X-ray guided for hip.

more likely due to wear-and-tear than nodes Treatment – NSAIDs or Tylenol. can do injections particularly for base of thumb.Osteoarthritis – Hands Heberden’s nodes – DIP joint bony nodules Bouchard’s nodes – PIP joint bony nodules Both “nodes” are diagnostic for hand OA. rarely ever surgery . 10 times more common in women than men. and have a strong genetic component Base of thumb (1st CMC joint) very commonly affected.

infrequent injections. but becomes very common in 7th and 8th decades of life – Rotator cuff symptoms often accompany – Treatment – NSAIDs. but used rarely because not as successful as hip + knee Feet – 1st MTP commonly affected (“bunion” deformity) – Treatment – better shoes. Total replacement is possible. surgery for severe .Shoulder Osteoarthritis – Shoulder and Feet – uncommon in 40s and 50s.

think inflammatory!! .Osteoarthritis –Joints Not Typically Affected Joints which are not typically affected by OA unless injury/secondary cause: – MCPs – Wrist – Ankle – Elbow If these are affected.

joint erosion. 2:1 female to male ratio. and systemic inflammation Most common inflammatory arthritis.Rheumatoid Arthritis – definition and prevalence Definition – symmetric inflammatory joint condition characterized by pannus formation. peak incidence between ages 40 to 60 Onset usually insidious over months . 1% of the population.

TNFAIP3 Environmental factors – cigarette smoking increases both risk of disease and severity of disease. also risk in coal miners (Kaplan syndrome) .Rheumatoid Arthritis – Predisposition Genetic factors clearly important – HLA “shared epitope” is strongest risk factor. STAT4. but also non-HLA genes such as PTPN22.

protein tyrosine phosphatase. type IV. cytotoxic T-lymphocyte antigen 4. GP39. Nat Rev Immunol.7(6):429-442. cartilage glycoprotein 39. non-receptor type 22. 2007.Course of RA CCP. cyclic citrullinated peptide. PTPN22. et al. CTLA4. 16 . Reproduced with permission from McInnes IB. peptidyl arginine deiminase. PADI4.

ankles most common. but fever is VERY RARE – Steady. wrists. shoulders – Morning stiffness – better with activity – Constitutional symptoms – fatigue. even weight loss are common.Rheumatoid Arthritis – Diagnosis History and physical are majority of diagnosis – lab not that helpful – Symmetric pain and swelling in small joints of hands. feet. progressive. elbows. additive onset is by far most common presentation . followed by knees.

eds. pain. fatigue 8%-15% Fever. Kelley’s Textbook of Rheumatology. swelling. weight loss. et al. fatigue. 2008.Patterns of Onset Insidious Acute 55%-65% Joint stiffness. In: Firestein GS. joint abnormalities present but often not prominent Intermediate 15%-20% Systemic complaints more noticeable than insidious onset Harris ED Jr. et al. 8th ed. .

Joints Commonly Involved .

splenomegaly. but probably testable) Scleritis Rheumatoid vasculitis (rare) Felty’s syndrome (neutropenia. recurrent infection) .Rheumatoid Arthritis – Extraarticular features Rheumatoid nodules Pleural effusions Atherosclerosis (new.

greater likelihood of extra-articular manifestations Anti-CCP antibodies .relatively new (but very clinically useful and testable!!) – Found in about 50% of patients without much overlap with rheumatoid factor – Highly sensitive – positive test almost always indicates disease (>90% specificity for RA.Rheumatoid Arthritis – Laboratory High ESR or CRP common but not required Rheumatoid factor positive in about 50% – RF usually indicates more severe disease. but low sensitivity prevents “rule out” . even in mixed autoimmune cohorts) – So can “rule in”.

22 .Major RA Subsets Based on ACPA Reproduced with permission from Klareskog L. Paget S. Lancet. Catrina AI.373(9664):659-672. 2009.

osteopenia instead of sclerosis.Rheumatoid Arthritis – X-ray Classical findings of inflammatory arthritis: – Periarticular joint erosions – Periarticular osteopenia – Symmetric joint space narrowing Note that each of these is the opposite of OA!! – (erosions instead of spurs. and symmetric instead of asymmetric joint narrowing) .

Arthritis Rheum. et al. .Early Radiographic Progression Joint-space narrowing and erosion are seen in up to two thirds of patients within the first 2 to 5 years of disease Reproduced with permission from Wolfe F. 1998.41(9):1571-1582.

Rheumatoid arthritis erosions on X-ray .

Low-Field MRI .Early RA: Radiographic Findings High-Detail X-Ray Courtesy of Charles Peterfy. MD.

and tocilizumab are all second or third line . rituximab. abatacept. usually around 15-20mg/week with daily folate 1mg/day – Sulfasalazine.Rheumatoid Arthritis – Treatment Early treatment with a disease modifying drug is standard of care Non-disease modifying – NSAIDs – Prednisone Disease modifying – Methotrexate – most common first line. leflunomide also effective – Biological agents such as TNF-alpha blockers.

non-biologics have risk of GI intolerance and hair loss. TNF blockers are associated with reactivation of tuberculosis and rarely an MS-like disease.Rheumatoid Arthritis – Treatment Goal of treatment is clinical remission if possible Control of disease prevents bone erosions and subsequent deformity and loss of function All disease modifying drugs are immunosuppressive. other biologics are not currently in wide use .

ankylosing spondylitis characterized by a 3:1 male to female ratio . pelvis). may also demonstrate asymmetric oligoarthritis and enthesitis (inflammation of tendon insertions) Prevalence – about 1 per 1000 in US.Spondylarthropathies – Definition and Prevalence Group of inflammatory conditions affecting the axial skeletion (spine.

Spondylarthropathies – Patterns of Disease Inflammatory spinal involvement is typical. and differentiates from other arthridities Enthesitis or inflammation of tendon insertions is classical Asymmetric oligoarthritis is typical pattern of peripheral joint arthritis Eye involvement (uveitis) is common Aortitis with valvular insufficiency is also an important complication .

Spondylarthropathies Ankylosing Spondylitis Psoriatic Arthritis Enteropathic Arthritis and Reactive Arthritis .

ascending ankylosis of spine gradually over the years Symptoms are inflammatory back pain Can also affect hips and shoulders. rare to affect more distal joints HLA-B27 in 90% of European ancestry Diagnosis – Sacroileitis and anklyosis on X-ray Treatment – NSAIDs for mild disease. TNF-blockers are effective second-line therapy . sulfasalazine or methotrexate.Spondylarthropathies Ankylosing Spondylitis Sacroileitis in all cases.

X-ray of sacroileitis .

bamboo spine .Ankylosing spondylitis: lumbar vertebrae.

TNF-blockers as second line therapy .Spondylarthropathies . destructive changes such as “pencil-in-cup” Treatment – Steroids may result in flare of skin disease when tapered. methotrexate and sulfasalazine common. can affect DIP joints Diagnosis – Psoriasis required.Psoriatic Arthritis A subset of patients with psoriasis (5-7%) have psoriatic arthritis Inflammatory spine disease and peripheral oligoarthritis common. X-rays often show erosive joint disease with little osteopenia.

Psoriatic arthritis: hand .

Often selflimited. for IBD works for arthritis.Spondylarthropathies Enteropathic Arthritis and Reactive Arthritis Enteropathic arthritis – spondylarthritis associated with inflammatory bowel disease. but can either be recurrent or persistent . rx. too Reactive arthritis – spondylarthropathy following GI or GU infection. spine + peripheral joints.

Questions??? .