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ARTHRITIS Anna Jaatinen Rotary Doctor Bank Finland, Ilembula Hospital Today’s topics Osteoarthritis Rheumatoid arthritis Reactive arthritis Crystal-induced Synovitis Infectious Arthritis HIV-associated arthritis Rheumatoid arthritis 1 Systemic diseace Unknown etiology Symmetric inflammatory polyarthritis Extra-articular manifestations Rheumatoid nodules Pulmonary fibrosis Serositis Vasculitis Rheumatoid factor up to 80% Rheumatoid arthritis 2 Clinical Presentation Insidous oncet of the pain, swelling and morning stiffness in the joints (hands, wrists) Synovitis! Typical places: MCP, PIP, wrist Rheumatoid nodules on extensor surfaces Course is often chronic and progressive Erosions! Rheumatoid arthritis may substatial long-term disability and is associated with increased mortality! Rheumatoid arthritis 3 American Collece of Rheumatology 1987 Classification Criteria Morning stiffness (>60 min) Arthritis of three of more joints Arthritis of hand joints Rheumatoid nodules Serum rheumatoid factor X-ray changes (erosions and decalcification) 4 of the 7 criteria should be met, with criteria 1 to 4 present for more than 6 weeks Rheumatoid arthritis 4 TREATMENT NSAID Ibuprofen 400-800 mg TDS as long as needed Acetylsalicylic acid Corticosteroids Prednison 5 to 20 mg OD With long treatments remember to decrease the dose slowly! Intra-articulr administration Hydrocortison i.a. 25-100 mg DMARDs (Diseacemodifying antirheumatic drugs) Methotrexate Hydroxychloroquine Sulfasalazine Leflunomide Biologic DMARDs Patients with itractable symptoms may require special treatment at spesialist centre! Osteoarthritis 1 = Degenerative joint disease = Arthrosis Most common form of arthritis! Degenerative loss of articular cartilage with subsequent formation of reactive new bone at the cartilage surface Most common: PIP, DIP, hips, knees, cervical and lumbar spine Common in the elderly, but may occur any age especially after joint trauma, chronic inflammatory arthritis or congenital malformation. Osteoarthritis 2 Clinical Presentation Pain! Specific clinical features depend on the joint involved Knee: possible hydrops, no signs of infection or severe inflammation DIP: enlarged joint Bouchard’s nodes X-ray shows cartilage damage and sometimes even deformity Osteoarthritis 3 TREATMENT Nonpharmacologic approaches Prief period of rest Good shoes: Walkers Crepe bandage or brace can help Physiotherapy and exercise to affected joints Reduction on weight in obese patients Medications Paracetamol 1 g TID (QID) NSAID (As low dose as possible) Ibuprofen TID 200-600 mg Itra-articular clucocorticoid Should not be given more than every 3 to 6 months Systemic clucocorticoid should be avoided! Reactive arhtritis 1 Inflammatory arthritis, which occasionally follows certain GI or genitourinary infections Reiter sdr = arthritis + conjuctivitis + urethritis Most common after Chlamydia trachomatis, Shigella flexneri, Salmonella species, Yersinia enterocolitica, Campylobacter jejuni Genetic predisposition HLA-27 positive 60-80% Reactive arthritis 2 Clinical Presentation Asymmetric oligoarthritis Urethritis Conjuctivitis Skin and mucous lesions Usually transient, lastin one to several months Some patients develope chronic arthritis Reactive arthritis 3 TREATMENT Control of pain and inflammation! NSAIDs Severe cases short glucocorticoid therapy Remember and search for infection! Clamydia Antibiotic treatment if still needed Prolonged Ophthalmologic referral if you suspect iritis tr antiobiotic therapy has NOT been showed to be beneficial Crystal-Induced Arthritis 1 Gout (Urate crystals) Pseudogout (Calcium pyrophosphate dihydrate crystals) Apatite disease Gout arthritis developes when urate crystals deposites in the joints Primary: hyperuricemia due to undersecretion of uric acid Secondary: Renal disease, diuretic therapy, low-dose aspirin, ethanol, starvation, lactic asidosis, dehydration, preeclampsia, diabetic ketoasidosis Crystal Induced Arthritis 2 Clinical Presentation Excruciating pain Usually in single joint in foot or ankle Occasionally a polyarthritic oncet can mimic rheumatoid arthritis Joint is swollen, skin erythema, warm/hot Chronic gout: With time acute gouty attacs more often, even chronic joint deformity may appear Lab: Uric acid levels with 70%, Crystals seen in the joint fluid examined with microscope Crystal Induced Arthritis 3 TREATMENT Acute gout NSAID high dose Indomethacin 75 mg start then 50 mg every 6 hours 24 hrs, 50 mg TDS 24 h, 25 mg TDS 24 h Diclofenac 75 mg BDS Ibuprofen 400-800 mg TDS Prevention Glucocorticoids (especcially when NSAID is contraindicated) Anti-hyperuricaemic therapy; Allopurinol Goal serum uric acid below 8 mg/dl (0.48 mmol/l) Avoid precipitants (alcohol, small fish, diuretics) Reduce weight in obese patients Intra-articular injection Prednison 40 mg OD 3-5 days Colchisine 1 mg stat followed 0,5 mg every 2 hours orally until patient improves or ad 10 mg Remember that allopurinol can make acute gout even worse! Start after clinical improvement! Infectious Arthritis 1 Septic infection! Non-conococcal: Staphylococcus Aureus, Streptococci Conococcal arthritis Occasionally: M Tuberculosis, Brucella, Fungi Non-bacterial infectious arthritis Viral infections: Hepatitis B, Rubella, Mumps, Mononucleosis, parvovirus, enterovirus, adenovirus Infectious Arthritis 2 Clinical Presentation Non-gonococcal infectious arthritis Fever Acute monoarticular arthritis Multiple joint may be affected by hematogenous spread of pathogens Gonococcal arthritis Migratory or additive polyarthralgias followed by tenosynovitis or arthritis of wrist, ankle or knee and vesicopustular skin lesions Infectious Arthritis 3 TREATMENT Immediate antibiotic therapy Cover S. Aureus, Streptococcus, Neisseria gonorrhoeae IV-antibiotics are recommended for at least 2 weeks, followed by oral antibiotics 2(-4) weeks When definite gonococcal arthritis Ceftriaxone i.v. For 3 days followin 7-14 days treatment with cefixime or Amoxicillin/clavulanate Surgical drainage especcially if there is big joint (shoulder, hip), lobulation of pus, osteomyelitis or delay with response to treatment Supportive treatment for septic infection! NSAID HIV-infection and arthritis 1 HIV-associated arthralgia Any stage of HIV infection Mild to moderate, involves usually large joints (shoulders, elbows, knees) No synovitis! Treatment: Pain medication, support HIV-infection and arthritis 2 Reactive arthritis Psoriatic arthritis HIV-assosiated arthritis Virus is directly involving joint synovium Oligoarticular, occurs predominantly in the lower extremities Self-limiting course, lasting <6 weeks X-ray: no erosion in the joints Also HIV-associated polyarthritis is possible, resembles rhematoid arthritis Synovitis continues abates when CD4 is declining, but joint destruction Diagnose with intra-articular puncture Main principles Clear synovial fluid: Osteoarthritis, Rheumatoid arthritis Leukocyte Thick, fuzzy: Crystal-induced Arthritis Crystals amount seen in microscope Purulent: Infectious arthritis Culture, Gram stain Assure that your technique is clean! Take Home Message Osteoarthritis is the most common reason for joint pain; treat the pain and educate the patient Treat with antibiotics when… It’s infectious arthritis! Reactive arthritis if there still is infection If you suspect Rheumatoid arthritis, treat aggressively, consider refferal for specialist Asante, Thank you!
