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Kevin Latinis, M.D./Ph.D. Division of Rheumatology Dept. of Internal Medicine klatinis@kumc.edu Rheumatology 101: What you need to know for your ambulatory medicine experience
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Rheumatology 101 Arthritis -Inflammatory (RA, spondyloarthropathies) -Mechanical (OA) LupusFibromyalgia Low back pain and other peri-articular complaints General musculoskeletal exam (time permitting)
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Mechanical vs. Inflammatory Arthritis Latinis, K., et al The Washington Manual Rheumatology Subspecialty Consult., LWW, 2003.
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Osteoarthritis-Background Very common -2 nd leading cause for disability in USA -In patients 60 and older: affects 17% of men and 30% of women -Estimated that 59.4 million patients will have OA by the year 2020 Etiology -primary idiopathic -secondary
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Osteoarthritis-Distribution Latinis, K., Dao, K, Shepherd, R, Gutierrez, E, Velazquez, C. The Washington Manual Rheumatology Subspecialty Consult., LWW, 2003. Bouchard’s Heberden’s
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Osteoarthritis-Diagnosis Clinical Supported by X-rays Non-inflammatory lab data, if any
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Osteoarthritis-Treatment Pain relief -Analgesics and NSAIDs/Cox-2 Inhibitors SMOADs (structure modifying osteoarthritis drugs) -Glucosamine Sulfate -see meta-analysis McAlindon et al. JAMA, 283: 3/2000, p. 1469 -many under development Non-pharmacologic approaches -Reduce stress/load on joint -Strengthen surrounding muscles-PT/OT -Weight reduction -Patient education Limit disability and improve quality of life
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Osteoarthritis-Treatment Joint Replacement Surgery -Primarily of knee and hip, but also available in hands, shoulders,& elbows -Indications: 1. pain at rest 2. instability -patients benefit from aggressive PT before & after surgery Other surgical procedures
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Clinical Pearl: Arthritis of the DIP joint OA (non-inflammatory)Psoriatic Arthritis (inflammatory)
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Inflammatory Arthritis Rheumatoid arthritis Spondyloarthropathies -Undifferentiated -Ankylosing spondylitis -Psoriatic arthritis -Reactive arthritis (formerly Reiter’s syndrome) -Enteropathic arthritis SLE, Sjogrens, Scleroderma, Polymyalgia rheumatica, Vasculitis, Infectious (bacterial, viral, other), Undifferentiated connective tissue disease
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Latinis, K., et al The Washington Manual Rheumatology Subspecialty Consult., LWW, 2003.
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Rheumatoid Arthritis-Background Symmetric, inflammatory polyarthritis Affects ~1% of our population Occurs in women 3x more than men Etiology -Genetic, class II molecules (HLA-DRB1) -Autoimmune -?Environmental
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Rheumatoid Arthritis-Distribution Latinis, K., et al The Washington Manual Rheumatology Subspecialty Consult., LWW, 2003.
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Definition -An inflammatory multisystem disease of unknown etiology with protean clinical and laboratory manifestations and a variable course and prognosis. -Immunologic aberrations give rise to excessive autoantibody production, some of which cause cytotoxic damage, while others participate in immune complex formation resulting in immune inflammation. Systemic Lupus Erythematosus (Lupus)-Background
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Clinical features -Clinical manifestations may be constitutional or result from inflammation in various organ systems including skin and mucous membranes, joints, kidney, brain, serous membranes, lung, heart and occasionally gastrointestinal tract. -Organ systems may be involved singly or in any combination. -Involvement of vital organs, particularly the kidneys and central nervous system, accounts for significant morbidity and mortality. -Morbidity and mortality result from tissue damage due to the disease process or its therapy. Systemic Lupus Erythematosus (Lupus)-Background
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Systemic lupus erythematosus classification criteria (SOAP BRAIN MD) S 1. Serositis: (a) pleuritis, or (b) pericarditis O 2. Oral ulcers A 3. Arthritis P 4. Photosensitivity M 10. Malar rash D 11. Discoid rash B 5. Blood/Hematologic disorder: (a) hemolytic anemia or (b) leukopenia of < 4.0 x 10 9 (c) lymphopenia of < 1.5 x 10 9 (d) thrombocytopenia < 100 X 10 9 R 6. Renal disorder: (a) proteinuria > 0.5 gm/24 h or 3+ dipstick or (b) cellular casts A 7. Antinuclear antibody (positive ANA) I 8. Immunologic disorders: (a) raised anti-native DNA antibody binding or (b) anti-Sm antibody or (c) positive anti-phospholipid antibody work-up N 9. Neurological disorder: (a) seizures or (b) psychosis "...A person shall be said to have SLE if four or more of the 11 criteria are present, serially or simultaneously, during any interval of observation."
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53 yo BF with severe generalized weakness, weight loss, and chronic psychosis Alopecia Malar rash Arthritis Psychosis
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Laboratory Data 139 4.3 106 21 16 1.4 101 7.7 22.3 3.9 Absolute lymph=0.5 298 MCV=83 ESR=119 CH50=67 (118-226) C3=31 (83-185) C4=18 (12-54) ANA + 1:5280 Anti DNA + Direct & Indirect Coombs + Anti-IgG + 24 hour urine Protein=514
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Treatment of SLE Arthritis, arthralgias, myalgias: NSAIDS, anti-malarials (eg. Plaquenil), Steroids- injections, oral methotrexate Photosensitivity, dermatitis avoid Sun exposure topical steroids Plaquenil Weight loss and fatigue steroids Abortion, fetal loss ASA immunosuppression Thrombosis anti-coagulants Glomerulonephritis steroids pulse cytotoxics mycophenylate mofetil CNS disease anti-coagulants for thrombosis steroids and cytotoxics for vasculitis Infarction (secondary to vasculitis) steroids cytotoxics prostacyclin Cytopenias steroids IVIG-short term for thrombocytopenia danazol cytotoxics-if bone marrow status is known
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Steroids in Lupus Steroid responsive Dermatitis (local) PolyarthritisSerositisVasculitisHematological Glomerulonephritis (most) Myelopathies Steroid non-responsive Thrombosis Chronic renal damage Hypertension Steroid-induced psychosis Infection
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Latinis, K., et al The Washington Manual Rheumatology Subspecialty Consult., LWW, 2003. ANA-When to order and how to follow up on a positive test
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Latinis, K., et al The Washington Manual Rheumatology Subspecialty Consult., LWW, 2003.
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Fibromyalgia-Background Chronic musculoskeletal pain syndrome of unknown etiology Characterized by diffuse pain, tender points, fatigue, and sleep disturbances Prevalence is 2-5% with a female to male predominance of 8:1 Mean age is 30-60
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Fibromyalgia-Diagnosis
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1 2 3 4 5 6 7 8 9
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Fibromyalgia-Treatment
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Low back pain and other peri-articular complaints- background Very common, one of the most frequent reasons to visit primary care physicians Articular vs peri-articular problems -Articular pain is generally deep or diffuse and worsens with active and passive motion -Periarticular pain usually exibits point tenderness and increased tenderness with active, but NOT passive motion
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Latinis, K., et al The Washington Manual Rheumatology Subspecialty Consult., LWW, 2003.
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Muscles of the rotator cuff: Supraspinatus Infraspinatus Subscapularis Teres Minor
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Low back pain and other peri-articular complaints- Treatment RICE -Rest -Ice -Compression -Elevation NSAIDs and analgesics TimeOther
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General Musculoskeletal Exam Underutilized by primary care providers Should be simple and quick Goal is to recognize signs of rheumatological diseases and determine if it is appropriate to refer to a rheumatologist or manage independently
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Summary Arthritis -Inflammatory (RA, spondyloarthropathies) -Mechanical (OA) LupusFibromyalgia Low back pain and other peri-articular complaints General musculoskeletal exam (time permitting)
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