1. Rheumatoid Arthritis VS Osteoarthritis Phong Dao

2. Definition Rheumatoid arthritis It is an autoimmune disease that causes chronic inflammation of the joints Chronic inflammation leads to the destruction of the cartilage, bone and ligaments causing deformity of the jointsOsteoarthritis It is a joint disease It is a joint disease caused by the breakdown and eventual loss of the cartilage of one or more joints **Not autoimmune Inflammation may be present; however, it is usually mild and involves only the periarticular tissues

3. Definition Rheumatoid arthritis 1. It is more of a systemic illness and therefore can affect other organs in the bodyOsteoarthritis 1. It 1. It does not affect other organs of the body 2. It is a chronic disease that has NO CURE, so prevention and treating the symptoms are the key

4. Definition Rheumatoid arthritis Extra-articular Manifestations Heart: pericarditis and myocarditis Lungs: pleurisy with effusion. Glucose concentration n the effusion are uniquely low (<20-30) while the LDH is elevated (exudate) Blood: anemia of chronic disease Renal: Amyloid renal disease occurs late in RA

5. Who gets it? Rheumatoid 1. 3X more common in women as in men 2. The disease can begin at any age, but most often starts after age forty and before sixty Osteoarthritis 1. Most often occurs in people over 65, but can develop earlier in life 2. Both men and women get the disease - Before age of 45 more common in men - Before age of 45 more common in men - After age of 45 more common in women, usually in the hands - After age of 45 more common in women, usually in the hands 3. People with joints that move or fit together incorrectly, such as bow leg, a dislocated hip, or double-jointedness, are more likely to develop OA.

6. Risk Factors Rheumatoid 1. 3X more common in women as in men 2. The disease can begin at any age, but most often starts after age forty and before sixty Osteoarthritis 1. Obesity (esp. for knee OA) 2. History of significant injury,particularly of the knee or hip (ligament or meniscal tear) 3. History of surgery (a history of menisectomy ) 4. Low dietary intake or serum levels of vitamin D

8. Osteoarthritis

9. Symptoms & Signs Rheumatoid Arthritis Fatigue General discomfort, uneasiness, or malaise malaise Loss of appetite Loss of appetite Low-grade fever fever Joint painJoint pain, joint stiffness, and joint swelling joint swelling Joint painjoint swelling Often symmetrical May involve wrist pain, knee pain, elbow pain, finger pain, toe pain, ankle pain, or neck pain wrist painknee painelbow painfinger painankle painneck painwrist painknee painelbow painfinger painankle painneck pain Limited range of motion Limited range of motion The spine except the atlanto-axial articulation in late disease is never affected Morning stiffness usually lasting more than 30 min Deformities of hands and feet Round, painless nodules under the skin nodules Skin redness or inflammation Skin redness or inflammation Paleness Swollen glands Swollen glands Eye burning, itching, and discharge Eye burning, itching, and discharge Numbness and/or tingling Symmetric swelling of peripheral joints is the hallmark of the disease Osteoarthritis Pain in the affected joint(s) after repetitive use A crunching feeling or sound of bone rubbing on bone Stiffness after getting out of bed Join swelling or tenderness in one or more joints Early in the disease the joints may ache after exercise, late in the disease the joints ache even at rest Most often occurs in hands, knee, hips, or spine/lower back Can have morning stiffness but usually last less than 30 min

10. Affected Joints Rheumatoid Arthritis Osteoarthritis Bouchard's node The localized enlargement seen on the proximal interphalangeal (PIP) joint May not be painful

11. Affected Joints Rheumatoid Arthritis Unlike OA, the distal interphalangeal (DIP) joints are generally spared Osteoarthritis Heberden's Node The localized enlargement seen on the proximal interphalangeal (DIP) joint May not be painful

12. Nodules Rheumatoid Arthritis Osteoarthritis Typically does not have skin nodules

13. Blood Work Rheumatoid 1. Chemistries are normal in rheumatoid arthritis with the exception of a slight decrease in albumin and increase in total protein reflecting the chronic inflammatory process. 2. A mild anemia with hematocrit values in the range of 30 — 34% occurs in approximately 25 to 35% of patients with rheumatoid arthritis (due to chronic disease or even from blood loss from NSAIDS) (due to chronic disease or even from blood loss from NSAIDS) Osteoarthritis Most routine blood tests are normal in patients with uncomplicated osteoarthritis. Analysis of synovial fluid usually reveals a white blood cell count of less than 2,000 per mm3 (2.0 3 109 per L).

14. Blood Work Rheumatoid 3. The white cell count (WBC) is usually normal but can be mildly elevated secondary to inflammation 4. Platelet count is usually normal but thrombocytosis occurs in response to inflammation 5. The erythrocyte sedimentation rate (ESR) is usually elevated, especially in an acute inflammatory state.

15. Blood Work Rheumatoid Rheumatoid factors Rheumatoid factors - are antibodies directed against the Fc portion of immunoglobulin G (IgG) - are antibodies directed against the Fc portion of immunoglobulin G (IgG) - A positive test for rheumatoid factor is by no means pathognomonic of rheumatoid arthritis, but is present in 70 to 90% of patients with the disease - A positive test for rheumatoid factor is by no means pathognomonic of rheumatoid arthritis, but is present in 70 to 90% of patients with the disease - patients with a high titer rheumatoid factor are more likely to have erosive joint disease, extra-articular manifestations, and greater functional disability - patients with a high titer rheumatoid factor are more likely to have erosive joint disease, extra-articular manifestations, and greater functional disability - Rheumatoid factors are also detectable in non-rheumatoid patients (endocarditis, TB, HIV, collagen vascular disease) - Rheumatoid factors are also detectable in non-rheumatoid patients (endocarditis, TB, HIV, collagen vascular disease)

16. Blood Work Rheumatoid Rheumatoid factors Low titers of rheumatoid factors may be detected in the serum of apparently normal people, especially over the age of 70, where its prevalence is anywhere from 10 - 25% Anti-nuclear antibody (ANA) Positive in 20-30% of patients with rheumatoid arthritis and is more common in patients with extra-articular manifestations HLA-DR4 antigen It is associated with aggressive RA It is associated with aggressive RA

17. Blood Work Rheumatoid RF titers A titer is a measure of how much the agglutination test blood sample can be diluted before RF can no longer be detected. A titer of 1 to 20 (1:20) means that RF can be detected when 1 part of the blood sample is diluted by up to 20 parts of a salt solution (saline). A larger second number means there is more RF in the blood. Therefore, a titer of 1 to 80 indicates more RF in the blood than a titer of 1 to 20 Normal value: 1:20 or less

18. X-RAY Rheumatoid Osteoarthritis

19. X-RAY Rheumatoid Osteoarthritis

20. Diagnosis Rheumatoid Any 4 of the following criteria must be present to classify patients as having RA: 1. Morning stiffness for > or = to 1 hour * 2. Arthritis of 3 or more joints * 3. Arthritis of hand joints (wrist, MCP, or PIP) 4. Symmetric arthritis * 5. Rheumatoid nodules 6. Serum rheumatoid factor 7. Radiographic changes (hand x-ray film changes typical of RA must include erosions or unequivocal bony decalification * Must be present for > or = 6 wks Osteoarthritis Classification Criteria for Osteoarthritis of the Hand Hand pain, aching, or stiffness and 3 or 4 of the following features: 1. Hard tissue enlargement of 2 or more of 10 selected joints 1. Hard tissue enlargement of 2 or more of 10 selected joints 2. Hard tissue enlargement of 2 or more DIP joints 2. Hard tissue enlargement of 2 or more DIP joints 3. Fewer than 3 swollen MCP joints 3. Fewer than 3 swollen MCP joints 4. Deformity of at least 1 of 10 selected joints 4. Deformity of at least 1 of 10 selected joints * The 10 selected joints are the second and third distal interphalangeal (DIP), the second and third proximal interphalangeal, and the first carpometacarpal joints of both hands. This classification method yields a sensitivity of 94% and a specificity of 87%.

21. Diagnosis Osteoarthritis Classification Criteria for Osteoarthritis of the Hip Hip pain plus at least two of the following: –ESR of less than 20 mm per hour –Femoral or acetabular osteophytes on radiographs –Joint space narrowing on radiographs

22. Diagnosis Osteoarthritis Classification Criteria for Osteoarthritis of the Knee Knee pain plus osteophytes on radiographs and at least one of the following: –Patient age older than 50 years Morning stiffness lasting 30 minutes or less –Crepitus on motion

23. Treatment of RA NSAIDs: Usually part of the initial treatment. NSAIDs decrease inflammation and joint swelling but do not alter the course of the disease COX-2 inhibitors : Celebrex 100-200 mg PO BID Glucocorticoids: low-dose oral prednisone (< 10 mg/d or equivalent) and joint injections of glucocorticoids effective for relieving the symptoms of RA….but does not slow the disease process. TNF inhibitors : Infliximab (Remicade) and etanercept (Enbrel) inhibit tumor necrosis factor (TNF), an important mediator of the inflammatory response in RA. They are used alone or with methotrexate for moderate-to-severe RA. Remicade IV infusion: 3 mg/kg + Methotrexate Enbrel: 50 mg SQ/wk (25 mg SQ X 2)

24. Treatment of RA Disease modifying antirheumatic drugs (DMARDs) – have slow onset of action, usually over several months. They have minimal, if any, anti-inflammatory effect so concurrent NSAIDs are required during use. Methotrexate (MTX): widely used as the initial DMARD, especially for aggressive disease. - best tolerated, so patients tend to take it longer - best tolerated, so patients tend to take it longer - it is an antifolate agent (contraindicated in renal, liver dz or ETOH abuse) - it is an antifolate agent (contraindicated in renal, liver dz or ETOH abuse) - side effects (nausea, diarrhea, stomatitis, and less often alopecia) - side effects (nausea, diarrhea, stomatitis, and less often alopecia) - cause bone marrow suppression - cause bone marrow suppression - can cause idiopathic pnemonitis - can cause idiopathic pnemonitis - LFTs and CBC should be monitored every 4-8 weeks - LFTs and CBC should be monitored every 4-8 weeks Dosage: 7.5 mg PO QD or 2.5 mg Q12 hr X 3 doses (Max 20 mg Q/week) w/ folate

25. Treatment of RA Disease modifying antirheumatic drugs (DMARDs) Hydroxychloroquine (HCQ): need regular eye checks for possible retinopathy (Plaquenil 400-600 mg QD) Sulfasalazine (SSZ): side effects N/V, diarrhea, and crampy addominal pain, reversible oligospermia, decrease in RBCs, WBCs, and platelets (periodic CBC required) (500 mg PO qd-bid after meals up to 1 gm QD) Leflunomide (Arava): 100 mg PO qd X 3 days. Maintenance: 10-20 mg QD These are used for patients with milder disease because of low side effects and low cost.

26. Treatment of RA Other meds: Gold salts: good response. Gold treatment is generally not stopped if the patients gets a nonpruritic rash, mild stomatitis, slight decrease in WBCs, or slight proteinuria. - IM injection is better than oral - IM injection is better than oral D-penicillamine side effects similar to gold.

27. Treatment of OA Disease management OA is a condition which progresses slowly over a period of many years and cannot be cured. Treatment is directed at decreasing the symptoms of the condition, and slowing the progress of the condition Functional treatment goals: 1. Limit pain 1. Limit pain 2. Increase range of motion 2. Increase range of motion 3. Increase muscle strength 3. Increase muscle strength

28. Treatment of OA Step-wise approach Step 1 (Non-pharmacologic therapy) a. Patient education b. Programs for aerobic exercise c. If overweight, weight loss d. Physical therapy or occupational therapy e. Walking aids f. Shock absorption g. Re-alignment through orthotics

29. Treatment of OA Step-wise approach Step 2 (Pharmacologic therapy) Initial approach: For mild to moderate pain can use Tylenol, up to 4 gm QD/ 1 mg QID (caution in liver disease and ETOH abuse); NSAIDS (caution GI bleeder/PPI) alternative  topical capsaicin cream (Zostrix) or methyl salicylate cream (Ben Gay). For moderate to severe pain and swollen joints can do aspiration and injection of glucocorticoids such as Aristospan (triamcinolone hexacetonide 40 mg ) or prednisone 8-20 mg with maximum of 3-4 times per year. (can reduce pain for up to 4 weeks)

30. Treatment of OA Step-wise approach Step 2 (Pharmacologic therapy) When initial therapy is inadequate: 1. COX-2 inhibitor (Celebrex) 200 mg PO qd or 100 mg BID 2. If contraindicated to COX-2 inhibitor or NSAIDS, then can try Ultram 200- 300 mg divided evenly, QID. Other medication: Sodium hyaluronate injection (Synvisc, Hyalgan) is indicated only for the treatment of patients with osteoarthritis of the knee. 5 injections (once per week of 20 mg)

31. Treatment of OA Step-wise approach Step 2 (Pharmacologic therapy) Alternative medicines: (Glucosamine & Chondroitin) 1. Glucosamine sulfate- a form of amino sugar that is believed to play a role in cartilage formation and repair. (crab, lobster, shrimp shells) 1,500 mg QD 2. Chondroitin sulfate- part of a large protein molecule (proteoglycan) that gives cartilage elasticity. (shark cartilage) 1,200 mg QD Side effects: intestinal gas/softened stool Caution: glucosamin-diabetic/ chondroitin (similar to heparin), caution in ASA/coumadin use chondroitin (similar to heparin), caution in ASA/coumadin use

32. Treatment of OA Step-wise approach Step 3 (Surgery) 1. Proximal Tibial Osteotomy 2. Total knee replacement

33. Treatment of OA Proximal Tibial Osteotomy (for younger, active patients with 1 side of knee affected) OA usually affects the medial compartments more often than the lateral compartments  Bowlegged Closing wedge vs. Opening wedge Successful operation would last 5-7 years.

34. Treatment of OA Total Knee Replacement - Usually considered in patients over the age of 60 - Last for about 12 years Not recommend in younger patients because: 1. The younger the patient, the more likely the artificial joint will fail 1. The younger the patient, the more likely the artificial joint will fail 2. Younger patients are more active and place more stress on thartificial 2. Younger patients are more active and place more stress on thartificial joint, that can lead to loosening and failure earlier joint, that can lead to loosening and failure earlier 3. Younger patient are more likely to outlive their artificial joint, and will almost surely require a revision at some point down the road 3. Younger patient are more likely to outlive their artificial joint, and will almost surely require a revision at some point down the road 4. Replacing the knee the second or third time is much harder and and much less likely to succeed. 4. Replacing the knee the second or third time is much harder and and much less likely to succeed.

35. Treatment of OA Total knee replacement

36. Questions

37. Questions