Approach to the patient with Monoarthritis

Diseases that commonly present with 1 joint:

Approach to the pt w/ Monoarticular sx:Diseases that commonly p/w monoarthritis

Septic: bacterial, mycobacterial, lyme, fungal Traumatic: fx, internal derangemt, hemarthrosis

(sickle) Crystal deposition: gout, CPPD, hydroxyapatite

deposition disease, calcium oxalate Other: OA, JA, coagulopathy, AVN bone, foreign-

body synovitis, tumor

Polyarticular diseases occasionally p/w one joint of onset

RA JA Viral Sarcoid ReA PsA IBD-arthritis Whipples OA

Important questions? What should you ask the patient? What’s critical to determine ASAP? What’s the most useful test to determine

etiology? What other labs/studies should be obtained?

The patient with polyarticular symptoms Diseases that present with acute polyarticular sx:

Chronic polyarticular sx?

Acute polyarticular Infection: GC, Meningococcal, lyme, ARF, BE,

viral (hepatitis B/C, parvovirus, EBV, HIV)

Other inflammatory: RA, systemic JA, SLE, ReA, PsA, polyarticular gout, sarcoid

Chronic polyarticular

Chronic Polyarthritis Inflammatory: RA, JA, SLE, SSc, polymyositis,

ReA, PsA, gout, IBD, CPPD, sarcoid, vasculitis,

PMR Non-inflammatory: OA, FM, hypermobility

syndrome, hemochromatosis

Migratory, Additive, Intermittent

Evaluation and Management of Osteoarthritis

Osteoarthritis: Case 1

• A 65-year-old man comes to your office complaining of knee pain that began insidiously about a year ago. He has no other rheumatic symptoms• What further questions should you ask?• What are the pertinent physical findings?• Which diagnostic studies are appropriate?

OA: Symptoms and Signs Pain is related to use Pain gets worse

during the day Minimal morning

stiffness (<20 min) and after inactivity (gelling)

Range of motion decreases

Joint instability Bony enlargement Restricted movement Crepitus Variable swelling

and/or instability

OA Case 1: Radiographic Features Joint space narrowing Marginal osteophytes Subchondral cysts Bony sclerosis Malalignment MAKE THE

DIAGNOSIS

OA: Laboratory Tests No specific tests No associated laboratory abnormalities;

eg, sedimentation rate Investigational: Cartilage degradation products in

serum and joint fluid

Understanding Disease Mechanisms OA is mechanically driven, but chemically

mediated…

Immunostain of OA Cartilage

Melchiorri, et. al. 1998

TN Fa

IL -1 B

IL -6

IL -8

MC P-1

N O

PGE2

IL -1 8

0 2 0 4 0 6 0 8 0 1 0 0

IL-18

PGE2

NO

MCP-1

IL-8

IL-1

TNF

IL-6

0 20 40 60 80 100

EL

ISA

Units

Spontaneous Production of Inflammatory Mediators by Normal and OA-affected Cartilage

Attur et al. Osteoarthritis and Cartilage 2002

Candidate Biomarkers in OA

• CRP (obesity??)• COMP, Keratan sulfate, HA, YPL-70• Type II collagen fragments• Type II C-propeptide (synthesis)• Proteoglycan/aggrecan fragments• Markers of bone turnover

(osteocalcin,NTx)• Imaging (x-ray, MRI, ultrasound)

OA: Risk Factors Why did this patient develop osteoarthritis?

OA: Risk Factors (cont’d) Age: 75% of persons over age 70 have OA Female sex Obesity Hereditary Trauma Neuromuscular dysfunction Metabolic disorders

Case 1: Cause of Knee OA On further questioning, patient recalls fairly

serious knee injury during sport event many years ago

Therefore, posttraumatic OA is most likely diagnosis

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Case 1: Prognosis Natural history of OA: Progressive cartilage loss,

subchondral thickening, marginal osteophytes

OA: Case 2 A 75-year-old woman presents to your office with

complaints of pain and stiffness in both knees, hips, and thumbs. She also has occasional back pain

Family history reveals that her mother had similar problems

On exam she has bony enlargement of both knees, restricted ROM of both hips, squaring at base of both thumbs, and multiple Heberden’s and Bouchard’s nodes

Distribution of Primary OA Primary OA typically

involves variable number of joints in characteristic locations, as shown

Exceptions may occur, but should trigger consideration of secondary causes of OA

0

20

40

60

80

20 40 60 80

Men

Age (years)

Pre

vale

nce

of O

A (

%)

0

20

40

60

80

20 40 60 80

Women

Age (years)

Pre

vale

nce

of O

A (

%)

Age-Related Prevalence of OA: Changes on X-Ray

DIP

Knee

Hip

DIP

Knee

Hip

Case 2: Distal and Proximal Interphalangeal Joints

Radiograph shows severe changes

Most common location in hand

May cause significant loss of function

Case 2: Carpometacarpal Joint

X-ray shows osteophytes, subchondral sclerosis, and complete loss of joint space

Patients often present with deep groin pain that radiates into the medial thigh

Case 2: Hip Joint

What If Case 2 Had OA in the “Wrong” Joint, eg, the Ankle?

• Then you must consider secondary causes of OA• Ask about previous trauma and/or overuse• Consider neuromuscular disease, especially

diabetic or other neuropathies• Consider metabolic disorders, especially

CPPD (calcium pyrophosphate deposition disease—aka pseudogout)

Secondary OA: Diabetic Neuropathy MTPs 2 to 5 involved

in addition to the 1st bilaterally

Destructive changes on x-ray far in excess of those seen in primary OA

Midfoot involvement also common

Underlying Disease Associations of OA and CPPD Disease (pseudogout)

Hemochromatosis Hyperparathyroidism Hypothyroidism Hypophosphatasia Hypomagnesemia Neuropathic joints Trauma Aging, hereditary

Management of OA

• Establish the diagnosis of OA on the basis of history and physical and x-ray examinations

• Decrease pain to increase function• Prescribe progressive exercise to

• Increase function• Increase endurance and strength• Reduce fall risk

• Patient education: Self-Help Course• Weight loss• Heat/cold modalities

Pharmacologic Management of OA Nonopioid analgesics Topical agents Intra-articular agents Opioid analgesics NSAIDs Unconventional therapies

Strengthening Exercise for OA

• Decreases pain and increases function• Physical training rather than passive therapy• General program for muscle strengthening

• Warm-up with ROM stretching• Step 1: Lift the body part against gravity,

begin with 6 to 10 repetitions

• Step 2: Progressively increase resistance with

free weights or elastic bands• Cool-down with ROM stretchingRogind, et al. Arch Phys Med Rehabil. 1998;79:1421–1427.

Jette, et al. Am J Public Health. 1999;89:66–72.

Reconditioning Exercise Program for OA

• Low-impact, continuous movement exercise for 15 to 30 minutes 3 times per week• Fitness walking: Increases endurance, gait

speed, balance, and safety• Aquatics exercise programs—group support• Exercycle with minimal or no tension• Treadmill with minimal or no elevation

Nonopioid Analgesic Therapy

• First-line—Acetaminophen• Pain relief comparable to NSAIDs, less toxicity• Beware of toxicity from use of multiple

acetaminophen-containing products• Maximum safe dose = 4 grams/day

Nonopioid Analgesic Therapy (cont’d)

• NSAIDs• Use generic NSAIDs first• If no response to one may respond to another• Lower doses may be effective• Do not retard disease progression• Gastroprotection increases expense• Side effects: GI, renal, worsening CHF, edema• Antiplatelet effects may be hazardous

Nonopioid Analgesics in OA

• Cyclooxygenase-2 (COX-2) inhibitors• Pain relief equivalent to older NSAIDs• Probably less GI toxicity• No effect on platelet aggregation or bleeding

time• Side effects: Renal, edema• Older populations with multiple medical

problems not tested• Cost similar to generic NSAIDs plus proton

pump inhibitor or misoprostol

Medical Letter. 1999;41:11–12.

Medical Letter. 1999;41:11–12.

Nonopioid Analgesics in OA (cont’d)

• Tramadol • Affects opioid and serotonin pathways• Nonulcerogenic• May be added to NSAIDs, acetaminophen• Side effects: Nausea, vomiting, lowered

seizure threshold, rash, constipation, drowsiness, dizziness

Opioid Analgesics for OA

• Codeine, oxycodone• Anticipate and prevent constipation• Long-acting oxycodone may have fewer CNS

side effects• Propoxyphene• Morphine and fentanyl patches for severe pain

interfering with daily activity and sleep

Topical Agents for Analgesia in OA

• Local cold or heat: Hot packs, hydrotherapy• Capsaicin-containing topicals

• Use moderately supported by evidence • Use daily for up to 2 weeks before benefit• Compliance poor without full instruction• Avoid contact with eyes

OA: Intra-articular Therapy• Intra-articular steroids

• Good pain relief • Most often used in

knees, up to q 3 mo• With frequent

injections, risk infection, worsening diabetes, or CHF

• Joint lavage• Significant

symptomatic benefit demonstrated

• Hyaluronate injections*• Symptomatic relief • Improved function• Expensive• Require series of

injections• No evidence of long-

term benefit• Limited to knees

* Altman, et al. J Rheumatol. 1998;25:2203.

OA: Unconventional Therapies

• Polysulfated glycosaminoglycans—nutriceuticals • Glucosamine +/- chondroitin sulfate:

Symptomatic benefit, no known side effects

• Doxycycline as protease/cytokine inhibitors• Under study• Have disease-modifying potential

OA: Unconventional Therapies (cont’d)

• Keep in touch with current information.

• ACR Website (http://www.rheumatology.org)

• Arthritis Foundation Website (www.arthritis.org)

Referral and Imaging If pain out of proportion to XRAY findings, can

refer to rheum or ortho, and get MRI Also, for unstable joints, need MR Primary or secondary failure of treatment regimen

should prompt further imaging and referral Please obtain imaging BEFORE THE PATIENT

GETS TO THE CONSULTANT If there is any question of systemic inflammatory

disease, check labs including CBC, ESR, CRP, rheumatoid factor, anti-CCP, (ANA), IgGs as well

Surgical Therapy for OA

• Arthroscopy• May reveal unsuspected focal abnormalities• Results in tidal lavage• Expensive, complications possible

• Osteotomy: May delay need for TKR for 2 to 3 years

• Total joint replacement: When pain severe and function significantly limited

OA: Management Summary

• First: Be sure the pain is joint related (not a tendonitis or bursitis adjacent to joint)

• Initial treatment• Muscle strengthening exercises and

reconditioning walking program• Weight loss• Acetaminophen first• Local heat/cold and topical agents

OA: Management Summary (cont’d)

• Second-line approach• NSAIDs if acetaminophen fails• Intra-articular agents or lavage• Opioids

• Third-line • Arthroscopy• Osteotomy• Total joint replacement