rheumatoid arthritis case presented at orthopedic rheumatology rounds at physical medicine and...

7/27/2019 Rheumatoid Arthritis Case presented at Orthopedic Rheumatology Rounds at Physical Medicine and Rehabilitation Grand Rounds

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Mr. T (no, the other Mr. T)

46 y/o RHD AA male professional furnituremover for ~ 30 years

Decreased hand strength and pain for ~ 3years

Concerned about not being able to continueto move furniture due to pain and weakness

(concern for possible injury to himself orco-workers)

Also, intermittent pain in the right instep


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Mr. T continued

Originally evaluated by his PCP and wasreferred to NRH based on his Xray.

Initially seen in MSK outpatient clinic,diagnosed with an inflammatory arthritis Office Xrays showed moderate to marked erosive

changes in the osseous structures of the wrists,distal radius, ulna carpal bones and metacarpal

bases, right hand > left hand

Treated at that time with Dose Pack, Feldeneand referred to Rheumatology


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Mr. T continued

PMH:

HTN

Medications: IB or Naprosyn prn

Allergies:

NKDA

Social History:

Denies EtOH

16 pack year history (quit 1 year ago)


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Mr. T Fam Hx

No FH of gout

2 healthy brothers

Mother: DM

Spine disease

Arthritis in hands and fingers

Father: unsure of history, possible stroke andHTN


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Mr. T, ROS

Stiffness in the mornings Could not quantify time

OTC NSAIDS do help some

Occasional nonproductive cough Denied any back pain

Appetite normal

Lost ~ 15 pounds in 2 months Denied fevers, chills, sweats, h/o infections, tick

bite exposure, psoriasis, podagra, infectiousdiarrhea, or chlamydia exposure


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Mr T. Physical Exam

Healthy appearing muscular male in NAD

Neck, Heart, Lungs, Abdomen and Skin wereunremarkable

Extremities: Pain and swelling in his bilateral hands, wrists and

MCP joints.

Dorsal subluxation, warmth, tenderness anddorsal wrist swelling

Separation of his fingernails from the plate

Clubbing of the fingernails


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Mr. T, Physical Exam

continued Mild tenderness over his right instep.

Functional range of motion in all joints

+ evidence of fingernail and toenail fungalinfection


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Mr. T, right wrist 2007


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Mr. T, January 2012


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Mr. T, January 2012


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Mr. T, January 2012


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Mr. T, January 2012


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Labs

WNL except: ALT: 62

HCT: 36

RF: 113 Anticitrullinated protein antibody (ACPA ) or Anti

Cyclic Citrullinated Peptide (Anti-CCP) antibody: > 250

19 Units or less: Negative

20-39 Units: Weak positive 40-59 Units: Moderate positive

60 Units or Greater: Strong positive

Uric Acid: elevated


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Diagnosis and Treatment

Diagnosis Rheumatoid Arthritis

Possible superimposed gout

Treatment Methotrexate

Obtain Hepatitis screening to R/O Viral hepatitisprior to starting Methotrexate

Anti-TNF Therapy

PPD prior to TNF therapy

Allopurinol


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RA Classic manifestations


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RA hand deformities

A: Pt with early RA. No jointdeformities, but the soft tissuesynovial swelling around the 3rdand 5th PIP joints is easily seen.

B: A patient with advanced RAwith severe joint deformitiesincluding subluxation at the MCP

joints and swan-neck deformities(hyperextension at the PIP joints).


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Progressive destruction of

an MCP joint by RASequential radiographs ofthe same 2nd MCP joint.A: The joint is normal 1 yearprior to the development ofRA.B: 6 months following theonset RA, there is a bonyerosion adjacent to the

joint and joint spacenarrowing.C: After 3 years of disease,diffuse loss of articularcartilage has led to marked

joint space narrowing.


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Keys to Optimize Outcome


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Medication

DMARDs

BRMs

Passive treatments Cold/heat

Compression andelevation

Massage TENS

Acupuncture

Orthosis

Surgery

Synovectomy

Arthrodesis

Tendon reconstruction

BRM, Biologic responsemodifier;

DMARD, disease-

modifying antirheumaticdrug;

TENS, transcutaneouselectrical nervestimulation.

Treatment Options for RA


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Exercise, Equipment, and Education

Treatment Options in Rheumatoid Arthritis

Exercise, Equipment, andEducation Treatment Options inRheumatoid Arthritis

Exercises

LE strengthening

Walking

Whole-body physical activity

Jogging in water

Combined LE strengthening,flexibility, and mobility

Aerobic exercises LE range of motion, mobility, or

flexibility

Manual therapy with exercises

Equipment

Adaptive for ADL

Assistive for ambulation

Appropriate footwear or insoles

Education

Self-management

Weight loss (if obese)

Activity management or jointprotection

Social support Stress management/relaxation

ADL, activities of daily living; LE,Lower extremity.


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Old ACR criteria

The previous criteria (revised 1987)

Provided the benchmark in defining RA

Helped discriminate patients with established RAfrom those with a combination of otherrheumatologic diagnoses.

Was somewhat limited because they did not

identify patients who would benefit from earlyeffective intervention


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1987 ACR Criteria

Criterion Definition

1. Morning stiffness Morning stiffness in and around the joints, lasting at least 1hour before maximal improvement

2. Arthritis of 3 or more joint areas At least 3 joint areas simultaneously have had soft tissueswelling or fluid (not bony overgrowth alone) observed by

a physician. The 14 possible areas are right or left PIP,

MCP, wrist, elbow, knee, ankle, and MTP joints

3. Arthritis of hand joints At least 1 area swollen (as defined above) in a wrist, MCP, or PIPjoint

4. Symmetric arthritis Simultaneous involvement of the same joint areas (as definedin 2) on both sides fo the body (bilateral involvement of PIPs,MCPs, or MTPs is acceptable without absolute symmetry)

5. Rheumatoid nodules Subcutaneous nodules, over bony prominences, or extensorsurfaces, or in juxtaarticular regions, observed by a physician

6. Serum rheumatoid factor Demonstration of abnormal amounts of serum rheumatoidfactor by any method for which the result has been positive in


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Misc

Smoking increases the risk of RA 20-40 fold

In pre-RA, anti-citrullinated proteinantibodies and other auto-antibodies like RFs

can appear more than 10 years before clinicalarthritis.

Rheumatoid synovium has many

characteristics of locally invasive malignancy But never becomes completely unresponsive to

anti-inflammatory and anti-proliferative factors

In 2010, things changed a bit


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New (2010) Criteria Goals

Prevent a chronic, erosive disease state (asexemplified by the 1987 criteria) by earlytreatment

Set of rules to be applied to newly presentingpatients with undifferentiated synovitis thatwould 1) identify the subset at high risk of chronicity and

erosive damage;

2) be used as a basis for initiating disease- modifyingtherapy; 3) not exclude the capture of patients later in the

disease course.


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The New ACR/EULAR

classification Helps identify patients with a relatively short

duration of symptoms

Helps those that may benefit from entry intoclinical trials of promising new agents

By initiating these new medications, may haltthe development of the disease that currently

fulfills the 1987 ACR criteria.


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Who can the criteria be

applied to? The classification criteria can be applied to:

any patient or otherwise healthy individual, aslong as 2 mandatory requirements are met:

First, there must be evidence of currently activeclinical synovitis (i.e., swelling) in at least 1 joint

Second, the observed synovitis is not betterexplained by another diagnosis


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The New Classification

Criteria Jointly published by the American College of

Rheumatology (ACR) and the European LeagueAgainst Rheumatism (EULAR)

Uses a point value between 0 and 10. 6 is unequivocally classified as an RA patient

provided he has synovitis in at least one joint andgiven that there is no other diagnosis better explaining

the synovitis. Addresses 4 areas: Joint involvement,

Serological Parameters, Acute phase reactantsand arthritis duration


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2010 Classification Tree Criteria for

Rheumatoid Arthritis (RA)


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Joint Involvement

Joint involvement refers to any swollen ortender joint on examination, which may beconfirmed by imaging evidence of synovitis.

DIP joints, 1st CMC joints, and 1st MTP jointsare excluded from assessment because theyare commonly found in OA.


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Small joints

MCP

PIP

thumb IP

2nd-5th MTP

Wrist

Large joints

Elbows

Hips

knees

Whats in a joint?


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Joint Involvement and

scoringType of Joint Points applied

1 large joint 0 points

2-10 joints 1 point

1-3 small joints (+ or large joints) 2 points

4-10 small joints (+ or large joints) 3 points

> 10 joints (w/ at least 1 small joint) 1 joint must be a small joint; the

other joints can include any combo oflarge and additional small joints, aswell as other joints not specifically

listed elsewhere (e.g., TMJ, AC SCJ, etc)

5 points


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Serologic

Serology criteria:

at least 1 test result is needed for classification

i.e., Anti-Citrullinated Peptide Antibodies or

Rheumatoid Factor


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Serologic

Serologic Marker Points

Negative RF and negative ACPA 0 points

Low-positive RF or low-positive ACPA 2 points

High-positive RF and/or high-positive

ACPA

3 points

Neg test ULN

Low positive > ULN ULN X 3

High Positive > ULN X 3

ULN = upper limit of normalRF = rheumatoid FactorACPA = anticitrullinated protein antibody


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What is CCP

The cyclic citrullinated peptide antibody (CCP)test is an assay that detects the presence ofcitrulline antibodies in the blood.

These autoantibodies are proteins produced by theimmune system in response to a perceived threat fromcitrulline.

Citrulline is an unusual amino acid produced when theamino acid arginine is altered

There is speculation that the conversion of arginine tocitrulline may play a role in the autoimmuneinflammatory process seen in the joints of those withRA


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Why CCP/ACPA?

2nd generation CCP antibody testing:

sensitivity of 80% and a specificity of 98% for RA


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Robust Rheumatoid Arthritis

Cohort of patients that had:

robust personality

Practically infinite capacity for work

Substantial subcutaneous nodules (often thereason for the referral)

High titer on the Rose test


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ROM was unaffected and unguarded

Joints were at sometime painful, but rarely hadto stop working

Shoulder joints affected in all patients Subcutaneous nodules at the elbows and the

fingers in 3 patients Pathology confirmed RA histology

Function: Decreased grip strength

Most were on maintenance Gold Therapy



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Psychologically the Robust patient scoredmore closely to normals, with regard to:

exploitation of disease-induced dependence

Neuroticism

Robust RA scores normal, in contrast to most RApatients who tended to have higher scores



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Robust type rheumatoid arthritis represents aspecial reaction to the disease of a strongbody supported by a tough mind, but is in no

other way a separate clinical entity.



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They had the prognostically unfavorablesymptoms of subcutaneous nodules and a hightiter of the Rose test

However the were robust, felt well and workednormally.

Additional sthentic (i.e., strong, vigorous, oractive) properties included:

Athletic build, good grip strength, high pain thresholdin the finger joints, mental stolidity and independence

Raised question of possibility of mental attitudeon disease and disability



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Outcome Measures and

Treatment Efficacy counts of the number of tender and swollen

joints;

patient and physician global assessment ofdisease activity;

pain assessment using a visual analoguescale;

a validated measure of disability; and

an acute phase reactant (e.g., erythrocytesedimentation rate or C-reactive protein).


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Commonly Used Outcome Measures For

The Rheumatic Diseases


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Treatment to Target Schema


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Treatment to Target

Recommendations

Treating rheumatoid arthritis to target:recommendations of an international taskforce

http://ard.bmj.com/content/69/4/631.short
http://ard.bmj.com/content/69/4/631.shorthttp://ard.bmj.com/content/69/4/631.short


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Treatment to Target

Treatment of RA must be based on a shared decisionbetween the patient and the rheumatologist

The primary goal of treating the patient with RA is tomaximize long-term health-related quality of life

through control of symptoms, prevention ofstructural damage and normalization of function andsocial participation

Abrogation of inflammation is the most importantway to achieve these goals

Treatment to target by measuring disease activityand adjusting therapy accordingly optimizesoutcomes in RA


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Medication Options

NSAIDS

Glucocorticoids

DMARDS Biological DMARDS


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Medication Options - DMARDS

Conventional (synthetic) DMARDs:

methotrexate

sulfasalazine

gold no longer commonly used

antimalarials

leflunomide

azathioprine penicillamine

minocycline.


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Biological DMARDS

Biological DMARDs:

Biological therapies have had a significant impacton the treatment of patients with RA.

It is now clear that proinflammatory cytokines,most notably tumor necrosis factor- (TNF- ) andinterleukin-1, play a central role in thepathophysiology of RA


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Biological DMARDS

Anti TNF

Etanercept (Enbrel)

Infliximab (Remicade)

Adalimumab (Humira)

Interleukin-1 (anakinra)

Block T-cell co-stimulation

Abatacept (Orencia)

Target B-cells Rituximab (Rituxan)


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References

Aletaha, D., et al.:2010 Rheumatoid Arthritis Classification Criteria, Arthritis &Rheumatism Vol. 62, No. 9, September 2010, pp 25692581

http://www.rheumatology.org/practice/clinical/classification/ra/ratree_2010.asp

Schur, PH, et al.: Pathogenesis of rheumatoid arthritis; www.uptodate.com

De Haas, WH, et al: Rheumatoid arthritis of the robust reaction type.;

Annals of Rheum Disease. 1974 January; 33(1): 8185. Atzeni, F, et: Anti-cyclic citrullinated peptide antibodies in primary Sjgren

syndrome may be associated with non-erosive synovitis.; http://arthritis-research.com/content/10/3/R51,Arthritis Research & Therapy 2008, 10:R51

Vossenaar, ER: Citrullinated proteins: sparks that may ignite the fire inrheumatoid arthritis.; Arthritis Research and Ther 2004, 6:107-111 (DOI10.1186/ar1184).

Braddom, Physical Medicine and Rehabilitation 3rd Edition Current Rheumatology Diagnosis & Treatment, 2nd edition
http://www.rheumatology.org/practice/clinical/classification/ra/ratree_2010.asphttp://www.uptodate.com/http://arthritis-research.com/content/10/3/R51http://arthritis-research.com/content/10/3/R51http://arthritis-research.com/content/10/3/R51http://arthritis-research.com/content/10/3/R51http://accessmedicine.com/resourceTOC.aspx?resourceID=38http://accessmedicine.com/resourceTOC.aspx?resourceID=38http://accessmedicine.com/resourceTOC.aspx?resourceID=38http://accessmedicine.com/resourceTOC.aspx?resourceID=38http://arthritis-research.com/content/10/3/R51http://arthritis-research.com/content/10/3/R51http://arthritis-research.com/content/10/3/R51http://www.uptodate.com/http://www.rheumatology.org/practice/clinical/classification/ra/ratree_2010.asp

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