Transcript Rheumatoid Arthritis VS Osteoarthritis

Rheumatoid Arthritis
VS
Osteoarthritis
Phong Dao
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 joints
Osteoarthritis
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
Definition
Rheumatoid arthritis
1. It is more of a systemic illness and
therefore can affect other organs
in the body
Osteoarthritis
1.
2.
It does not affect other organs of
the body
It is a chronic disease that has
NO CURE, so prevention and
treating the symptoms are the
key
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
Who gets it?
Osteoarthritis
Rheumatoid
1.
2.
3X more common in women as
in men
The disease can begin at any
age, but most often starts after
age forty and before sixty
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
- 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.
1.
Risk Factors
Rheumatoid
1.
2.
3X more common in women as
in men
The disease can begin at any
age, but most often starts after
age forty and before sixty
Osteoarthritis
1.
2.
3.
Obesity (esp. for knee OA)
History of significant
injury,particularly of the knee
or hip (ligament or meniscal
tear)
History of surgery (a history
of menisectomy)
4.
Low dietary intake or serum
levels of vitamin D
Osteoarthritis
Symptoms & Signs
Rheumatoid Arthritis
Fatigue
General discomfort, uneasiness, or malaise
Loss of appetite
Low-grade fever
Joint pain, joint stiffness, and joint swelling
Often symmetrical
May involve wrist pain, knee pain, elbow pain, finger
pain, toe pain, ankle pain, or neck pain
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
Skin redness or inflammation
Paleness
Swollen glands
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
Affected Joints
Rheumatoid Arthritis
Osteoarthritis
Bouchard's node
The localized enlargement seen on the
proximal interphalangeal (PIP) joint
May not be painful
Affected Joints
Rheumatoid Arthritis
Osteoarthritis
Heberden's Node
Unlike OA, the distal
interphalangeal (DIP)
joints are generally spared
The localized enlargement seen on the
proximal interphalangeal (DIP) joint
May not be painful
Nodules
Rheumatoid Arthritis
Osteoarthritis
Typically does not have skin
nodules
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)
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).
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.
Blood Work
Rheumatoid
Rheumatoid factors
- 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
- 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)
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
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
X-RAY
Rheumatoid
Osteoarthritis
X-RAY
Rheumatoid
Osteoarthritis
Diagnosis
Rheumatoid
Any 4 of the following criteria must be present to
classify patients as having RA:
1.
2.
3.
4.
5.
6.
7.
Morning stiffness for > or = to 1 hour *
Arthritis of 3 or more joints *
Arthritis of hand joints (wrist, MCP, or PIP)
Symmetric arthritis *
Rheumatoid nodules
Serum rheumatoid factor
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
2. Hard tissue enlargement of 2 or more
DIP joints
3. Fewer than 3 swollen MCP 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%.
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
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
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)
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
- it is an antifolate agent (contraindicated in renal, liver dz or ETOH
abuse)
- side effects (nausea, diarrhea, stomatitis, and less often alopecia)
- cause bone marrow suppression
- can cause idiopathic pnemonitis
- 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
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.
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
D-penicillamine side effects similar to gold.
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
2. Increase range of motion
3. Increase muscle strength
Treatment of OA
Step-wise approach
Step 1 (Non-pharmacologic therapy)
a.
b.
c.
d.
e.
f.
g.
Patient education
Programs for aerobic exercise
If overweight, weight loss
Physical therapy or occupational therapy
Walking aids
Shock absorption
Re-alignment through orthotics
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)
Treatment of OA
Step-wise approach
Step 2 (Pharmacologic therapy)
When initial therapy is inadequate:
1.
2.
COX-2 inhibitor (Celebrex) 200 mg PO qd or 100 mg BID
If contraindicated to COX-2 inhibitor or NSAIDS, then can try Ultram 200300 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)
Treatment of OA
Step-wise approach
Step 2 (Pharmacologic therapy)
Alternative medicines: (Glucosamine & Chondroitin)
1.
2.
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
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
Treatment of OA
Step-wise approach
Step 3 (Surgery)
1.
2.
Proximal Tibial Osteotomy
Total knee replacement
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.
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
2. Younger patients are more active and place more stress on thartificial
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
4. Replacing the knee the second or third time is much harder and and much
less likely to succeed.
Treatment of OA
Total knee replacement
Questions
Questions