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Rheumatological disease Rheumatology Pathologies Part 1: Osteoarthritis, osteoporosis & rheumatoid arthritis Dr Steven Gopaul JANUARY 9TH 2022 18:00 @BRITISHINDIANMEDICASSOCIATIONNMEDICS @BIMA BIMA Clinical Crash Course Dr Steven Gopaul is an FY1 Foundation Doctor with a keen interest in surgery. He is an international medical graduate. Steven has a strong interest in medical education and has delivered over 10 lectures to medical students. In his free time, he likes to watch/play any type of sport and stock investing. Dr Steven Gopaul FY1 East of England Deanery BIMA Clinical Crash Course Contents ● Osteoarthritis (OA) ● Osteoporosis (OP) ● Rheumatoid arthritis (RA) sgopaul@doctors.org.uk BIMA Clinical Crash Course Objectives ● Recognise signs and symptoms ● Which investigation and when? ● Basic understanding of the condition ● Management of the condition BIMA Clinical Crash CourseDefinitions? BIMA Clinical Crash CourseStatistics ● OA: 10% M, 18% F over 60yrs. ~ 8.75 million people sought treatment between 200—2010. ● OP: F>M. ~2 million women suffer with OP. 2% at 50yrs…50% at 80yrs. ● RA: ~1% of population, 2-4 times more common in F than M. 1/3 stop work within 2 years of onset. BIMA Clinical Crash CourseRisk factors ● OA: genetic, age, female, obesity, trauma, exercise ● OP *: 1. Reducing BMD - DM, falls, hyperthyroidism, testosterone deficiency, IBD, gastrectomy, menopause 2. No effect – age, medications, smoking, RA, previous # ● RA: age, HLA association, sex, smoking, obesity, g0p0 BIMA Clinical Crash CourseOsteoarthritis Knee (18%) > hip (8%) > hand and wrist (6%) BIMA Clinical Crash Course Presentation of OA • There may be a history of: • Activity-related joint pain, and • No morning joint-related stiffness, or morning stiffness lasting no longer than 30 minutes. • Functional impairment. • On examination there may be: • Bony swelling and joint deformity, instability, effusion (uncommon). • Joint warmth and/or tenderness (suggesting synovitis). • Muscle wasting and weakness. • Restricted and painful range of joint movement, crepitus. BIMA Clinical Crash CourseFeatures of OA on XR 1. Joint space narrowing 2. Subchondral sclerosis 3. Osteophytes 4. Subchondral cysts BIMA Clinical Crash CourseOA Knee ● Typically is bilateral and symmetrical, affecting the medial tibiofemoral (mTF), lateral tibiofemoral (lTF), or patellofemoral (PF) compartments, with pain localized to the affected compartment. ● If unilateral -> Likely secondary to predisposing trauma or disease. ● mTF involvement causes anteromedial pain, mainly on walking. ● lTF involvement causes anterolateral pain, mainly on walking. ● PF involvement causes anterior knee pain worsened on inclines or stairs, particularly when going down; and progressive aching on prolonged sitting that is relieved by standing. BIMA Clinical Crash CourseBIMA Clinical Crash CourseOA Hip ● It accounts for significant morbidity and total hip replacement is now one of the most common operations performed in the developed world. ● chronic history of groin ache following exercise and relieved by rest ● red flag features suggesting an alternative cause include rest pain, night pain and morning stiffness > 2 hours ● the Oxford Hip Score is widely used to assess severity BIMA Clinical Crash CourseBIMA Clinical Crash CourseBIMA Clinical Crash CourseOA Hand ● Usually bilateral: Usually one joint at a time is affected over a period of several years. The carpometacarpal joints (CMCs), distal interphalangeal joints (DIPJs) are affected more than the proximal interphalangeal joints (PIPJs). ● Episodic joint pain: An intermittent ache. Provoked by movement and relieved by resting the joint. ● Stiffness: Worse after long periods of inactivity e.g. waking up in the morning. Stiffness lasts only a few minutes compared to the morning joint stiffness seen in rheumatoid arthritis. ● Painless nodes (bony swellings): Heberden’s nodes at the DIPJs, Bouchard’s Nodes at the PIPJs. These nodes are the result of osteophyte formation. ● Squaring of the thumbs: Deformity of the carpometacarpal joint of the thumb resulting in fixed adduction of the thumb. ● Functionally patients do not usually have any problems. If there is severe involvement of the DIPJs, there may be reduced grip strength which can result in disuse atrophy. BIMA Clinical Crash CourseBIMA Clinical Crash CourseManagement NICE published guidelines on the management of osteoarthritis (OA) in 2014 all patients should be offered help with weight loss, given advice about local muscle strengthening exercises and general aerobic fitness ● paracetamol and topical NSAIDs are first-line analgesics. Topical NSAIDs are indicated only for OA of the knee or hand ● second-line treatment is oral NSAIDs/COX-2 inhibitors, opioids, capsaicin cream and intra-articular corticosteroids. A proton pump inhibitor should be co-prescribed with NSAIDs and COX-2 inhibitors. These drugs should be avoided if the patient takes aspirin ● non-pharmacological treatment options include supports and braces, TENS and shock- absorbing insoles or shoes ● if conservative methods fail then refer for consideration of joint replacement BIMA Clinical Crash CourseQuestion time… A 54-year-old farm worker presents for review. She has recently been diagnosed with osteoarthritis of the hand but has no other past medical history of note. Despite regular paracetamol she is still experiencing considerable pain, especially around the base of both thumbs. What is the most suitable next management step? 1. Add oral diclofenac + lansoprazole 2. Switch paracetamol for co-codamol 8/500 3. Add topical ibuprofen 4. Add oral ibuprofen BIMA Clinical Crash CourseQuestion time… A 62-year-old woman presents to her general practitioner with bilateral hip pain. The pain has been worsening over a period of 6 months and is now preventing the patient from going on her usual evening walks. The pain worsens throughout the day and is particularly bad on exercise. She drinks half a bottle of red wine every night and is a life-long non-smoker. Her past medical history is remarkable for recurrent gout and Sjogren syndrome. What is the most likely diagnosis? 1. Gout 2. Osteoarthritis 3. Polymyalgia rheumatica 4. Rheumatoid arthritis BIMA Clinical Crash CourseOsteoporosis BIMA Clinical Crash CourseThe basics ● Risk factors that reduce BMD (DM, falls, hyperthyroidism, IBD, menopause) or have no effect (age, corticosteroids, smoking, RA, previous #) ● Symptoms are pain, immobility, bruising etc. ● Signs are bone pain, #, change in stature or posture ● If DEXA T score <-2.5, treatment recommended ● DEXA also has Z score which is the comparison of a person’s bone density with that of an average person of the same age, sex and race BIMA Clinical Crash CourseInvestigations for OP ● Blood tests including ESR, CRP and Thyroid function tests ● DEXA scan ● XR of Lumbar and Thoracic spine ● Myeloma screen ● 25OHD ● Testosterone levels ● 24hr urinary cortisol/dexamethasone suppression test ● Markers of bone turnover BIMA Clinical Crash CourseAssessing risk for fragility fractures ● All women >65yrs and men >75yrs. ● Due to risk factors such as previous fragility fracture, history of falls, current/frequent recent use of glucocorticoids, smoking, low BMI… ● FRAX or Qfracture risk tools ● Recalculate if original risk was in intervention threshold or change in person’s risk factors after min. 2yrs. BIMA Clinical Crash Course● 10 year risk assessment ● 40-90yrs ● International ● Based on age, sex, weight, height, previous #, current smoking, RA, 2ndary OP, alcohol intake, glucocorticoids, ● BMD optional BIMA Clinical Crash Course● 10 year risk assessment ● 30-99yrs ● UK ● Based on CV disease, history of falls, chronic liver disease, RA, T2DM, tricyclic antidepressants BIMA Clinical Crash CoursePost fragility fracture risk of OP If >75yrs: ● Presumed to have underlying OP and should be started on oral bisphosphonate without DEXA If <75 yrs: ● DEXA first and then calculate into FRAX, manage according to FRAX BIMA Clinical Crash CourseBIMA Clinical Crash CourseBIMA Clinical Crash CourseBIMA Clinical Crash CourseManagement Indicated for treatment following osteoporotic fragility fracture in postmenopausal women with confirmed OP post DEXA scan. If >75yrs, DEXA not always needed. ● Alendronate is 1 line, 2 ndline drugs are Risedronate or Etidronate ● Vitamin D and calcium supplementation ● Raloxifene and Strontium ranelate also viable alternatives ● Denosumab – mAntibody which is a RANK inhibitor ● ?Surgery BIMA Clinical Crash CourseQuestion time… A 66-year-old woman visits the outpatient department for a review of her osteoporosis, where she is booked in for a DEXA scan. Her T-score from the scan is recorded as -1.6. Her consultant wishes to calculate her Z-score What patient factors are required to calculate this? 1. Age, BMI, ethnicity 2. Age, BMI, smoking history 3. Age, income, Instagram followers 4. Age, gender, ethnicity BIMA Clinical Crash CourseQuestion time… A 83-year-old lady visits your clinic and is wondering whether she needs something to protect her bones. Her PMHx is NOF # 10 months ago, CKD stage IV, HTN and Ischaemic heart disease. After her NOF #, she was discharged with Alendronic acid. This was stopped 6 months ago due to intolerable acid reflux. She was unable to tolerate Risedronate for the same reason. Her DEXA scan showed a T-score of -4.2. What is the most appropriate action? 1. Treat with calcium and Vit.D supplements 2. Repeat DEXA 3. Consider Denosumab 4. Consider IV Bisphosphonates such as Zoledronate BIMA Clinical Crash CourseQuestion time… A 77-year-old Afro-Carribean woman suffered a NOF # after slipping whilst on a walk. Her PMHx is Ischaemic heart disease and rheumatoid arthritis. She went through menopause at 55 and was a keen jogger until then. A DEXA was performed as an OPA and returns a T-score of -2.9, indicating that she suffers from osteoporosis. Which feature of the patient’s history is most associated with an increased risk of osteoporosis? 1. Late menopause 2. Rheumatic fever 3. Rheumatoid arthritis 4. Ischaemic heart disease BIMA Clinical Crash CourseARE YOU AWAKE? Which one of the following X-ray changes is not associated with Osteoarthritis? 1. Decreased joint space 2. Subchondral sclerosis 3. Subchondral cysts 4. Osteophytes at the joint margin 5. Periarticular erosions BIMA Clinical Crash CourseRheumatoid arthritis BIMA Clinical Crash Course Presentation of RA ● Persistent synovitis ● Symmetrical pattern on small joints of hands and feet, however any joint can be affected ● Pain at rest/inactivity ● Swelling around joint ● Stiffness – morning and >1hr ● Rheumatoid nodules ● Extra-articular manifestations (vasculitis, keratoconjunctivitis sicca and pulmonary fibrosis) ● General features of illness BIMA Clinical Crash CourseBIMA Clinical Crash CourseExtra-articular manifestations BIMA Clinical Crash CourseInvestigations for RA Clinical > diagnostic ● General blood tests ● Specific blood tests – Rheumatoid factor (non specific), anti-cylic- citrullinated peptide (anti-CCP) antibodies (more specific), ESR ● XR of hands and feet ● US ● MRI BIMA Clinical Crash CourseBIMA Clinical Crash CourseManagement of RA ● Initially, monotherapy of DMARDs (Methotrexate, Sulfasalazine, Hydroxychloroquine, Leflunomide) with short course of Prednisolone ● If poor response to at least 2 DMARDs, trial of TNF-inhibitors (Etanercept, Infliximab, Adalimumab) ● Rituximab (anti-CD20) infusions every 2 weeks ● Surgery BIMA Clinical Crash CourseFlare ups ● Worsening symptoms ● Firstly exclude septic arthritis (hot and swollen joint along with septic features Management: ● Specialist advice ● Short course of glucocorticoids either IA, IM or PO ● +/- NSAID BIMA Clinical Crash CoursePrognosis Poor prognosis linked with: ● Rheumatoid factor positive ● Anti-CCP antibodies ● HLA-DR4 ● Insidious onset ● Poor day to day function ● Advanced disease on XR ● Extra-articular manifestations ● ?Female BIMA Clinical Crash CourseQuestion time… A 26-year-old woman presents to the GP with pain and swelling in her hand joints for the last 4 months. She mentions her joint are stiff in the morning, and the stiffness usually lasts for an hour. She denies pain or swelling of her elbows, ankles, or knees. nd rd O/E she has swelling and tenderness of the 2 and 3 metacarpophalangeal (MCP) joints of both hands. Lab results show an elevated ESR and CRP. NICE has recommended which of the following investigations, to be performed on all such patients? 1. Anti-neutrophil cytoplasmic antibody (ANCA) 2. Antinuclear antibodies (ANA) 3. Serum uric acid 4. X-ray of hands and feet BIMA Clinical Crash CourseQuestion time… You are a Rheumatology SpR and today you will be seeing outpatients in clinic. Your first patient is a 36-year-old woman who presents with intermittent pain and swelling of the metacarpal phalangeal joints for the past 3 months. An X-ray shows loss of joint space and soft tissue swelling. Rheumatoid factor is positive and a diagnosis of Rheumatoid arthritis is made. What will your plan be for this lady’s initial management? 1. Infliximab 2. Methotrexate and short course of Prednisolone 3. Methotrexate and Infliximab 4. Methotrexate, Sulfasalazine and short course of Prednisolone BIMA Clinical Crash CourseWhat are the differences between Osteoarthritis and Rheumatoid arthritis? BIMA Clinical Crash Course References ● NICE Guidelines ● PassMedicine textbook and question bank ● BMJ Best Practice BIMA Clinical Crash CourseTHANK YOU FOR LISTENING ANY QUESTIONS? sgopaul@doctors.org.uk BIMA Clinical Crash Course