OLD FRIENDS REVISITED

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OLD FRIENDS REVISITED

• POLYMYALGIA RHEUMATICA or
• LATE ONSET RHEUMATOID ARTHRITIS
• GOUT CHANGING PRESENTATIONS SIMPLIFIED
  MANAGEMENT APPROACH
• Dr Graham Reid
• March 2007

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Polymyalgia Rheumatica or Rheumatoid Arthritis

• Can you tell the difference ?
• Does it matter ?

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Polymyalgia Rheumatica

• Age 50
• Abrupt onset shoulder and pelvic girdle stiffness
  and pain
• Pronounced morning symptoms
• Symmetrical
• ESR elevated
• Dramatic response to Prednisone

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Polymyalgia Rheumatica

• If its pink and grunts its probably a pig

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Polymyalgia Rheumatica not so easy ?

• 72 year old retired banker
• Slowly increasing right shoulder pain over last 2
  months.
• Pain wakes at night
• Last few weeks left shoulder pain
• Right shoulder frozen
• Left shoulder impingement signs
• ESR 40

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Polymayalgia Rheumatica mimics

• Rotator cuff syndromes
• PMR may be somewhat asymmetrical
• If bilateral shoulder (or hip) symptoms consider
  PMR

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Polymyalgia Rheumatica not so easy ?

• Classic PMR presentation and response to
  prednisone.
• On reducing prednisone to 10mg complains of
  stiffness in fingers and wrists.
• Shoulder and hip exam normal
• Now has pain on MCP and MTP compression

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Polymyalgia Rheumatica mimics

• Late onset Rheumatoid Arthritis
• Sero negative Rheumatoid Arthritis
• Maturity onset Seronegative Synovitis MOSS
• Remitting Symmetrical Seronegative Synovitis and
  Pitting Edema RS3PE
• Late onset Systemic Lupus Erythematosus

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Polymyalgia Rheumatica mimics

• 63yr old woman
• Challenging historian with shoulder and hip pains
  without morning predominance
• No physical signs except fibromyalgia
• ESR 86
• Prednisone 20mg/day 60 improved
• Repeat ESR (on prednisone) 72 CRP 3

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Polymyalgia Rheumatica ESR and CRP

• ? 20 cases PMR have normal ESR
• CRP may be more reliable ?
• High ESR with normal CRP Check Protein
  Electropheresis
• High CRP with normal ESR ignore ESR

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PMR or Rheumatoid ArthritsDoes it matter ?

• Both respond well to Prednisone
• Add osteoporosis treatment with Prednisone
• If PMR must consider associated Giant Cell
  Arteritis -GCAhigher prednisone dose
• PMR common in patients presenting with GCA but
  rare for GCA to develop in patients with PMR
  symptoms alone.
• PMR requires treatment 12 but
• Rheumatoid arthritis consider DMARDs
• Careful review over time important for both

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Gout Changing faces ?

• 64 yr old Longshoreman
• BMI 32
• Normal alcohol intake after work
• Hypertension
• Hyperlipidemia
• Increasing 1st MTP inflammation episodes for 10
  years
• Polyarticular episodes for 5 years
• Lumps on ears

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Gout Changing faces ?

• 68yr old woman
• Vasculopath smoker carotid/femoral bypass
  surgeries
• Hypertensive with Creatinine 170
• Admitted with stroke
• c/o pain R wrist and fingers,L knee, L olecranon
  bursa. No prior history gout
• Early tophi fingers and toes

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Gout Changing faces ?

• Polyarticular presentations more common
• Finger and toe tophi more common than ear helix
  and Achilles tendon tophi
• Tophi present with few historical episodes
  suggestive of gout
• More common diagnosis
• More challenging to manage because of
  comorbidities

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GOUT
A PRACTICAL APPROACH
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Uric Acid Production
Uric Acid Excretion
Body Urate Pool
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Increased Uric Acid Production
Enzyme Defect Cell Breakdown Chemotherapy
Increased Body Urate Pool
Uric Acid Excretion
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Kidney
Decreased Excretion
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Decreased Excretion
Genetic Renal Disease Medications Ketoacidosis La
ctic acidosis Hypothyroidism
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Increased Urate stores
Decreased Excretion
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Overflow
Decreased Excretion
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Inflammation
Overflow
Decreased Excretion
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Inflammation
Colchicine NSAIDs Cox 2 agents Corticosteroids
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Increased Urate Pool
Recurrent Inflammation
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Uricosurics
Decreased Urate Pool
Probenecid Sulphinpyrazone
Increased Excretion
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ALLOPURINOL
Decreased Production
Decreased Urate Pool
6 months
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MOBILISATION GOUT
Body Urate Stores
GOUT
Concentration Gradient
Blood Stream
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Gout Management
TREAT INFLAMMATION
STEP 1
ADDRESS INCREASED URATE STORES
STEP 2
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Gout 2007

• Increasing frequency
• Polyarticular presentations more common
• Tophi in digits
• Compliance with treatment poor
• Patient education may help ?