Approach%20to%20the%20patient%20with%20Monoarthritis

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Approach to the patient with Monoarthritis

• Diseases that commonly present with 1 joint

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Approach to the pt w/ Monoarticular sxDiseases
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

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Polyarticular diseases occasionally p/w one joint
of onset

• RA
• JA
• Viral
• Sarcoid
• ReA
• PsA
• IBD-arthritis
• Whipples
• OA

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Important questions?

• What should you ask the patient?
• Whats critical to determine ASAP?
• Whats the most useful test to determine
  etiology?
• What other labs/studies should be obtained?

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The patient with polyarticular symptoms

• Diseases that present with acute polyarticular
  sx
• Chronic polyarticular sx?

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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

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Chronic polyarticular
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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

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Evaluation and Management of Osteoarthritis
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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?

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OA Symptoms and Signs

• Pain is related to use
• Pain gets worse during the day
• Minimal morning stiffness (lt20 min) and after
  inactivity (gelling)
• Range of motion decreases

• Joint instability
• Bony enlargement
• Restricted movement
• Crepitus
• Variable swelling and/or instability

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OA Case 1 Radiographic Features

• Joint space narrowing
• Marginal osteophytes
• Subchondral cysts
• Bony sclerosis
• Malalignment
• MAKE THE DIAGNOSIS

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OA Laboratory Tests

• No specific tests
• No associated laboratory abnormalities eg,
  sedimentation rate
• Investigational Cartilage degradation products
  in serum and joint fluid

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Understanding Disease Mechanisms

• OA is mechanically driven, but chemically
• mediated

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Immunostain of OA Cartilage
Melchiorri, et. al. 1998
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Spontaneous Production of Inflammatory Mediators
by Normal and OA-affected Cartilage
IL-18
PGE2
NO
MCP-1
ELISA
IL-8
IL-6
IL-1b
TNFa
0 20 40
60 80
100
Units
Attur et al. Osteoarthritis and Cartilage 2002
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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)

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OA Risk Factors

• Why did this patient develop osteoarthritis?

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OA Risk Factors (contd)

• Age 75 of persons over age 70 have OA
• Female sex
• Obesity
• Hereditary
• Trauma
• Neuromuscular dysfunction
• Metabolic disorders

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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

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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 Heberdens and
  Bouchards nodes

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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

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Age-Related Prevalence of OA Changes on X-Ray
Men
Women
DIP
DIP
Knee
Prevalence of OA ()
Prevalence of OA ()
Knee
Hip
Hip
Age (years)
Age (years)
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Case 2 Distal and Proximal Interphalangeal Joints
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Case 2 Carpometacarpal Joint

• Radiograph shows severe changes
• Most common location in hand
• May cause significant loss of function

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Case 2 Hip 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

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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 diseaseaka
  pseudogout)

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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

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Underlying Disease Associations of OA and CPPD
Disease (pseudogout)

• Hemochromatosis
• Hyperparathyroidism
• Hypothyroidism
• Hypophosphatasia
• Hypomagnesemia
• Neuropathic joints
• Trauma
• Aging, hereditary

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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

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Pharmacologic Management of OA

• Nonopioid analgesics
• Topical agents
• Intra-articular agents
• Opioid analgesics
• NSAIDs
• Unconventional therapies

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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 stretching

Rogind, et al. Arch Phys Med Rehabil.
19987914211427. Jette, et al. Am J Public
Health. 1999896672.
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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 programsgroup support
• Exercycle with minimal or no tension
• Treadmill with minimal or no elevation

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Nonopioid Analgesic Therapy

• First-lineAcetaminophen
• Pain relief comparable to NSAIDs, less toxicity
• Beware of toxicity from use of multiple
  acetaminophen-containing products
• Maximum safe dose 4 grams/day

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Nonopioid Analgesic Therapy (contd)

• 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

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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. 1999411112.
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Nonopioid Analgesics in OA (contd)

• Tramadol
• Affects opioid and serotonin pathways
• Nonulcerogenic
• May be added to NSAIDs, acetaminophen
• Side effects Nausea, vomiting, lowered seizure
  threshold, rash, constipation, drowsiness,
  dizziness

Medical Letter. 1999411112.
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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

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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

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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. 1998252203.
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OA Unconventional Therapies

• Polysulfated glycosaminoglycansnutriceuticals
• Glucosamine /- chondroitin sulfate Symptomatic
  benefit, no known side effects
• Doxycycline as protease/cytokine inhibitors
• Under study
• Have disease-modifying potential

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OA Unconventional Therapies (contd)

• Keep in touch with current information.
• ACR Website (http//www.rheumatology.org)
• Arthritis Foundation Website (www.arthritis.org)

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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

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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

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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

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OA Management Summary (contd)

• Second-line approach
• NSAIDs if acetaminophen fails
• Intra-articular agents or lavage
• Opioids
• Third-line
• Arthroscopy
• Osteotomy
• Total joint replacement