Managing Rheumatoid arthritis Chandrashekara .S

Diagnostic dilemmas Early presentation- Typical but no serological markers positive especially RF. No EMS or erosions.

Hand and foot arthritis- is it RA Other features RF and Anti-CCP Joint pattern Other unusual mimickers

Single large joint Duration, feature and inflammations RF/ anti-CCP + infection exclusion X ray of joint MRI role Imaging other site- Pelvis for sacroiilitis Synovial biopsy

Other special tests in monoarthritis PCR- Variety Tb work-up HLA B 27 Synovial fluid ADA

Radiology in monoarthritis Plain radiography- May not be useful in early 6 weeks- except in osteomyelitis, Aggressive infective arthritis, Pherstister triad-no joint narrowing, marginal erosion and juxtra articular osteoporosis. Osteo-arthritis- can be misleading. ? Something is missing?

Other Imaging MRI- soft tissue, pannus, and ligament injury even infection and infiltrative pathology, few changes and scoring pattern for RA and SSA are being developed CT- may be a replacement but not a substitute Nuclear scan may help to work-up if asymptomatic other joint inflammation or metastasis is considered as Diagnosis

Synovial fluid analysis All tapped fluid unless sure of diagnosis should be evaluated Collection is critical including sterility of container An EDTA tube collection willhelp to delineate cells better Interpretation algorithms are available.

How much is less in clinical history and examination MORE is not enough Each finding should preferably explainable Often missed info- Raynuds, ulcers, skin rashes, drug abuse, eye disease, steroid use, urethritis, drugs like PZA, tophi

X ray Pelvis Presence of inflammatory back pain Atypical oligo arthritis presentation with restricted back movement (Shober’s) Presence of eye problem with atypical arthritis Young male with arthritis Family history Other modalities- MRI, CT and Nuclear Scan

Hand X- rays Differential diagnosis Severity Pattern of involvement Erosions Marginal Central Degree of Changes Osteoporosis/sclerosis Severity

Red flag signs to evaluate further Life threatening Infection in joints or elsewhere SLE or Vasculitis Organ threatening Rising creatinine and urine sediment Eye disease association Lung symptoms Neurological changes Window of Opportunity

Atypically typical RF /anti-CCP +, normal inflammatory parameter, symptomatic and joint swelling + Asymmetrical and less than 2 weeks Less than 2 weeks typical How to proceed

Co-morbidity RFT LFT CPK X ray Chest HTN DM others

Infection with chronic viral disease HIV Hepatitis B Hepatitis C Should we screen all How and when

Disease Burden estimation Damage Extent Severity Duration.

Future How to start therapy Counseling and issue in counseling Pregnancy and other personal perspectives Issues related to compliance Exercise or rest Physiotherapy Managing Pain and patients symptoms

Future volume Initiating DMARD Managing AE Attempting combinations and their rationale Biologics Other issues of concern

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