1. Identifying Early Inflammatory Arthritis
Dr Catherine Gwynne
Consultant Rheumatologist
Torbay and South Devon NHS Foundation Trust

2. What is Arthritis?
A condition causing pain or inflammation in a joint, often accompanied by structural changes

3. Types of Arthritis Osteoarthritis Also known as Inflammatory arthritis
Wear and tear
Degenerative arthritis
Crystal Arthritis
gout, pseudogout
Rheumatoid arthritis
Psoriatic arthritis
Ankylosing spondylitis
Sero negative arthritis
SLE/other connective tissue diseases

4. Osteoarthritis Pain, especially after activity Gelling
Limitation of movement
May have swelling
Typically no inflammation

5. Osteoarthritis Distribution: Treatment: Pain killers Exercise
Oral
Topical
Exercise
Weight loss
Podiatry
Physiotherapy
Injections?
Surgery

6. Inflammatory Arthritis
Rheumatoid arthritis Sero negative arthritis Ankylosing Spondylitis (Osteoarthritis)

7. Joint damage in Inflammatory Arthritis
Normal Joint

8. Consequences of Persistent Inflammation
Early disease
Late disease

9. Preventing damage
Early diagnosis and early treatment can prevent joint damage
Remission is the ultimate goal of inflammatory arthritis treatment

10. NICE Quality Standard QS 33: Rheumatoid Arthritis
Statement 1. People with suspected persistent synovitis affecting the small joints of the hands or feet, or more than one joint, are referred to a rheumatology service within 3 working days of presentation.
Statement 2. People with suspected persistent synovitis are assessed in a rheumatology service within 3 weeks of referral.
Statement 3. People with newly diagnosed rheumatoid arthritis are offered short-term glucocorticoids and a combination of disease-modifying anti-rheumatic drugs by a rheumatology service within 6 weeks of referral.

11. Achieving Remission Disease activity score (DAS28) of <2.6
Reduces disease progression
Protects against joint damage
Reduces pain
Reduces limitations in mobility

12. How do we control inflammation?
DMARDs
Methotrexate
Sulphasalasine
Leflunomide
Hydroxychloroquine
Steroids
Biologics
Anti TNF
Tocilizumab
Rituximab
Abatacept

13. Identifying inflammatory Arthritis
Rheumatoid arthritis Sero negative arthritis Ankylosing Spondylitis (Osteoarthritis)

14. General Features of Early Inflammatory arthritis
Persistent joint inflammation
Swelling
Prolonged stiffness
(>30 minutes early morning stiffness)
Pain
Redness
Family History
Systemic upset
Extra-articular features
Skin
Nails
Lungs
Eyes
Partial response to NSAIDs

15. Early Rheumatoid Arthritis

16. Early Rheumatoid Arthritis
Positive MCP/MTP squeeze
?Rheumatoid Nodules

17. Disease activity in Rheumatoid Arthritis
Disease activity score (DAS28)
Tender Joint Count
Swollen Joint Count
CRP or ESR
Patient Global Score (0-100)

18. Seronegative Inflammatory Arthritis
Psoriatic Arthritis
Enteric Arthritis (IBD)
Spondyloarthritis / Ankylosing Spondylitis
Reactive Arthritis
Asymmetric Oligo-arthritis

19. Early Sero-Negative Arthritis
Inflammatory Arthritis
Dactylitis
Enthesitis
Inflammatory tendopathies
Asymmetric Oligo-arthritis

20. Early Sero-Negative Arthritis
Inflammatory Arthritis
Dactylitis
Enthesitis
Inflammatory tendopathies
Dactylitis Tendonitis

22. Psoriatic Arthritis
Nail changes
Pitting, onychloysis
Skin Psoriasis

23. Ankylosing Spondylitis
Peripheral musculoskeletal involvement in 30-50%
Peripheral enthesitis is the basic pathologic process
The following sites are commonly involved:
Achilles tendon insertion
Insertion of the plantar fascia on the calcaneus or the metatarsal heads
Base of the fifth metatarsal head
Tibial tuberosity

24. Identifying Ankylosing Spondylitis
Males>females, Age <45 years
Morning stiffness > 30 minutes
Improvement of back pain with exercise but not rest
Nocturnal back pain during the second half of the night only
Alternating buttock pain

25. Summary
Identifying and treating early inflammatory arthritis prevents joint damage
Look out for inflammatory changes within the foot (joint inflammation, dactylitis, enthesitis)
Ask about other joint involvement- particularly prolonged joint stiffness and swelling, test MCP squeeze
Consider associated conditions and family history
Direct patient urgently to GP or rheumatology if suspicions

26. Thank you
Any questions?