1. ARTHRITIS Anna Jaatinen Rotary Doctor Bank Finland, Ilembula Hospital

2. Today’s topics  Osteoarthritis  Rheumatoid arthritis  Reactive arthritis  Crystal-induced Synovitis  Infectious Arthritis  HIV-associated arthritis

3. Rheumatoid arthritis 1  Systemic diseace  Unknown etiology  Symmetric inflammatory polyarthritis  Extra-articular manifestations  Rheumatoid nodules  Pulmonary fibrosis  Serositis  Vasculitis  Rheumatoid factor up to 80%

5. Rheumatoid arthritis 2  Clinical Presentation  Insidous oncet of the pain, swelling and morning stiffness in the joints (hands, wrists)  Synovitis! Typical places: MCP, PIP, wrist  Rheumatoid nodules on extensor surfaces  Course is often chronic and progressive  Erosions!  Rheumatoid arthritis may substatial long-term disability and is associated with increased mortality!

7. Rheumatoid arthritis 3  American Collece of Rheumatology 1987 Classification Criteria Morning stiffness (>60 min) Arthritis of three of more joints Arthritis of hand joints Rheumatoid nodules Serum rheumatoid factor X-ray changes (erosions and decalcification) 4 of the 7 criteria should be met, with criteria 1 to 4 present for more than 6 weeks Morning stiffness (>60 min) Arthritis of three of more joints Arthritis of hand joints Rheumatoid nodules Serum rheumatoid factor X-ray changes (erosions and decalcification) 4 of the 7 criteria should be met, with criteria 1 to 4 present for more than 6 weeks

9. Rheumatoid arthritis 4 TREATMENT  NSAID  Ibuprofen 400-800 mg TDS as long as needed  Acetylsalicylic acid  Corticosteroids  Prednison 5 to 20 mg OD  With long treatments remember to decrease the dose slowly!  Intra-articulr administration  Hydrocortison 25-100 mg i.a.  DMARDs (Diseace- modifying antirheumatic drugs)  Methotrexate  Hydroxychloroquine  Sulfasalazine  Leflunomide  Biologic DMARDs Patients with itractable symptoms may require special treatment at spesialist centre!

10. Osteoarthritis 1 = Degenerative joint disease = Arthrosis  Most common form of arthritis!  Degenerative loss of articular cartilage with subsequent formation of reactive new bone at the cartilage surface  Most common: PIP, DIP, hips, knees, cervical and lumbar spine  Common in the elderly, but may occur any age especially after joint trauma, chronic inflammatory arthritis or congenital malformation.

12. Osteoarthritis 2  Clinical Presentation  Pain!  Specific clinical features depend on the joint involved  Knee: possible hydrops, no signs of infection or severe inflammation  DIP: enlarged joint Bouchard’s nodes  X-ray shows cartilage damage and sometimes even deformity

13. Osteoarthritis 3 TREATMENT  Nonpharmacologic approaches  Prief period of rest  Good shoes: Walkers  Crepe bandage or brace can help  Physiotherapy and exercise to affected joints  Reduction on weight in obese patients  Medications  Paracetamol 1 g TID (QID)  NSAID (As low dose as possible)  Ibuprofen 200-600 mg TID  Itra-articular clucocorticoid  Should not be given more than every 3 to 6 months  Systemic clucocorticoid should be avoided!

14. Reactive arhtritis 1  Inflammatory arthritis, which occasionally follows certain GI or genitourinary infections  Reiter sdr = arthritis + conjuctivitis + urethritis  Most common after  Chlamydia trachomatis, Shigella flexneri, Salmonella species, Yersinia enterocolitica, Campylobacter jejuni  Genetic predisposition  HLA-27 positive 60-80%

15. Reactive arthritis 2  Clinical Presentation  Asymmetric oligoarthritis  Urethritis  Conjuctivitis  Skin and mucous lesions  Usually transient, lastin one to several months  Some patients develope chronic arthritis

16. Reactive arthritis 3 TREATMENT  Control of pain and inflammation!  NSAIDs  Severe cases short glucocorticoid therapy  Ophthalmologic referral if you suspect iritis  Remember and search for infection!  Clamydia tr  Antibiotic treatment if still needed  Prolonged antiobiotic therapy has NOT been showed to be beneficial

17. Crystal-Induced Arthritis 1  Gout (Urate crystals)  Pseudogout (Calcium pyrophosphate dihydrate crystals)  Apatite disease  Gout arthritis developes when urate crystals deposites in the joints  Primary: hyperuricemia due to undersecretion of uric acid  Secondary: Renal disease, diuretic therapy, low-dose aspirin, ethanol, starvation, lactic asidosis, dehydration, pre- eclampsia, diabetic ketoasidosis

18. Crystal Induced Arthritis 2  Clinical Presentation  Excruciating pain  Usually in single joint in foot or ankle  Occasionally a polyarthritic oncet can mimic rheumatoid arthritis  Joint is swollen, skin erythema, warm/hot  Chronic gout: With time acute gouty attacs more often, even chronic joint deformity may appear  Lab: Uric acid levels  with 70%, Crystals seen in the joint fluid examined with microscope

19. Crystal Induced Arthritis 3 TREATMENT  Acute gout  NSAID high dose  Indomethacin 75 mg start then 50 mg every 6 hours 24 hrs, 50 mg TDS 24 h, 25 mg TDS 24 h  Diclofenac 75 mg BDS  Ibuprofen 400-800 mg TDS  Glucocorticoids (especcially when NSAID is contraindicated)  Intra-articular injection  Prednison 40 mg OD 3-5 days  Colchisine  1 mg stat followed 0,5 mg every 2 hours orally until patient improves or ad 10 mg  Prevention  Anti-hyperuricaemic therapy; Allopurinol  Goal serum uric acid below 8 mg/dl (0.48 mmol/l)  Avoid precipitants (alcohol, small fish, diuretics)  Reduce weight in obese patients Remember that allopurinol can make acute gout even worse! Start after clinical improvement!

20. Infectious Arthritis 1  Septic infection!  Non-conococcal: Staphylococcus Aureus, Streptococci  Conococcal arthritis  Occasionally: M Tuberculosis, Brucella, Fungi  Non-bacterial infectious arthritis  Viral infections: Hepatitis B, Rubella, Mumps, Mononucleosis, parvovirus, enterovirus, adenovirus

21. Infectious Arthritis 2  Clinical Presentation  Non-gonococcal infectious arthritis  Fever  Acute monoarticular arthritis  Multiple joint may be affected by hematogenous spread of pathogens  Gonococcal arthritis  Migratory or additive polyarthralgias followed by tenosynovitis or arthritis of wrist, ankle or knee and vesicopustular skin lesions

22. Infectious Arthritis 3 TREATMENT  Immediate antibiotic therapy  Cover S. Aureus, Streptococcus, Neisseria gonorrhoeae  IV-antibiotics are recommended for at least 2 weeks, followed by oral antibiotics 2(-4) weeks  When definite gonococcal arthritis Ceftriaxone i.v. For 3 days followin 7-14 days treatment with cefixime or Amoxicillin/clavulanate  Surgical drainage especcially if there is big joint (shoulder, hip), lobulation of pus, osteomyelitis or delay with response to treatment  Supportive treatment for septic infection!  NSAID

23. HIV-infection and arthritis 1  HIV-associated arthralgia  Any stage of HIV infection  Mild to moderate, involves usually large joints (shoulders, elbows, knees)  No synovitis!  Treatment: Pain medication, support

24. HIV-infection and arthritis 2  Reactive arthritis  Psoriatic arthritis  HIV-assosiated arthritis  Virus is directly involving joint synovium  Oligoarticular, occurs predominantly in the lower extremities  Self-limiting course, lasting <6 weeks  X-ray: no erosion in the joints  Also HIV-associated polyarthritis is possible, resembles rhematoid arthritis  Synovitis abates when CD4 is declining, but joint destruction continues

25. Diagnose with intra-articular puncture Main principles  Clear synovial fluid: Osteoarthritis, Rheumatoid arthritis  Leukocyte amount  Thick, fuzzy: Crystal-induced Arthritis  Crystals seen in microscope  Purulent: Infectious arthritis  Culture, Gram stain Assure that your technique is clean!

26. Take Home Message  Osteoarthritis is the most common reason for joint pain; treat the pain and educate the patient  Treat with antibiotics when…  It’s infectious arthritis!  Reactive arthritis if there still is infection  If you suspect Rheumatoid arthritis, treat aggressively, consider refferal for specialist Asante, Thank you!