Osteoarthritis. Rheumatology Update. Gout 1/17/2013

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1 Osteoarthritis Rheumatology Update Richard Zweig, MD January, 2013 Degeneration of cartilage over time accompanied by increase in bone density and bone formation around the joint Risks include: aging, female sex, genetic predisposition, obesity (especially in the knee and hand), Trauma, and some occupations Higher bone mass OA Symptoms: pain on initiation of activity or with activity Inflammatory type has pain and stiffness X ray show joint space narrowing, subchondral sclerosis, bone cysts and osteophyte formation Most common joints: apophyseal joins of the lumbar and cervical spine, finger ip joints, first cmc, knee and hip OA Treatment: for knees, weight loss PT for quads strengthening Should be isometric Canes acetaminophen up to 3 g per day Ibuprofen < 1600 mg per day May need omeprazole Intraarticular steroids Capsacin cream Glucosamine has been shown to provide symptomatic benefit in the short term Gout 44 % increase in this decade 8 12 million cases in the U.S. It is the most common inflammatory arthritis in the U.S. Obesity and longevity Cost: $26,000 per year for six attacks 1

2 Gout Gout patients have an average of four comorbidities: HT, Lipids, DM and CKD Hyperuricemia causes HT in animal models Hyperuricemiamay i prove to be an independent risk factor for atherosclerosis Gout appears to increase cardiovascular mortality Gout Causes Associated with hyperuricemia Rapid fluctuations of uric acid can trigger attacks Intercurrent illness, trauma or hospitalization i Diet: meat, seafood, high fructose corn syrup Alcohol: beer is worst, liquor is next Wine does not seem to raise uric acid levels Gout Diagnosis Gout diagnosis depends on the demonstration of MSU crystals in a joint or tophus May be presumed with the appropriate presentation Most common joints: 1 st MTP, small joints of the foot, ankle, knee Can occur in any joint Gout Treating the Acute Attack The sooner you can start treatment, the better Any NSAID, but in adequate doses; continue for two days after the attack has passed Colchicine 1.2 mg stat, then0 0.6 mg one hour later Prednisone 30 mg per day to taper over the length of time the attack has lasted Use reluctantly if attacks are becoming chronic, since rebound is likely Gout Treating the Acute Attack Intraarticular steroids are very effective Canakinumab??? FDA has safety concerns Anakinra 100 mg subcutaneously daily for three days Do not start or stop allopurinol in the midst of an attack 2

3 Gout Clinical Course Attacks separated in time, then becoming more frequent until the arthritis becomes chronic Chronic gouty arthritis is difficult to treat and is best prevented Explain this to your patients presenting with their first attacks Gout Prevention Allopurinol Reduces body urate pool Dissolves crystals Prevents gout attacks and improves quality of life Eating ten cherries for two days seems to decrease the frequency of attacks 35% Gout Prevention Do not start a urate lowering agent in the midst of an attack. Once the attack is over, start colchicine 0.6 mg bid and wait a week Then, start allopurinol 100 mg per day and recheck uric acid level in about two weeks While keeping the patient on colchicine, increase allopurinol in 100 mg increments every three weeks until uric acid < 6.0 Gout Prevention Maintain allopurinol dose. Do not stop if the patient flares Continue colchicine bid no more than six months Use with care in people p with reduced renal function Old data advising against using allopurinol in renal insufficiency no longer accepted Febuxostat 40 mg per day. Use only if the patient is allergic to allopurinol Gout Prevention and Treatment Pegylated Uricase 8 mg IV every two weeks for six months Dissolves tophi and reduces uric acid to almost zero Many infusion reactions Treat HT, obesity, and preserve renal function 3

4 Rheumatoid Arthritis Medicare 5 Star measure: 86% of patients diagnosed with should have picked up a prescription for a remittive agent These include: gold, penicillamine, doxycycline, methotrexate, sulfazine, leflunomide, Plaquenil, TNF inhibitors, Orencia, azathiprine, BUT NOT PREDNISONE OR NSAIDS EULAR/ACR CRITERIA FOR CLASSIFICATION OF PATIENTS: Classification criteria more specific than diagnostic criteria 6/10 points makes the diagnosis, as follows: 2 10 large joints involved gets 1 point 1 3 small joints gets 2 points 4 10 small joints gets 3 points >10 small joints gets 5 points Serologic positivity (either RF or CCP) Low positive gets 2 points High positive gets 3 points (> 3x uln) Elevated ESR or CRP gets 1 point Duration more than 6 weeks gets 1 point involved means either swollen or tender Large joints are shoulders, hips, knees, elbows and ankles Small joints are the metacarpophalangeal joints, proximal interphalangeal joints, second through fifth metatarsophalangeal joints, thumb interphalangeal joints, and wrists. Distal interphalangeal joints, first carpometacarpal joints, and first metatarsophalangeal joints are excluded from assessment. Differential: viral syndromes, hypermobility, fibromyalgia Tends to involve small joints of the hands and feet and produces AM stiffness and pain Treat early with remittive agents Avoid opiates Low doses of prednisone may help Plaquenil: 200 mg to 400 mg per day Works slowly Monitoring: Ocular Coherence Tomography once in the first five years of use, then yearly thereafter Methotrexate: 2.5 to 25 mg per week Works more quickly than Plaquenil Give with folate 1 mg per day to prevent side effects Side effects include oral ulcers, stomatitis, hair loss, pulmonary infiltrates, fl hepatic fb fibrosis and cytopenias Do not give to men or women contemplating conception wait four months after stopping to try No alcohol Monitor with ALT, CBC, and creatinine every 2 3 months 4

5 Leflunomide (Arava) 10 or 20 mg daily Similar to methotrexate in efficacy Side effects include diarrhea, hair loss and elevated LFTs Like methotrexate, can also be used for psoriatic arthritis Biologic agents excellent response with remarkably little toxicity VERY EXPENSIVE, in the range of $20,000 yearly Usually given with methotrexate Check PPD, HBsAg and CXR before starting SQ: etanercept, adalimumab, golimumab, IV: infliximab, abatacept (T cell co stimulation inhibitor), rituximab, tocilizumab (IL 6 inhibitor) Side effects are unusual: dissemination of TB, sepsis, lymphoma, injection site reactions Monitoring: yearly PPD Polymyalgia Rheumatica Female > Male Almost always older than 50 Temporal Arteritis NEVER occurs in people younger than 50 Achiness and stiffness, first in shoulder and then hip girdle, back of the neck, worst at night and the morning Abrupt onset Northern European ancestry PMR Differential is OA of the neck and low back Up to 40 percent of patients experience systemic signs or symptoms, including malaise, fatigue, depression, anorexia, weight loss, and fever. There may be a low grade anemia ESR may be above 40 mm/h (78 to 93 percent in some series), with some patients having values that can exceed 100 mm/h PMR Treatment is prednisone 20 mg per day Taper by 2.5 mg per month until at 10 mg, then by 1 mg per month l Relapses are common Don t forget calcium, vitamin dand bisphosphonate 5

6 Giant Cell Arteritis Symptoms: Cranial arteritis: headaches, scalp tenderness, ischemic optic neuropathy, jaw claudication, PMR B symptoms: fever, chills, night sweats, weakness, depression Large vessel GCA: arm claudication, pulselessness, Aortic aneurysm,pmr Can present as an FUO Prevalence 15 25/100,000 in Sweden; 1 2/100,00 in blacks and Hispanics Giant Cell Arteritis Symptoms most closely associated with a positive biopsy: 1. jaw claudication 2. tender, enlarged temporal artery on exam 3. diplopia GCA ESR is often very high, but up to 25% can have a normal ESR Diagnostic test is the TA biopsy Bilateral l biopsy only adds 3% additional i positives, so not necessary May get biopsy up to 2 weeks after starting treatment Up to 10% false negatives GCA Treatment: prednisone 40 to 60 mg per day for a month After one month, taper by 10% of the dose every one to two weeks until at 10 mg, then reduce by 1 mg per month If there is visual loss, 1 giv daily for three days, then as above 6