Rheumatology for the Nurse Practitioner. Mary Derlacki, FNP Eugene Rheumatology

Transcription

1 Rheumatology for the Nurse Practitioner Mary Derlacki, FNP Eugene Rheumatology

2 Financial Relationships Amgen Genentech AbbVie

3 IS THIS LUPUS? S.T. is a 45 y/o woman with 9 months of joint pain, fatigue, Raynaud's, and morning stiffness. Involved joints are shoulders, knees, and hands at the PIP joints. Feel swollen to her. Morning stiffness is 15 min. Sleep is poor. Global pain... run over head to toe Worried she has Lupus, Sister has RA.

4 LABS Positive ANA of 1:80 with negative reflex CBC: normal Urinalysis: no protein or casts Sed rate: 18

5 PHYSICAL EXAM Hands tender at PIP with trace swelling by touch, not by sight Right shoulder tender at end of ROM No Raynaud's on visual exam Segmented demarcation is the key Tender points consistent with Fibromyalgia Must always evaluate for Fibro

6 CRITERIA FOR LUPUS 4 of 11 at any time Butterfly rash: spares nasolabial fold, scarring, fixed Oral/Nasal ulcers: painless Photosensitivity: Itchy skin rash or nausea/headache Arthritis: not arthralgia...2+ swollen and tender Hematologic: WBC<4000 x2, Neutrophils <1500 x2 Platelets<100K, Hemolytic anemia+ Autoantibodies: ANA+, dsdna+ or Sm+ Renal: Proteinuria 3+ or more, red cell casts Serositis: Pleurisy or Pericarditis

7 Photo of Butterfly rash

8 Antinuclear antibody: ANA Negative ANA excludes Lupus Positive ANA lacks specificity malignancies, infectious diseases, aging and gender, and relatives with Rheumatic Disease False-positive ANAs occur At 1:40 32% At 1:80 13% At 1:320 3% Clinically significant titers are usually >1:160 The ANA is a screening test, not a diagnosis

9 DOES SHE HAVE LUPUS? NO Osteoarthritis, Raynaud's, Fibromyalgia, Shoulder Bursitis and... +ANA

10 TREATMENT Treat the Fibromyalgia as it will confuse and confound the diagnosis! Meloxicam 15mg QD Nortryptyline 10-75mg HS Shoulder injection, Physical therapy Raynaud's: Heat the core, acupuncture, Rx See her back in 2 months

11 Lupus is a diagnosis of clinical signs and symptoms and laboratory findings Laboratory values SUPPORT Physical Findings not vice versa

12 PMR: A Diagnosis by Constellation

13 Polymyalgia Rheumatica (PMR) Age 55 and over Elevated Sed Rate >55, often over 75 Uncommon in Non Caucasian Proximal Girdle stiffness and pain which is abrupt, symmetric and profound Systemic illness with weight loss, fatigue, flu like symptoms

14 POLYMYALGIA RHEUMATICA Women:Men 2:1 Pain at night is common Distribution pattern: shoulders and hip girdle with Quad/hamstrings Screen for Giant Cell Arteritis symptoms 15% coexist Headache, Scalp pain, Jaw/Tongue pain, Visual changes:dim Dark Double, Fainting

15 PREDNISONE The Double Edge Sword... 10mg is Diagnostic and Therapeutic Rarely need 15mg, Avoid 20mg 10mg QD for 3 months, then slow taper by 1mg per month to 7mg, then by 0.5mg per month...slow is best! Average length of use is months

16 POLYMYALGIA RHEUMATICA Adjust Prednisone dose based on Return of Symptoms Not ESR Protect against Osteoporosis Rx Bisphosphonate all women and men over 70 Vit D 40mg/dL and above

17 PSEUDOGOUT AKA Pseudo Rheumatoid Calcium Pyrophosphate Crystals Wrist MCP/PIP 2-3 Mother/Daughter Knees Many are asymptomatic for decades 30% of people over 75 Trauma/Overuse can bring on first flare

18 PSEUDOGOUT Rapid onset with peak in 36 hours 7-10 day duration Complete resolution between flares

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23 PSEUDOGOUT Mimic Septic Arthritis Orthopedic Emergency! Diagnosis by Joint Aspiration Treatment: NSAIDS, colchicine 0.6 x 5 HS Prednisone 40mg/day & taper Colchicine 0.6 QD prevents frequent flares

24 RHEUMATOID ARTHRITIS CHRONIC More than 6 weeks ADDITIVE Lacks complete resolution between flares SYMMETRICAL One side may be dominant, but both affected INFLAMMATORY Synovitis

25 RHEUMATOID ARTHRITIS Criteria for RA...3 or more joints +RF and/or CCP Elevated ESR or CRP More than 6 weeks Morning stiffness is NOT official criteria, But often profound and > 60min Night time waking DUE TO pain is common

26 RHEUMATOID ARTHRITIS LABORATORY VALUES Rheumatoid Factor RF+ is not diagnostic! 20-25% are false positive Hepatitis C, Close relative, Age, Gender Anti-cyclic citrullinated peptide +CCP 5-8% are false positive Usually not seen in Hep C

27 RHEUMATOID ARTHRITIS LABORATORY VALUES CBC is very helpful! Anemia, mild and normocytic Thrombocytosis with inflammation Leukocytosis, mild

28 RHEUMATOID ARTHRITIS TREATMENT IN YOUR OFFICE Short term, high dose NSAIDS with GI protection for 2-4 weeks Diclofenac 50 TID or 75 BID + Omeprazole Flurbuprofen 100 BID-TID + Omeprazole 20 Naproxen 500 BID-TID + Omeprazole 20 Ibuprofen TID + Omeprazole 20

29 RHEUMATOID ARTHRITIS PREDNISONE...Good News! LOW dose effective in RA 4mg Prednisone BID Can use with Meloxicam 15mg Or Celebrex 200 BID Protect GI with Omeprazole 20 May take 5-7 days to begin working

30 RHEUMATOID ARTHRITIS PREDNISONE...Bad News! Can effectively mask all symptoms of RA Must taper off Prednisone before a reliable diagnosis can be made Creates more confusion for patient and NP Please call for urgent work-in!

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32 FIBROMYALGIA Primary Fibro is Diagnosis of Exclusion Secondary Fibro is VERY common in Rheumatology Widespread pain, head to toe... Feel like I've been run over or beat up

33 FIBROMYALGIA Disorder of pain regulation via the Central Nervous System...my favorite! Fight or Flight was turned on, Never turned off... Cure for Fibro is to Fight or Flight...exercise! Regular exercise flips brain into Rest and Digest

34 FIBROMYALGIA Regular Exercise...10 min a day! Deep, restorative Sleep Eliminate Caffeine, Alcohol, Sugar Myofascial Release, Acupuncture, Massage

35 FIBROMYALGIA Meloxicam 15mg QD for global aches Nortriptyline 10mg at HS, increase by 10mg every 2-3 nights till sleeping deeper Sleep first, global pain relief in 3-4 weeks Usual dose is 20-75mg. Split dose helps fall asleep and stay asleep 10mg at Supper and 20mg at Bedtime

36 FIBROMYALGIA Tizanadine 4mg HS for flare, May use up to TID If Nortriptyline is too sedating, use Doxepin If Nortriptyline is no help at 100mg, Switch to Amytriptyline 25mg 1-2 with Supper and 1-2 HS Recheck in 2 months and fine tune plan

37 FIBROMYALGIA Gabapentin 100 to start then up to 3000mg Lyrica 25mg to start then up to 450mg IT IS OUR DUTY TO TREAT FIBROMYALGIA IN ALL RHEUMATIC DISEASES

38 CONCLUSION GROWING NEED FOR MORE NP in RHEUMATOLOGY INTELLECTUALLY STIMULATING FIELD OF IMMUNOLOGY IS EXPLODING! HANDS ON APPROACH TO EXAMS, JOINT INJECTIONS, TRIGGER POINTS LONG TERM RELATIONSHIPS GIVE PATIENTS COUNSELING/ADVICE INTERSECTS WITH EVERY OTHER SPECIALITY IN MEDICINE WE TRANSFORM PEOPLE'S LIVES WE MAKE A DIFFERENCE

39 MARY DERLACKI, FNP X Text or Call mderlacki@comcast.net Eugene Rheumatology 132 E. Broadway #830 Eugene, OR 97401