Rheumatology Updates for Primary Care Olympic Peninsula Medical Conference. Erin M. Bauer MD Rheumatology

Transcription

1 Rheumatology Updates for Primary Care Olympic Peninsula Medical Conference Erin M. Bauer MD Rheumatology November 2017

2 Objectives 1. Discuss common Rheumatology referrals and diagnoses 2. Describe initial work up (laboratory and radiographic) 3. Consider initial management approaches and recent updates in therapy 1. Gout 2. Rheumatoid Arthritis 3. Psoriatic Arthritis 4. Giant Cell Arteritis 2

3 Disclosures None 3

4 4 Lawrence-Wolff K, Hildebrand B, Monrad S, Ditmyer M, Fitzgerald J, Erickson A, Bass AR, Battafarano D ACR/ARHP Workforce Study in the United States: A Maldistribution of Adult Rheumatologists [abstract]. Arthritis Rheumatol. 2016; 68 (suppl 10). Accessed January 17, 2017.

5 Case 1 52 yo M with diabetes (Hgb A1c 6%), chronic kidney disease (GFR ~35), hypertension, congestive heart failure (EF 45%) presenting with right ankle pain for 2 days Meds: lisinopril, metoprolol, sitagliptin, pravastatin, aspirin 81 mg, furosemide Labs: CBC wnl, CMP notable for Cr 2.1, uric acid

6 Case 1 Could this be gout? - prior episodes of self limited joint pain/swelling (MTPs) - sudden onset - clear triggers - dietary, dehydration, medications - hx of kidney stones Could this be something else? - injury - infection - GC/bacterial, Lyme, fungal - travel hx - autoimmune inflammatory arthritis - sarcoid, IBD associated 6

7 Case 1 Hx: episodes a year of acute 1 st MTP pain/swelling lasting 5-7 days then self resolving/improve with NSAIDs - Woke him up from sleep, no clear trauma, no preceding infections - Recently started on furosemide Exam: Temp: 99 F BP: 135/90 HR: 95 Uncomfortable but not ill appearing No joint pain or swelling aside from ankle which is able to be fully ranged No rashes 7

8 Case 1 Work up: - attempt synovial aspirate - CBC, CMP, ESR/CRP - uric acid after flare resolved -? Blood cultures, HLA B27 - XRs (hands/feet ankles) Results: - CBC with normal white count - GFR at baseline of 35 - Uric acid: 7.7 8

9 Case 1 Management: Today: A. Prednisone 20 mg daily x 7 days B. Colchicine 1.2 mg x 1 then 0.6 mg 1 hour later C. Indomethacin 50 mg TID x 7 days 9

10 Case 1 Management: Today: A. Prednisone 20 mg daily x 7 days B. Colchicine 1.2 mg x 1 then 0.6 mg 1 hour later C. Indomethacin 50 mg TID x 7 days 10

11 Case 1 Management: Today: A. Prednisone 20 mg daily x 7 days B. Colchicine 1.2 mg x 1 then 0.6 mg 1 hour later C. Indomethacin 50 mg TID x 7 days After flare has resolved: A. Allopurinol 100 mg B. Allopurinol 100 mg, Colchicine 0.6 mg daily C. Fubuxostat 40 mg daily D. No further treatment 11

12 Case 1 Management: Today: A. Prednisone 30 mg daily x 7 days B. Colchicine 1.2 mg x 1 then Acute: 0.6 mg 1 hour later C. Indomethacin 50 mg TID x 7 days After flare has resolved: A. Allopurinol 100 mg B. Allopurinol 100 mg, Colchicine 0.6 mg daily C. Fubuxostat 40 mg daily D. No further treatment Renally dosed Colchicine: GFR >30: no adjustment GFR<30: no adjustment but do not redose for 2 wks Prophylaxis: GFR >30: no adjustment GFR <30: 0.3 mg daily No colchicine in dialysis Renally dosed Allopurinol GFR <30: start at 50 mg daily 12

13 Case 1 1 month later: Allopurinol 200 mg daily Colchicine 0.6 mg daily Uric acid GFR

14 Goal uric acid <5 in patients with: - gout arthropathy - tophi -? CKD Duration of prophylactic therapy: - 3 months after reaching goal in non-tophaceous gout - 6 months after goal in tophaceous gout 14

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16 Updates in gout management Medication Febuxostat (Uloric) Mechanism of action XO inhibitor Common SE Considerations for use Dosing Elevated LFTs Nausea Rash? MI Failed Allopurinol >800 mg Unable to tolerate Allopurinol HLA-B*5801 CKD4 + failed Allopurinol>500 mg 40 mg 80 mg?120 mg Lesinurad (Zurampic) Uric Acid Transporter 1 (URAT1) Inhibitor Headache GERD Cr elevation In combo ONLY with XOI Avoid in GFR< 45, hx of kidney stones 200 mg daily Pegloticase (Krystexxa) Urate-Oxidase (Recombinant) Rash Flu like illness Antibody formation Anaphylaxis Heavy tophus burden OK in severe renal impairment Avoid in G6PD deficiency 8 mg every 2 weeks 16

17 Gout Management Pearls Tophi/arthropathy Goal uric acid <5 Need prophylaxis for 6 months after reaching goal Start treatment after 1 flare No/mild CKD? After flare resolved: GFR <30 Colchicine 0.6 mg daily Start Allopurinol 100 mg daily and increase by 100 mg every 2-4 weeks until at goal After flare resolved: Colchicine 0.3 mg daily Start Allopurinol 50 mg daily and increase by 50 every 2-4 weeks until at goal Consider Febuxostat early 17

18 Case 2 56 yo M with psoriasis, HTN, DM2, Hep C and ischemic cardiomyopathy (EF 45%) presenting with joint pain in the fingers/hands, elbows and feet. Meds: lisinopril, metoprolol, sitagliptin, pravastatin, ASA 81, furosemide Labs: CBC wnl, CMP notable for Cr 1.5 HgbA1c: 6.5% 18 Slide courtesy Andrew J. Gross, MD

19 Case 2 Reason for consult: does this patient have psoriatic arthritis? - Hep C related arthralgia - Medications (sitagliptin) - Osteoarthritis - Neuropathy - Gout - Psoriatic arthritis

20 Case 2 HPI: - Psoriasis hx - Onset of joint pain: relation to meds, migratory? additive? - Distribution? - DIPs/PIPs - Inflammatory? - AM stiffness >60 mins - Improve with activity - Improve with NSAIDs - Back pain? Enthitis? Uveitis? Nail changes? - Family hx 20

21 Case 2 HPI: Psoriasis of the scalp, elbows/knees x 10 years (tx with occ topicals). 2-3 years of pain in his DIPs, PIPs, R elbow, L heel and low back. Has noticed occ swelling. Pain worse in AM, improves with heat/nsaids. Exam: Obese, NAD. Tender/swollen over b/l 3 rd, 4 th, and 5 th DIPs and 2 nd, and 4 th PIPs, R lateral epicondyle, R Achilles tendon insertion site. Swelling of several toes. Psoriatic rash ~10% BSA. Nail changes. 21

22 PsA Diagnosis 22

23 Case 2 Work Up Labs: ESR/CRP, Uric acid, RF/CCP, (Cryoglobulins), HIV, quant gold, Hep B Imaging: XRs hands/feet, knees and SI joints 23

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26 PsA Initial Management - NSAIDs if no contraindications - MTX (2.5 mg): 3 tabs PO q week x 2 weeks, if CBC/CMP OK increase by 2 tabs PO q 2-3 weeks up to 30 mg/wk. - Consider IM if GI intolerance - Check CBC/CMP q 3 months - Contraindications/Cautions: ILD, EtOH use, childbearing age, hepatic disease, renal insufficiency (GFR<50), malignancy - Weight loss, PT 26

27 PsA Updates Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA): Treatment Recommendations for Psoriatic Arthritis

28 PsA Updates 28

29 PsA Updates Medication Mechanism of action Common SE Monitoring Considerations Aprimilast (Otezla) PDE4 inhibitor PO BID Weight loss (20%) Diarrhea Weight Depression Secukinumab (Cosentyx) IL 17A monoclonal ab SQ q month Infection/TB reactivation IBD flare Ustekinumab (Stelara) IL 12/23 monoclonal ab SQ q 3 months Certolizumab (Cimzia) TNFi SQ q week Nausea Moderate to severe heart failure (NYHA Class III/IV) Malignancy Golimumab (Simponi) TNFi SQ q month IV q month Moderate to severe heart failure (NYHA Class III/IV) Malignancy Drug induced SLE LFTs q 3-6 mo 29

30 Case 3 64 yo F with hx of low back pain, hypertension and GERD who presents with 3 months of progressive pain in her PIPs, MCPs and wrists. Abrupt onset. Approx 60 mins of AM stiffness. Improves with heat and acetominophen. Meds: omeprazole, hydrochlorothiazide FHx: Mother with RA, sister with UC Soc Hx: Smokes 1 PPD, occ EtOH Labs: CBC/CMP wnl ESR: 49, CRP: 6, RF: negative 30

31 Case 3 Reason for consult: does this patient have rheumatoid arthritis? Does this patient have inflammatory arthritis? (Seronegative) RA PsA IBD associated arthritis AS Reactive arthritis OA Crystalline arthropathy (CPPD, gout) 31

32 Case 3 Fevers/chills Pleuritic chest pain/shortness of breath Nausea/vomiting Abdominal pain Diarrhea or constipation Blood in the stool Hx of uveitis Morning stiffness Muscle pain Focal weakness Numbness/tingling Rashes (psoriatic, EN) Preceding infections Unexpected weight loss/gain Oral/nasal/genital ulcers 32

33 Case 3 Work up: TSH/PTH CCP Hep C HIV HLA-B27 Uric Acid XRs Hands/Feet, SI joints 33

34 RA Management Initial Management: PO NSAIDs if not contraindicated Topical NSAIDs/lidocaine Low dose Prednisone (<15 mg) Hydroxychloroquine Methotrexate 34

35 RA Updates Medication Mechanism Side Effects Monitoring Abatacept (Orencia) Tocilizumab (Actemra) Tofacitinib (Xeljanz) Blocks T cell activation SQ / IV IL-6 inhibition SQ / IV JAK inhibitor PO Headache Nausea Abdominal pain Headache GI perforation URIs Zoster GI perforation Skin cancer HTN COPD CBC q 3 mo LFTs q 3 mo Lipids q 6 mo CBC q 3 mo LFTs q 3 mo Annual Derm 35

36 Most live vaccines OK for: MTX<20 mg weekly Prednisone<20 mg daily Imuran <100 mg daily 1 Ideally, provide 14 days before biologic initiation or wait 3 half-lives after stopping biologic therapy 2 Administer 4 weeks before biologic initiation or wait 3 half-lives after stopping biologic therapy 3 To ensure minimal immunosuppression (reduce risk of infection) and optimal vaccine response: recommend waiting 3 half-lives after stopping biologics to give live vaccines. 36

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38 Case 4 87 yo F with hx of HTN, diabetes who presents with 2 weeks of L sided headaches (primarily L sided, throbbing, minimal improvement with Tylenol) and fever. Labs: Hgb of 10.9, ESR: 97, CRP: 30 38

39 Case 4 Patient over the age of 50 who complains of or is found to have: New headaches Abrupt onset of visual disturbances Symptoms of polymyalgia rheumatica Jaw claudication: presence of jaw claudication has PPV of 78 percent Unexplained fever or anemia High ESR and/or CRP 39

40 Short term work up/management: - Prednisone mg daily - Temporal artery bx w/in 2 weeks - sensitivity 85% - specificity 94% - bilateral catches an additional 10% -? Imaging (MRI/A, PET, US) - Rheumatology referral Longer term management: - Slow prednisone taper - Patient education - PJP ppx - Bone health - Annual CXR x 10 years and AAA screen x 1 -?ASA 81 mg - MTX, TCZ 40

41 Patient Education American College of Rheumatology: Caregiver Arthritis Foundation: Creaky Joints: Lupus Foundation: 41

42 Questions? Phone: (206) Fax: (206) Pager: (206)

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