Mary Derlacki, FNP. No financial relationships to disclose. Office Rheumatology for the Nurse Practitioner. Rheumatoid Arthritis

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1 Office Rheumatology for the Nurse Practitioner Mary Derlacki, FNP Drs. Cassell and Boren Eugene, OR No financial relationships to disclose Rheumatoid Arthritis 1% of North Americans Females>Males 3:1, age Prefers hands, wrists, feet, ankles, knees MCP 1,2,3 hands MTP 4,5 feet Extra articular symptoms include fatigue, weight loss, dry eyes/mouth,rheumatoid nodules, pleurisy, pericarditis, pulmonary fibrosis and vasculitis. CHRONIC, SYMETRIC, ADDITIVE, INFLAMMATORY 1

2 Psoriatic Arthritis 0.1% in United States 5-7% of people with psoriasis will get arthritis Psoriasis first, 70%; Arthritis first 15%; occur together 15% Mono or Oligo asymmetric presentation with preference for lower extremity Knees, ankles, SI joints, wrists Dactylitis, nail pitting, tendonitis, enthesitis Erosive Osteoarthritis Subset of osteoarthritis which occurs primarily in women > 50 Often misdiagnosed as RA Labs are negative: ESR, RF, ANA Hands: DIP, PIP, first CMC Feet: first MTP No Systemic Infammatory symptoms 2

3 Systemic Lupus Prevalence 1 in 2000 Women to Men 8:1 Influenced by Estrogen 2 to 4 times higher in Blacks, Latinos, and Asians Systemic illness with fever, weight loss, fatigue, anemia, leukopenia, arthritis, depression, sun sensitivity, rash, hair loss Lupus is not diagnosed by a blood test Polymyalgia Rheumatica (PMR) Age 50 and over Women to Men 2:1 Uncommon in Black, Latino, Asian and Native American Proximal Girdle stiffness and pain which is insidious, symmetric and profound Systemic illness with weight loss, fatigue, anorexia, depression Fever is rare unless associated with GCA ESR and CRP Laboratory Tests Elevated with inflammatory illness: RA, PsorA, SLE, PMR Not with OA High sensitivity CRP (hs CRP) is not useful Rheumatoid Factor: RF 70% sensitivity, 80% specific Associated with more severe disease, but titer does not correlate with disease activity False positive seen with Hepatitis C and B, HIV, lymphoma, Lupus, Sjogren's 3

4 Laboratory Tests Anti-cyclic citrullinated peptide: anti-ccp 80% sensitive, 96% specific Rarely seen in Psoriatic Arthritis, SLE, Hepatitis C CBC can be very helpful Anemia and thrombocytosis occur with inflammatory disease Leukopenia and thrombocytopenia often occur in systemic Lupus Laboratory Tests Antinuclear antibody: ANA A negative ANA excludes Lupus in > 95% cases A positive ANA lacks specificity; also seen in malignancies, infectious diseases, aging and relatives of Lupus patients 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 Laboratory Tests ANA patterns...speckled, Homogenous, etc Not useful; an out dated method of diagnosis Specific Antibodies found in Lupus dsdna 60% specific for Lupus Chromatin 70% specific for Lupus Sm, RNP, SSA and Histone also seen in Lupus 4

5 2 Minute Exam Location Symmetry Synovitis vs Thickening Don't trust your eyes Lateral Squeeze Skin, Nails, Nodules? Do they appear ill or well? Case Study #1 42yr old White female, works as waitress, mother of 3, smoker 2 month history of hand and wrist pain. Hands fall asleep at night. Pain wakes her up at night. Hard to make a fist in the morning for 1 hour. Now feet and ankles hurt. Feels like I'm walking on marbles first thing in the morning. Complains of excessive fatigue, feels like she has the flu, weight loss of 7 lbs. Ibuprofen 400 TID no help. Hydrocodone 5/500 barely takes the edge off. Getting harder to do her job, fears she may lose her position. Case Study # 1 Exam: Tender MCP, PIP R/L with mild synovitis. Tender wrists with full ROM; guards the joints. Shoulders tight with ROM. MTP R/L tender with lateral squeeze. No fibromyalgia. Labs: Hct 32%, Platelets 498,000; ESR 42, RF 52, Anti-ccp 15. ANA 1:40, Hepatitis C negative Diagnosis: Early seropositive Rheumatoid Arthritis 5

6 Case Study #1 WHAT CAN YOU DO IN YOUR OFFICE? Stop Ibuprofen. Start Naproxyn 500 TID or Diclofenac 75 BID or Celebrocoxin 200 TID. Add Omeprazole 20 QAM to prevent GI bleed. Single injection of steroid into a large joint can bring relief to all joints. Avoid Prednisone! If you absolutely must, no more than 5mg BID. RA responds to low dose prednisone. Treat the sleep disruption with Nortriptyline, Amitriptyline, Trazadone, etc. Case Study #2 34 yr old Latino woman with 8 months of bilateral shoulder pain, hip pain, fatigue, myalgias, hair loss, mouth sores and depression. Intermittent fever of Feels stiff and sore all day. Not sleeping well. Mother has Lupus. Naproxyn 220 BID no help. Acetomeniphen PM helps a little with sleep, still feels tired in AM. Exam: No pain or swelling hands, wrists or feet R/L. Decreased ROM with tenderness in shoulders R/L. Trochanteric and gluteus medius bursitis R/L. Knees tender, no swelling, redness or warmth. Fibromyalgia present. Case Study #2 Labs: Hct 33%, Platelets 113,000; ESR 27, CRP 1.5. RF 30, CCP 0.1 ANA 1:640 with ds DNA 62. SSA/SSB weakly positive. Hepatitis C negative. Diagnosis: Lupus, Fibromyalgia, Bursitis WHAT CAN YOU DO IN YOUR OFFICE? Treat pain, sleep and muscle tightness with Meloxicam 15 QD and Nortriptyline 10-75mg at HS, or split between dinner and bedtime. Inject Shoulder and hip bursitis with Depomedrol 40 plus 1% Lidocaine. Heat and stretch. Don't start Prednisone! 6

7 Case Study #3 42 yr old White female with widespread aches and pains. Hurts to sleep on side, hurts to walk. Hands ache with use. Feet hurt if standing or walking. Low back pain interferes with her ability to work or perform regular house duties. Back pain worse with standing, better with sitting. No night time back pain. Sleep is poor. Morning stiffness is min. Ibuprofen and Naproxyn cause GI upset. Acetomeniphen 500 BID no help. Hydrocodone 10/325QID makes pain better but still present. Case Study #3 Exam: Tender at all joints but no synovitis, redness or warmth. Tender with full ROM at shoulders and hips. Bilateral lumbar tenderness, normal flexion. Trochanteric, Gluteus medius bursitis R/L. Fibromyalgia present on exam. Labs:CBC, ESR,CRP, RF and CCP all negative or normal. ANA 1:40, panel negative. Diagnosis: Bursitis, Fibromyalgia with a weakly positive ANA. Possible Lumbar Spinal Stenosis. Case Study #3 WHAT CAN YOU DO IN YOUR OFFICE? Meloxicam 15 mg QD or Tylenol 1000 QID Treat sleep disorder with Nortriptyline HS or split between dinner and bedtime. Physical therapy if affordable. Monitor ANA, but this is not a rheumatic disease...yet. 7

8 The Role of Complimentary Medicine in Rheumatology More than 50% of patients use some type of complimentary medicine such as supplements, chiropractic treatments, massage, acupuncture, and faith healing. All supplements affect the biochemistry of the body Grandma Advice to help the immune system Illness as an agent of Change Summary Diagnose an inflammatory arthritis by... Location, Location, Location Feeling synovitis...don't trust your eyes Morning stiffness >30 min Systemic symptoms such as weight loss, anemia, fever, excessive fatigue Treat the patient, not the lab test...but follow the labs Treat underlying sleep disorder Call me if you have any questions! 8

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

Rheumatology for the Nurse Practitioner Mary Derlacki, FNP Eugene Rheumatology Financial Relationships Amgen Genentech AbbVie IS THIS LUPUS? S.T. is a 45 y/o woman with 9 months of joint pain, fatigue,