First Presentation of Joint Pain Andrew Harrison Rheumatologist Wellington Regional Rheumatology Unit, HVDHB Bowen Centre, Crofton Downs, Wellington Assoc. Prof. in Medicine, University of Otago Wellington Clinical Leader, Research, CCDHB
Disclosures Advisory board member for AbbVie NZ and Pfizer NZ Research grants from Roche and Abbvie Sponsorship to attend conferences from AbbVie, Roche and Pfizer Consultancy work for AbbVie to develop educational materials for GPs and rheumatologists
Disclaimer No qualifications or experience in primary care
Learning Objectives To provide a structured approach to the assessment of newonset arthritis To review the important data needed to inform diagnosis and prognosis To understand the influence of different patterns of clinical and laboratory features on diagnosis and prognosis To recognise the cases that require urgent referral and/or treatment to optimise long-term outcome
Why Bother?
Why Bother?
Rationale for Early Immunomodulatory Treatment In RA, early use of corticoteroids improves long-term outcome DMARDs reduce symptoms reduce erosive progression reduce need for NSAIDs and long-term corticosteroids Early treatment associated with drug-free remission
A Diagnostic Algorithm Joint symptoms? inflammatory? non-inflammatory Pain helped by activity worse with activity Stiffness prolonged short-duration Restricted movement helped by activity fixed Swelling soft tissue hard tissue
A Diagnostic Algorithm Joint symptoms? inflammatory? non-inflammatory Pain helped by activity worse with activity Stiffness prolonged short-duration Restricted movement helped by activity fixed Swelling soft tissue hard tissue? mechanical? degenerative? neuropathic OA soft tissue syndromes FMS
A Diagnostic Algorithm Joint symptoms? inflammatory? non-inflammatory Pain helped by activity worse with activity Stiffness prolonged short-duration Restricted movement helped by activity fixed Swelling soft tissue hard tissue? mechanical? degenerative? neuropathic OA soft tissue syndromes FMS Small joint / distal? objective synovitis swelling/tenderness MTP squeeze RA PsA ReA CTD viral OA haemochromatosis vasculitis: HSP / GPA
A Diagnostic Algorithm Joint symptoms? inflammatory? non-inflammatory Pain helped by activity worse with activity Stiffness prolonged short-duration Restricted movement helped by activity fixed Swelling soft tissue hard tissue? mechanical? degenerative? neuropathic OA soft tissue syndromes FMS Small joint / distal Large joint / proximal? objective synovitis swelling/tenderness MTP squeeze RA PsA ReA CTD viral OA haemochromatosis vasculitis: HSP / GPA Limb girdle Consider PMR OA shoulders/hips soft tissue syndromes statin myopathy RA
A Diagnostic Algorithm Joint symptoms? inflammatory? non-inflammatory Pain helped by activity worse with activity Stiffness prolonged short-duration Restricted movement helped by activity fixed Swelling soft tissue hard tissue? mechanical? degenerative? neuropathic OA soft tissue syndromes FMS Small joint / distal? objective synovitis swelling/tenderness MTP squeeze Limb girdle Large joint / proximal Knee/ankle RA PsA ReA CTD viral OA haemochromatosis vasculitis: HSP / GPA Consider PMR OA shoulders/hips soft tissue syndromes statin myopathy RA SpA PsA / ReA OA knee/ankle sarcoidosis polyarticular gout pseudogout RA undifferentiated
A Diagnostic Algorithm Joint symptoms? inflammatory? non-inflammatory Pain helped by activity worse with activity Stiffness prolonged short-duration Restricted movement helped by activity fixed Swelling soft tissue hard tissue? mechanical? degenerative? neuropathic OA soft tissue syndromes FMS Small joint / distal Large joint / proximal Axial? objective synovitis swelling/tenderness MTP squeeze Limb girdle Knee/ankle? Inflammatory back pain? SI / heel / costochondral RA PsA ReA CTD viral OA haemochromatosis vasculitis: HSP / GPA Consider PMR OA shoulders/hips soft tissue syndromes statin myopathy RA SpA PsA / ReA OA knee/ankle sarcoidosis polyarticular gout pseudogout RA undifferentiated ankylosing spondylitis psoriatic SpA enteropathic SpA Reactive SpA degenerative spinal disease non-specific back pain
A Diagnostic Algorithm Joint symptoms? inflammatory? non-inflammatory Pain helped by activity worse with activity Stiffness prolonged short-duration Restricted movement helped by activity fixed Swelling soft tissue hard tissue? mechanical? degenerative? neuropathic OA soft tissue syndromes FMS Small joint / distal Large joint / proximal Axial? objective synovitis swelling/tenderness MTP squeeze Limb girdle Knee/ankle? Inflammatory back pain? SI / heel / costochondral RA PsA ReA CTD viral OA haemochromatosis vasculitis: HSP / GPA Consider PMR OA shoulders/hips soft tissue syndromes statin myopathy RA SpA PsA / ReA OA knee/ankle sarcoidosis polyarticular gout pseudogout RA undifferentiated ankylosing spondylitis psoriatic SpA enteropathic SpA Reactive SpA degenerative spinal disease non-specific back pain
Effective Use of Investigations
Effective Use of Investigations
Effective Use of Investigations
Effective Use of Investigations
Effective Use of Investigations
Effective Use of Investigations
Effective Use of Investigations
A Diagnostic Algorithm Joint symptoms? inflammatory? non-inflammatory Pain helped by activity worse with activity Stiffness prolonged short-duration Restricted movement helped by activity fixed Swelling soft tissue hard tissue? mechanical? degenerative? neuropathic OA soft tissue syndromes FMS Small joint / distal Large joint / proximal Axial? objective synovitis swelling/tenderness MTP squeeze Limb girdle Knee/ankle? Inflammatory back pain? SI / heel / costochondral RA PsA ReA CTD viral OA haemochromatosis vasculitis: HSP / GPA Consider PMR OA shoulders/hips soft tissue syndromes statin myopathy RA SpA PsA / ReA OA knee/ankle sarcoidosis polyarticular gout pseudogout RA undifferentiated ankylosing spondylitis psoriatic SpA enteropathic SpA Reactive SpA degenerative spinal disease non-specific back pain
Effective Use of Investigations
Effective Use of Investigations
Effective Use of Investigations
Effective Use of Investigations
Effective Use of Investigations
Effective Use of Investigations
A Diagnostic Algorithm Joint symptoms? inflammatory? non-inflammatory Pain helped by activity worse with activity Stiffness prolonged short-duration Restricted movement helped by activity fixed Swelling soft tissue hard tissue? mechanical? degenerative? neuropathic OA soft tissue syndromes FMS Small joint / distal Large joint / proximal Axial? objective synovitis swelling/tenderness MTP squeeze Limb girdle Knee/ankle? Inflammatory back pain? SI / heel / costochondral RA PsA ReA CTD viral OA haemochromatosis vasculitis: HSP / GPA Consider PMR OA shoulders/hips soft tissue syndromes statin myopathy RA SpA PsA / ReA OA knee/ankle sarcoidosis polyarticular gout pseudogout RA undifferentiated ankylosing spondylitis psoriatic SpA enteropathic SpA Reactive SpA degenerative spinal disease non-specific back pain
Effective Use of Investigations
Effective Use of Investigations
Effective Use of Investigations
Effective Use of Investigations
Effective Use of Investigations
Effective Use of Investigations
Effective Use of Investigations
A Diagnostic Algorithm Joint symptoms? inflammatory? non-inflammatory Pain helped by activity worse with activity Stiffness prolonged short-duration Restricted movement helped by activity fixed Swelling soft tissue hard tissue? mechanical? degenerative? neuropathic OA soft tissue syndromes FMS Small joint / distal Large joint / proximal Axial? objective synovitis swelling/tenderness MTP squeeze Limb girdle Knee/ankle? Inflammatory back pain? SI / heel / costochondral RA PsA ReA CTD viral OA haemochromatosis vasculitis: HSP / GPA Consider PMR OA shoulders/hips soft tissue syndromes statin myopathy RA SpA PsA / ReA OA knee/ankle sarcoidosis polyarticular gout pseudogout RA undifferentiated ankylosing spondylitis psoriatic SpA enteropathic SpA Reactive SpA degenerative spinal disease non-specific back pain
Effective Use of Investigations
Effective Use of Investigations
Effective Use of Investigations
Effective Use of Investigations
Effective Use of Investigations - Summary Base the choice of tests on the differential diagnosis Different patterns of presentation require different tests Avoid requesting irrelevant tests
Determining Urgency Rationale for early immunomodulatory treatment In RA, early use of corticoteroids improves long-term outcome DMARDs reduce symptoms reduce erosive progression reduce need for NSAIDs and long-term corticosteroids Early treatment associated with drug-free remission Urgency of treatment or referral determined by prognostic indicators value of early intervention potential consequences of delaying treatment current impact on patient
A Diagnostic Algorithm Joint symptoms? inflammatory? non-inflammatory Pain helped by activity worse with activity Stiffness prolonged short-duration Restricted movement helped by activity fixed Swelling soft tissue hard tissue? mechanical? degenerative? neuropathic OA soft tissue syndromes FMS Small joint / distal Large joint / proximal Axial? objective synovitis swelling/tenderness MTP squeeze Limb girdle Knee/ankle? Inflammatory back pain? SI / heel / costochondral RA PsA ReA CTD viral OA haemochromatosis vasculitis: HSP / GPA Consider PMR OA shoulders/hips soft tissue syndromes statin myopathy RA SpA PsA / ReA OA knee/ankle sarcoidosis polyarticular gout pseudogout RA undifferentiated ankylosing spondylitis psoriatic SpA enteropathic SpA Reactive SpA degenerative spinal disease non-specific back pain
Determining Urgency Small joint / distal inflammatory symptoms poor functional status objective synovitis MCP/MTP squeeze test extra-articular features (including systemic) acute phase response Rheumatoid factor and/or anti-ccp other lab features (e.g. ANA/ENA/dsDNA, ANCA/MPO/PR3)
A Diagnostic Algorithm Joint symptoms? inflammatory? non-inflammatory Pain helped by activity worse with activity Stiffness prolonged short-duration Restricted movement helped by activity fixed Swelling soft tissue hard tissue? mechanical? degenerative? neuropathic OA soft tissue syndromes FMS Small joint / distal Large joint / proximal Axial? objective synovitis swelling/tenderness MTP squeeze Limb girdle Knee/ankle? Inflammatory back pain? SI / heel / costochondral RA PsA ReA CTD viral OA haemochromatosis vasculitis: HSP / GPA Consider PMR OA shoulders/hips soft tissue syndromes statin myopathy RA SpA PsA / ReA OA knee/ankle sarcoidosis polyarticular gout pseudogout RA undifferentiated ankylosing spondylitis psoriatic SpA enteropathic SpA Reactive SpA degenerative spinal disease non-specific back pain
Determining Urgency Large joint / proximal limb girdle inflammatory symptoms poor functional status extra-articular features (including systemic) GCA symptoms visual, jaw claudication acute phase response
A Diagnostic Algorithm Joint symptoms? inflammatory? non-inflammatory Pain helped by activity worse with activity Stiffness prolonged short-duration Restricted movement helped by activity fixed Swelling soft tissue hard tissue? mechanical? degenerative? neuropathic OA soft tissue syndromes FMS Small joint / distal Large joint / proximal Axial? objective synovitis swelling/tenderness MTP squeeze Limb girdle Knee/ankle? Inflammatory back pain? SI / heel / costochondral RA PsA ReA CTD viral OA haemochromatosis vasculitis: HSP / GPA Consider PMR OA shoulders/hips soft tissue syndromes statin myopathy RA SpA PsA / ReA OA knee/ankle sarcoidosis polyarticular gout pseudogout RA undifferentiated ankylosing spondylitis psoriatic SpA enteropathic SpA Reactive SpA degenerative spinal disease non-specific back pain
Determining Urgency Large joint / proximal knee and ankle inflammatory symptoms poor functional status extra-articular features (including systemic) acute phase response (less important) need for arthrocentesis
A Diagnostic Algorithm Joint symptoms? inflammatory? non-inflammatory Pain helped by activity worse with activity Stiffness prolonged short-duration Restricted movement helped by activity fixed Swelling soft tissue hard tissue? mechanical? degenerative? neuropathic OA soft tissue syndromes FMS Small joint / distal Large joint / proximal Axial? objective synovitis swelling/tenderness MTP squeeze Limb girdle Knee/ankle? Inflammatory back pain? SI / heel / costochondral RA PsA ReA CTD viral OA haemochromatosis vasculitis: HSP / GPA Consider PMR OA shoulders/hips soft tissue syndromes statin myopathy RA SpA PsA / ReA OA knee/ankle sarcoidosis polyarticular gout pseudogout RA undifferentiated ankylosing spondylitis psoriatic SpA enteropathic SpA Reactive SpA degenerative spinal disease non-specific back pain
Determining Urgency Axial inflammatory symptoms poor functional status HLA-B27+ acute phase response
Early Interventions Suspected RA evidence to support early use of corticosteroids e.g. prednisone 20 mg daily tapering over 4 8 weeks while awaiting results or assessment for DMARDs
Early Interventions Suspected RA evidence to support early use of corticosteroids e.g. prednisone 20 mg daily tapering over 4 8 weeks while awaiting results or assessment for DMARDs Can also be applied to other peripheral inflammatory arthritides, e.g. PsA, ReA, viral
Early Interventions Suspected vasculitis multisystem inflammatory disease: neuro, renal, resp, skin joint discuss with rheumatologist before treating photographs can help
Early Interventions Suspected vasculitis multisystem inflammatory disease: neuro, renal, resp, skin joint discuss with rheumatologist before treating photographs can help Suspected GCA discuss with rheumatology registrar immediately if unable to contact, prednisone can be started before biopsy ideally CRP and ESR before stating treatment biopsy within 3 weeks of commencement of prednisone
Early Interventions Suspected vasculitis multisystem inflammatory disease: neuro, renal, resp, skin joint discuss with rheumatologist before treating photographs can help Suspected GCA discuss with rheumatology registrar immediately if unable to contact, prednisone can be started before biopsy ideally CRP and ESR before stating treatment biopsy within 3 weeks of commencement of prednisone Suspected PMR prednisone 15 mg daily 1/52, then 12.5 mg 1/52, then 10 mg reducing by 1 mg every 2/52 to 5 mg
Early Interventions Suspected gout three options: NSAIDs, colchicine, prednisone colchicine regimen: 1 g stat and 0.5 mg 1 hour later
Early Interventions Suspected ankylosing spondylitis / axial spondyloarthritis Full dose long acting NSAID nocte to bd refer for confirmation of diagnosis and monitoring corticosteroids seldom used Suspected OA can mimic inflammatory arthritis NSAIDs now favoured over paracetamol
Summary early intervention can reduce the long-term impact of inflammatory arthritis different patterns of involvement require different investigations urgency for intervention determined by clinical and laboratory features treatment can be started before diagnosis is confirmed.