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Brian J. Keroack, MD, FACP, FACR
Small Feedings of the Mind: Rheumatology
Question #1: What do I REALLY need to
know?English measured concordance rate between
Rheumatologist and Internist before and 6 months after spending a day with a Rheumatologist.
Before 0.4 (F) after 0.9 (A-)Two things stood out: First can you ask an intelligible
question about morning stiffness and Second can you find joint swelling (synovitis)
Inflammatory Arthritis is what you do not want to miss.1.5% of the US has Rheumatoid Arthritis, others of note
include Psoriatic Arthritis, Ankylosing Spondylitis. If you are to stand a chance there are certain TOOLS that
you will needNO NOT THE LAB!!!!
Location, Location, Location
It takes me till 11AM to…or, I just don’t get it I was splitting wood 4 weeks ago now I have trouble brushing my teeth
I have all these bumps and I cannot make a fist anymore. If symptomatic; use related
DIP JOINTS
Second/third MCP
Progression of Rheumatoid Arthritis
Make the diagnosis HERE SYNOVITIS NOT HERE
What’s left after the fire
Listen to the patient—they will tell you the diagnosis: William Osler
Age <40. Worst in AM. Pain IMPROVED by exercise not relieved by rest.
Need to file for disability cannot even lift a gallon of milk. Sharp/Mechanical Symptoms—Please don’t check HLA-B27
Case 27 year old male has had back
aching for 3 years. He states that the pain is worst in the morning and occasionally wakes him at night. He takes 600 mg Ibuprofen TID and ‘never misses a pill’. He almost cancelled the appointment because changing jobs from telemarketing to landscaping has improved his symptoms
Examination: Decreased side bend cervical spine at 30 degrees. Schober=2.5 cm (what is this?)
Most Psoriasis Patients Don’t have
Psoriatic Arthritis, But…
Note AsymmetryTenosynovitis dominates in Dactylitis
Dactylitis
Nails
Clinical Enthesitis (Spondyloarthropathy)
psoriasis
Achilles enthesitis
Psoriatic Arthritis “Enthesitis”Gutierrez, Grassi: Clin Rheumatology: (2010) 29: 133-42
Achilles
Erosion calcaneus+doppler
Medical Management: Immunosupressives 80 year old female with Rheumatoid Arthritis on
Enbrel. She presents to the ED with nausea having vomited once. Afebrile, no other symptoms. She is alert. Presumed viral gastroenteritis. 24 hours later she is delirious and has a BP of 60/40 with a HR of 121.
DiagnosisGram Negative sepsis from Urinary tract
infectionI’ve got at least 7 more stories like thisWhen these patients present they have a
greater burden of illness and FEWER symptoms
Plethora of ‘TOOLS”TNF- BlockadeIL-1 RAIL-6 Receptor BlockerIL-12/IL-23 (Stelara)IL-17 (coming soon)This category is
associated with standard bacterial infections
However, when patients do present they will be further along and will have fewer (more subtle symptoms)
?No Fever, ? No Cough, No Dysuria—makes it much more difficult
Change in Total Sharp ScorePREMIER
.
1.9
5.5
10.4
1.30.8
3.02.1
5.7
3.5
0
2
4
6
8
10
12
0 26 52 78 104
HUMIRA + MTX (n=268)
HUMIRA (n=274)
MTX (n=257)
†
†
*
*
†
*
Me
an
Ch
an
ge
Fro
m B
as
elin
e
WeeksOMG—If one is good TWO must be better!!! We see a 25% increase in remissions when we add Methotrexate to ANYTHING---And we add it to EVERYTHING!
Rituxan ‘Tags’ B-cellsNK Cells
Macrophages destroy them
Another system called complement drills holes in the rest
Remember not all antibody producing cells are ‘bad’
So what does THIS mean
Vaccine TIMING is everything
‘New’ Infection defenses impared
Hyopgammaglobulinemia
Beyond Biologic Response Modifiers
XELJANZ
Janus Kinase InhibitorCytokine hits
receptor but how does message get to Nucleus?
JAK-STAT SystemIL-6 (and others)
Activates JAK-STAT system
Typical Infections
Take Home Message?Therapeutic ‘revolution’ has occurred in the
management of Rheumatoid Arthritis and other inflammatory syndromes
Early diagnosis is the key—we need YOU!!!Wildly effective; wildly EXPENSIVEYou will hear about some associations: ? Multiple
Sclerosis, Lymphoma—These are not relevant and only provide a distraction to the real problems we face in patients on these medications (population based data—no statistical link)
Infection, Infection, Infection