Degenerative and Inflammatory Joint Disease Pit 2013 Dr Ayu p

8/13/2019 Degenerative and Inflammatory Joint Disease Pit 2013 Dr Ayu p

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Ayu Paramaiswari

Rheumatology sub division, Department of Internal

Medicine Sardjito General Hospital


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Inflammatory

Characterized by

inflammation affecting

Synovium

Synovial Cavity

Entheses

JOINT PAIN

Noninflammatory/

degenerative

Alteration in the structure or

mechanic of the joint

May occur as a result of:Cartilage or meniscal

damage

Alteration in joint anatomy

(congenital,

developmental,metabolic,

post inflammatory

Athralgia:

Joint tenderness withno abnormality Altered pain

sensation

Early rheumatic

syndrome(SLE).


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OSTEOARTHRITIS


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Age > 50 ys

Stiffness < 30 mts

Crepitus

Bony pain

Bony swelling

Palp: No warm

ESR < 40 mm/hrs

Sinovial Fluid

OA: 5 of the 9 above

Age > 50 yrs

Stiffness < 30 mts

Crepitus

Bony pain

Bony swelling

Palp: no warm

OA: 3 of the 6 above

Clinical & lab clinical

American College of Rheumatology (ACR 1986)

Adopt: IRA 2004, panduan Diagnosis &

Pengelolaan OA

Diagnosis knee OA


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Grade 0 = normal

Grade I = doubtful narrowing of joint space and possible

osteophyte lipping

Grade II = definite osteophyte and possible narrowing of

the joint space

Grade III = moderate multiple osteophytosis, definite

narrowing of joint space, some sclerosis and possible

deformity of bone contour.

Grade IV = large osteophytes, markednarrowing of joint

space, severe sclerosis and definite deformity of joint

contour

Radiological grading of Kellgren

Laurence


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Drugs in OA

Symptom modifying drugs

Analgesics, NSAIDs

Corticosteroids

Accupuncture?

Structure modifying drugs

Diacerein

Glucosaminechondroitin Hyaluronate

Doxycyclin, minocyclin


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RheumatoidArthritis

TheSpondiloarthropathies

Systemic LupusErithematosus (SLE)

Psoriatic arthritis Ankilosing Spondilitis

Reiter s disease

Entherophatic arthritis

+ RA : Rhupus Sydr + Scleroderma:MCTD

Type of inflammatory disorder


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Spondyloarthropathies

A group of Inflammatory diseases

Inheritance of human leukocyte antigen

(HLA)-B27 increases the relative risk of

developing spondyloarthropathy

These diseases are not associated withrheumatoid factor and thus are often

referred to as the "seronegative"

spondyloarthropathies

Insidious Disease


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Alternate buttock pain

Sacroiliitis

Positive family history

Psoriasis

Inflammatory bowel disease

Urethritis or cervicitis or acute diarrhea occurring within 1

month before the onset of arthritis

Clinical Symptoms and Sign ofSpondyloarthopathies

InflammatorySpinal Pain

Synovitis

(Asymmetrical or

Predominantly lower limbs)

OR

PLUS (One or more of the following:)

* European Spondyloarthropathy Study Group Criteria for Spondyloarthropathy, 1991

Dougados M, et al. Arthr i t is Rheum. 1991 Oct;34(10):1218-1227.Sensitivity 78-88%; Specificity 92-95%


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Spondyloarhtropathies (SpA)

Spondyloarthropathies

(SpA)

Arthritis of

IBD

Psoriatic

Arthritis

Arthritis

associated

with acute

anterior

uveitis

Ankylosing

Spondylitis

(AS)

Juvenile

Chronic

Arthritis

Reactive

Arthritis

(Reiters)

uSpA

Granfors, K. et al. Arthritis & Rheum 2002, 46:606-13.

DougadosM. et al. Arthritis & Rheum 1991;34:1218-1227

Munoz-Fernandez and Martin-Mola. Best Pract Res Clin Rheumatol. 2006 Jun;20:487-505

SpA are a group of

rheumatic disorders that

share several common

factors:

1. Synovitis and enthesitis

2. Similar association with

HLA-B27

3.AS is the prototype

Ankylosing

Spondylitis

(AS)

Psoriatic

Arthritis

Granfors, K. et al. Arthritis & Rheum 2002, 46:606-13.

DougadosM. et al. Arthritis & Rheum 1991;34:1218-1227

Munoz-Fernandez and Martin-Mola. Best Pract Res Clin Rheumatol. 2006 Jun;20:487-505


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Distribution of pain

with sacroiliitis.

INFLAMMATORY BACK PAIN
http://bmj.bmjjournals.com/cgi/content/full/310/6990/1321/F14http://bmj.bmjjournals.com/cgi/content/full/310/6990/1321/F14http://bmj.bmjjournals.com/cgi/content/full/310/6990/1321/F14http://bmj.bmjjournals.com/cgi/content/full/310/6990/1321/F14


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Arthritis ( Oligoarthritis)

Arthritis 4Polyarthritis ( joint)

Peripheral Arthritis

Rheumatoid ArthritisSpondyloarthropathy


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Manifestations in Ankylosing Spondylitis

(AS)

Gut

Inflammatory bowel disease (IBD)

Axial disease

Sacroiliitis, spondylitis

Peripheral diseaseArthritis, enthesitis, dactylitis

EyeUveitis

Skin

Psoriasis


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EntesitisTrigger finger

Achiles Tendinitis Plantar fasciitis

Carpal Tunnel

Syndrome

De Quervain

Tendinitis

Tendinitis dorsum


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Special maneuvers: Test of lumbar stifness

M difi d N Y k it i f


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Modified New York riteria forAS

Clinical criteria Low back pain and stiffness for >3 mo, which improves

with exercise, but is not relieved by rest

Limited lumbar spine motion: in sagittal and frontal planes

Limitations of chest expansion (age/sex standardized) Radiographic criteria: Requires EITHER Bilateral

sacroiliitis Grade 2 or Unilateral sacroiliitis Gr 3

Definite AS = 1 clinical plus 1 radiographic criteria

Probable AS = 3 clinical criteria and no radiologic

criteria or 1 radiologic criterion and no

clinical criteria

van der Linden S, et al. Arthr i t is Rheum .1984;27:361-368.


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Contrasted to RA

SpA

Mostly MALE

Negative RF

Primary involvementof AXIAL JOINT

Less prominent

involvement of

peripheral joint

RA

Mostly FEMALE

Typically RF positive

Primary involvementof PERIPHERAL

JOINT

Rare involvement of

axial joint.


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Treatment

Medication

NSAID

DMARDS ( mtx,

suflasalazine,

leflunomide,

azathioprine)

Anti Tnf alfa

Glucocorticoid

Non pharmacologic

Physical therapy

Exercise

Surgical intervention

Corrective surgery

Decompression

surgery

Peripheral joint

arthroplasty


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Rheumatoid Arthritis

Description Morning stiffness

Arthritis of 3 or more joints

Arthritis of hand joints

Symmetric arthritis

Rheumatoid nodules

Serum rheumatoid factor

Radiographic changes

A person shall be said tohave rheumatoid arthritis if

he or she has satisfied 4of 7 criteria, with criteria 1-4 present for at least 6weeks


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Rheumatoid Arthritis: PIP Swelling

Swelling is confinedto the area of the

joint capsule

Synovial thickeningfeels like a firm

sponge


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Rheumatoid Arthritis:

Ulnar Deviation and MCP SwellingAn across-the-room

diagnosis

Prominent ulnar

deviation in the righthand

MCP and PIP

swelling in both

hands

Synovitis of left wrist


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Classification 1987 Criteria

Arnett, A&R, Vol 31, pp. 315-324


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Classification 2010 Criteria

Aletaha, A&R, Vol 62, pp. 2569-2581


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Rheumatoid ArthritisDeformities

Rheumatoid vasculitis

Swan neck deformities

Boutenaire deformities

Rheumatoid Nodules

Bayonete

deformities


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Rheumatoid ArthritisExtraarticular Involvement

Pulmonary

Pleurasy


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Cyclic Citrullinated Peptide

Antibodies (anti CCP)

Schellekens, A&R, Vol 43, pp. 155-163

DMARD (Di M dif i A ti


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DMARDs (Disease-Modifying Anti-

Rheumatic Drugs)

Hydroxychloroquine(Plaquenil)

Sulfasalazine

Methotrexate Leflunomide (Arava)

Less commonly used: Minocycline

Azathioprine Gold, PO or IM

Cyclosporine

Etanercept (Enbrel) Infliximab (Remicade) Adalimumab (Humira) Golimumab (Simponi) Certolizumab Pegol

(Cimzia) Anakinra (Kineret) Rituximab (Rituxan) Abatacept (Orencia)

Tocilizumab (Actemra)

Traditional Biologics


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THANK YOU

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