Arthritis

Osteoarthritis:
Risk factors: age, female sex, obesity, genetics, sports, occupation, injury, acromegaly and other illnesses.
Treatment:

• Lifestyle: weight loss, exercise, PT and surgery
• Drugs:
  • APAP up to 3g daily
  • NSAIDS if APAP not working.  Take ASA at least 30 minutes before NSAID if on ASA.
  • Topical agents, especially for the knee (capsaicin, diclofenac 1% gel)
  • Intraarticular glucocorticoid injections with methylprednisolone or triamcinolone, 10 – 40 mg, may repeat every 3 months. *only for knee
  • Intraarticular hyaluronan *only for the knee and only 3-4 lifetime injections.
  • Glucosamine
  • Opioids like Vicodin are better than chronic NSAIDS.

Rheumatoid Arthritis
Patients present with joint stiffness, fatigue, warmth, redness and/or swelling of joints. Lab tests will reveal a positive rheumatoid factor., elevated sedimentation rate a, C-reactive protein and normochromic, normocytic anemia.

Treatment:

• Lifestyle changes: rest during disease exacerbations, PT, maintain a normal
  weight, surgery
• Start DMARD within 3 months of diagnosis.
  • Methotrexate is preferred. Start with an anti-inflammatory drug and reduce the anti-inflammatory slowly.
  • Methotrexate is followed by hydroxychloroquine (slow onset) and sulfasalazine (DOC in pregnancy).  Can also use leflunomide.
  • Biologic DMARDs used in combo with methotrexate in severe disease
    • TNF inhibitors: etanercept, infliximab, adalimumab, certolizumab,
      golimumab
    • Non – TWF: abatacept, anakinra, rituximab, tocilizumab
    • Biological kinase inhibitor: Tofacitinib
  • Methotrexate: Takes 3 – 6 weeks to see onset. Anything that changes
    kidneys function interacts.

ACR RA Classification Guidelines

• RA Classified with synovitis in 1 joint or more in absence of a better diagnosis that explains the symptoms and a score of 6 or more in the following domains:
  • Large joint involvement: 1 = 0 pts, 2-10 = 1 pt
  • Small joint involvement: 1-3 = 2 pts, 4-10 = 3 pts
  • Any joints:  >10 = 5 pts
  • Low positive RF or ACPA = 2 pts
  • High positive RF or ACPA = 3 pts
  • Abnormal CRP or ESR = 1 pt
  • Symptoms greater than 6 weeks = 1 pt