SLIDE 1 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
First Presentation of Joint Pain
SLIDE 2
- 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
Disclosures
SLIDE 3
- No qualifications or experience in primary care
Disclaimer
SLIDE 4
- To provide a structured approach to the assessment of new-
- nset 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
Learning Objectives
SLIDE 5
Why Bother?
SLIDE 6
Why Bother?
SLIDE 7 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
SLIDE 8 A Diagnostic Algorithm
Joint symptoms ? inflammatory ? non-inflammatory
helped by activity worse with activity
prolonged short-duration
helped by activity fixed
soft tissue hard tissue
SLIDE 9 A Diagnostic Algorithm
? mechanical ? degenerative ? neuropathic Consider:
syndromes
Joint symptoms ? inflammatory ? non-inflammatory
helped by activity worse with activity
prolonged short-duration
helped by activity fixed
soft tissue hard tissue
SLIDE 10 A Diagnostic Algorithm
? mechanical ? degenerative ? neuropathic Consider:
syndromes
Joint symptoms ? inflammatory ? non-inflammatory
helped by activity worse with activity
prolonged short-duration
helped by activity fixed
soft tissue hard tissue Small joint / distal ? objective synovitis
- swelling/tenderness
- MTP squeeze
Consider:
- RA
- PsA
- ReA
- CTD
- viral
- OA
- haemochromatosis
- vasculitis: HSP / GPA
SLIDE 11 A Diagnostic Algorithm
? mechanical ? degenerative ? neuropathic Consider:
syndromes
Joint symptoms ? inflammatory ? non-inflammatory
helped by activity worse with activity
prolonged short-duration
helped by activity fixed
soft tissue hard tissue Small joint / distal ? objective synovitis
- swelling/tenderness
- MTP squeeze
Consider:
- RA
- PsA
- ReA
- CTD
- viral
- OA
- haemochromatosis
- vasculitis: HSP / GPA
Large joint / proximal Limb girdle Consider
- PMR
- OA shoulders/hips
- soft tissue syndromes
- statin myopathy
- RA
SLIDE 12 A Diagnostic Algorithm
? mechanical ? degenerative ? neuropathic Consider:
syndromes
Joint symptoms ? inflammatory ? non-inflammatory
helped by activity worse with activity
prolonged short-duration
helped by activity fixed
soft tissue hard tissue Small joint / distal ? objective synovitis
- swelling/tenderness
- MTP squeeze
Consider:
- RA
- PsA
- ReA
- CTD
- viral
- OA
- haemochromatosis
- vasculitis: HSP / GPA
Large joint / proximal Limb girdle Consider
- PMR
- OA shoulders/hips
- soft tissue syndromes
- statin myopathy
- RA
Knee/ankle Consider:
- SpA – PsA / ReA
- OA knee/ankle
- sarcoidosis
- polyarticular gout
- pseudogout
- RA
- undifferentiated
SLIDE 13 A Diagnostic Algorithm
? mechanical ? degenerative ? neuropathic Consider:
syndromes
Joint symptoms ? inflammatory ? non-inflammatory
helped by activity worse with activity
prolonged short-duration
helped by activity fixed
soft tissue hard tissue Small joint / distal ? objective synovitis
- swelling/tenderness
- MTP squeeze
Consider:
- RA
- PsA
- ReA
- CTD
- viral
- OA
- haemochromatosis
- vasculitis: HSP / GPA
Large joint / proximal Axial ? Inflammatory back pain ? SI / heel / costochondral Consider:
- ankylosing spondylitis
- psoriatic SpA
- enteropathic SpA
- Reactive SpA
- degenerative spinal
disease
Limb girdle Consider
- PMR
- OA shoulders/hips
- soft tissue syndromes
- statin myopathy
- RA
Knee/ankle Consider:
- SpA – PsA / ReA
- OA knee/ankle
- sarcoidosis
- polyarticular gout
- pseudogout
- RA
- undifferentiated
SLIDE 14 A Diagnostic Algorithm
? mechanical ? degenerative ? neuropathic Consider:
syndromes
Joint symptoms ? inflammatory ? non-inflammatory
helped by activity worse with activity
prolonged short-duration
helped by activity fixed
soft tissue hard tissue Small joint / distal ? objective synovitis
- swelling/tenderness
- MTP squeeze
Consider:
- RA
- PsA
- ReA
- CTD
- viral
- OA
- haemochromatosis
- vasculitis: HSP / GPA
Large joint / proximal Axial ? Inflammatory back pain ? SI / heel / costochondral Consider:
- ankylosing spondylitis
- psoriatic SpA
- enteropathic SpA
- Reactive SpA
- degenerative spinal
disease
Limb girdle Consider
- PMR
- OA shoulders/hips
- soft tissue syndromes
- statin myopathy
- RA
Knee/ankle Consider:
- SpA – PsA / ReA
- OA knee/ankle
- sarcoidosis
- polyarticular gout
- pseudogout
- RA
- undifferentiated
SLIDE 15
Effective Use of Investigations
SLIDE 16
Effective Use of Investigations
SLIDE 17
Effective Use of Investigations
SLIDE 18
Effective Use of Investigations
SLIDE 19
Effective Use of Investigations
SLIDE 20
Effective Use of Investigations
SLIDE 21
Effective Use of Investigations
SLIDE 22 A Diagnostic Algorithm
? mechanical ? degenerative ? neuropathic Consider:
syndromes
Joint symptoms ? inflammatory ? non-inflammatory
helped by activity worse with activity
prolonged short-duration
helped by activity fixed
soft tissue hard tissue Small joint / distal ? objective synovitis
- swelling/tenderness
- MTP squeeze
Consider:
- RA
- PsA
- ReA
- CTD
- viral
- OA
- haemochromatosis
- vasculitis: HSP / GPA
Large joint / proximal Axial ? Inflammatory back pain ? SI / heel / costochondral Consider:
- ankylosing spondylitis
- psoriatic SpA
- enteropathic SpA
- Reactive SpA
- degenerative spinal
disease
Limb girdle Consider
- PMR
- OA shoulders/hips
- soft tissue syndromes
- statin myopathy
- RA
Knee/ankle Consider:
- SpA – PsA / ReA
- OA knee/ankle
- sarcoidosis
- polyarticular gout
- pseudogout
- RA
- undifferentiated
SLIDE 23
Effective Use of Investigations
SLIDE 24
Effective Use of Investigations
SLIDE 25
Effective Use of Investigations
SLIDE 26
Effective Use of Investigations
SLIDE 27
Effective Use of Investigations
SLIDE 28
Effective Use of Investigations
SLIDE 29 A Diagnostic Algorithm
? mechanical ? degenerative ? neuropathic Consider:
syndromes
Joint symptoms ? inflammatory ? non-inflammatory
helped by activity worse with activity
prolonged short-duration
helped by activity fixed
soft tissue hard tissue Small joint / distal ? objective synovitis
- swelling/tenderness
- MTP squeeze
Consider:
- RA
- PsA
- ReA
- CTD
- viral
- OA
- haemochromatosis
- vasculitis: HSP / GPA
Large joint / proximal Axial ? Inflammatory back pain ? SI / heel / costochondral Consider:
- ankylosing spondylitis
- psoriatic SpA
- enteropathic SpA
- Reactive SpA
- degenerative spinal
disease
Limb girdle Consider
- PMR
- OA shoulders/hips
- soft tissue syndromes
- statin myopathy
- RA
Knee/ankle Consider:
- SpA – PsA / ReA
- OA knee/ankle
- sarcoidosis
- polyarticular gout
- pseudogout
- RA
- undifferentiated
SLIDE 30
Effective Use of Investigations
SLIDE 31
Effective Use of Investigations
SLIDE 32
Effective Use of Investigations
SLIDE 33
Effective Use of Investigations
SLIDE 34
Effective Use of Investigations
SLIDE 35
Effective Use of Investigations
SLIDE 36
Effective Use of Investigations
SLIDE 37 A Diagnostic Algorithm
? mechanical ? degenerative ? neuropathic Consider:
syndromes
Joint symptoms ? inflammatory ? non-inflammatory
helped by activity worse with activity
prolonged short-duration
helped by activity fixed
soft tissue hard tissue Small joint / distal ? objective synovitis
- swelling/tenderness
- MTP squeeze
Consider:
- RA
- PsA
- ReA
- CTD
- viral
- OA
- haemochromatosis
- vasculitis: HSP / GPA
Large joint / proximal Axial ? Inflammatory back pain ? SI / heel / costochondral Consider:
- ankylosing spondylitis
- psoriatic SpA
- enteropathic SpA
- Reactive SpA
- degenerative spinal
disease
Limb girdle Consider
- PMR
- OA shoulders/hips
- soft tissue syndromes
- statin myopathy
- RA
Knee/ankle Consider:
- SpA – PsA / ReA
- OA knee/ankle
- sarcoidosis
- polyarticular gout
- pseudogout
- RA
- undifferentiated
SLIDE 38
Effective Use of Investigations
SLIDE 39
Effective Use of Investigations
SLIDE 40
Effective Use of Investigations
SLIDE 41
Effective Use of Investigations
SLIDE 42 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
SLIDE 43 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
SLIDE 44 A Diagnostic Algorithm
? mechanical ? degenerative ? neuropathic Consider:
syndromes
Joint symptoms ? inflammatory ? non-inflammatory
helped by activity worse with activity
prolonged short-duration
helped by activity fixed
soft tissue hard tissue Small joint / distal ? objective synovitis
- swelling/tenderness
- MTP squeeze
Consider:
- RA
- PsA
- ReA
- CTD
- viral
- OA
- haemochromatosis
- vasculitis: HSP / GPA
Large joint / proximal Axial ? Inflammatory back pain ? SI / heel / costochondral Consider:
- ankylosing spondylitis
- psoriatic SpA
- enteropathic SpA
- Reactive SpA
- degenerative spinal
disease
Limb girdle Consider
- PMR
- OA shoulders/hips
- soft tissue syndromes
- statin myopathy
- RA
Knee/ankle Consider:
- SpA – PsA / ReA
- OA knee/ankle
- sarcoidosis
- polyarticular gout
- pseudogout
- RA
- undifferentiated
SLIDE 45 Determining Urgency
Small joint / distal inflammatory symptoms poor functional status
MCP/MTP squeeze test extra-articular features (including systemic) acute phase response Rheumatoid factor and/or anti-CCP
- ther lab features (e.g. ANA/ENA/dsDNA, ANCA/MPO/PR3)
SLIDE 46 A Diagnostic Algorithm
? mechanical ? degenerative ? neuropathic Consider:
syndromes
Joint symptoms ? inflammatory ? non-inflammatory
helped by activity worse with activity
prolonged short-duration
helped by activity fixed
soft tissue hard tissue Small joint / distal ? objective synovitis
- swelling/tenderness
- MTP squeeze
Consider:
- RA
- PsA
- ReA
- CTD
- viral
- OA
- haemochromatosis
- vasculitis: HSP / GPA
Large joint / proximal Axial ? Inflammatory back pain ? SI / heel / costochondral Consider:
- ankylosing spondylitis
- psoriatic SpA
- enteropathic SpA
- Reactive SpA
- degenerative spinal
disease
Limb girdle Consider
- PMR
- OA shoulders/hips
- soft tissue syndromes
- statin myopathy
- RA
Knee/ankle Consider:
- SpA – PsA / ReA
- OA knee/ankle
- sarcoidosis
- polyarticular gout
- pseudogout
- RA
- undifferentiated
SLIDE 47
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
SLIDE 48 A Diagnostic Algorithm
? mechanical ? degenerative ? neuropathic Consider:
syndromes
Joint symptoms ? inflammatory ? non-inflammatory
helped by activity worse with activity
prolonged short-duration
helped by activity fixed
soft tissue hard tissue Small joint / distal ? objective synovitis
- swelling/tenderness
- MTP squeeze
Consider:
- RA
- PsA
- ReA
- CTD
- viral
- OA
- haemochromatosis
- vasculitis: HSP / GPA
Large joint / proximal Axial ? Inflammatory back pain ? SI / heel / costochondral Consider:
- ankylosing spondylitis
- psoriatic SpA
- enteropathic SpA
- Reactive SpA
- degenerative spinal
disease
Limb girdle Consider
- PMR
- OA shoulders/hips
- soft tissue syndromes
- statin myopathy
- RA
Knee/ankle Consider:
- SpA – PsA / ReA
- OA knee/ankle
- sarcoidosis
- polyarticular gout
- pseudogout
- RA
- undifferentiated
SLIDE 49
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
SLIDE 50 A Diagnostic Algorithm
? mechanical ? degenerative ? neuropathic Consider:
syndromes
Joint symptoms ? inflammatory ? non-inflammatory
helped by activity worse with activity
prolonged short-duration
helped by activity fixed
soft tissue hard tissue Small joint / distal ? objective synovitis
- swelling/tenderness
- MTP squeeze
Consider:
- RA
- PsA
- ReA
- CTD
- viral
- OA
- haemochromatosis
- vasculitis: HSP / GPA
Large joint / proximal Axial ? Inflammatory back pain ? SI / heel / costochondral Consider:
- ankylosing spondylitis
- psoriatic SpA
- enteropathic SpA
- Reactive SpA
- degenerative spinal
disease
Limb girdle Consider
- PMR
- OA shoulders/hips
- soft tissue syndromes
- statin myopathy
- RA
Knee/ankle Consider:
- SpA – PsA / ReA
- OA knee/ankle
- sarcoidosis
- polyarticular gout
- pseudogout
- RA
- undifferentiated
SLIDE 51
Determining Urgency
Axial inflammatory symptoms poor functional status HLA-B27+ acute phase response
SLIDE 52 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
SLIDE 53 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
SLIDE 54 Early Interventions
Suspected vasculitis
- multisystem inflammatory disease: neuro, renal, resp, skin joint
- discuss with rheumatologist before treating
- photographs can help
SLIDE 55 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
SLIDE 56 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
SLIDE 57 Early Interventions
Suspected gout
- three options: NSAIDs, colchicine, prednisone
- colchicine regimen: 1 g stat and 0.5 mg 1 hour later
SLIDE 58 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
SLIDE 59 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.
