[PDF] - Approach to the Achy Patient joint x-rays Questions: Management of PDF Document

SLIDE 1

1 Approach to the Achy Patient

Andrew J. Gross, MD Rheumatology Clinic Chief Associate Clinical Professor University of California, San Francisco

Notes

The talk went 41 minutes.
Drop the x-rays in evaluation of RA
Could add symptoms of inflammatory back pain & SI

joint x-rays

Questions:

– Management of fibromyalgia – How do you investigate other diseases in Fibromyalgia

patients. (include lab tests slide)

– ANA reflex testing – how useful are the highly specific antibodies like Scl-70 and dsDNA Ab – Peri-menopausal achiness

Disclosures

None

Clinical Case #1

52 year old woman with 5 months of

joint pain. Initially she had pain in her

hands. Over time, she developed pain

in her shoulders, knees and feet. Ibuprofen has been helpful for the pain.

Review of systems is notable for

moderately severe fatigue, and

ccasional sharp chest pains. She

also reports symptoms of Raynaud’s phenomenon.

Past medical, family and social history

are unremarkable.

SLIDE 2

2 Clinical Case #1

General physical examination is unremarkable.
On musculoskeletal exam, you are uncertain if there

are any swollen joints. Many joints are tender, particularly her PIP and MCP joints, her wrists and knees.

What is the diagnosis?

Let me just pull out my “tricorder” Differential Diagnosis

Inflammatory

Autoimmune

– Lupus/Scleroderma – Rheumatoid Arthritis – Spondyloarthritis

Crystal Disease
Infectious

– Viral – Chronic bacterial

Neoplastic

Non-Inflammatory

Osteoarthritis
Endocrine

– Thyroid Disease – Diabetes – Calcium metabolism

Overuse
Somatic/Fibromyalgia

– Hypermobility

Approach to Arthritis

(clinical clues)

age
gender
family history
onset of disease (acute/chronic)
pattern of joint involvement

(& presence of enthesitis)

SLIDE 3

3 Pattern of Joint Involvement

All of the following conditions commonly involve PIP & MCP joints, wrists and knees EXCEPT:

A. Osteoarthritis
B. Rheumatoid Arthritis
C. SLE
D. CPPD disease (“pseudogout”)
E. Parvovirus B19 induced arthritis

All of the following conditions commonly involve PIP & MCP joints, wrists and knees EXCEPT:

A. Osteoarthritis
B. Rheumatoid

Arthritis

C. SLE
D. CPPD disease

(“pseudogout”)

E. Parvovirus B19

induced arthritis

Pattern of Joint Involvement ¡

A. Osteoarthritis
B. Rheumatoid Arthritis
C. SLE
D. CPPD (“pseudogout”)
E. Parvovirus B19 arthritis

All of the following conditions commonly involve PIP & MCP joints, wrists and knees EXCEPT:

Pattern of Joint Involvement

All of the following conditions commonly involve PIP & MCP joints, wrists and knees EXCEPT:

A. Osteoarthritis
B. Rheumatoid Arthritis
C. SLE
D. CPPD disease (“pseudogout”)
E. Parvovirus B19 induced arthritis

SLIDE 4

4 Approach to Arthritis

(clinical clues)

age
gender
family history
onset of disease (acute/chronic)

Lupus/MCTD/ scleroderma Rheumatoid Arthritis Psoriatic Arthritis

pattern of joint involvement

(& presence of enthesitis)

Approach to Arthritis

(clinical clues)

age
gender
family history
onset of disease (acute/chronic)
pattern of joint involvement

(& presence of enthesitis)

extra-articular manifestations
diagnostic testing

Lupus/MCTD/ scleroderma Rheumatoid Arthritis Psoriatic Arthritis

Clinical Case #1

Re-examination

f the skin is

remarkable for mild erythema

f her fingers,

particularly between the knuckles.

What is the diagnosis?

Photo courtesy of Maria Dall’era

Clinical Case #1

Re-examination

f the skin is

remarkable for mild erythema

f her fingers,

particularly between the knuckles.

What is the diagnosis?

SLIDE 5

5

All of the following could cause this appearance EXCEPT: ¡

A. Dermatomyositis
B. Psoriasis
C. Lupus
D. Granuloma Annulare
E. Eczema

All of the following could cause this appearance EXCEPT:

1. Dermatomyositis
2. Psoriasis
3. Lupus
4. Granuloma Annulare
5. Eczema

All of the following could cause this appearance EXCEPT:

A. Dermatomyositis
B. Psoriasis
C. Lupus
D. Granuloma Annulare
E. Eczema

Tip

To help diagnose Inflammatory Arthritis

Search for extra-articular CLINICAL CLUES

SLIDE 6

6 Classification Criteria for Systemic Lupus Erythematosus

Rashes (~85%)

– Malar rash – Discoid rash (scarring) – Photosensitive

Oral/nasal ulcers (painless)
Arthritis (80-90%)

(usually small joints)

Serositis (~45%)
Glomerulonephritis

(50-70%)

CNS disease (25-35%)

(seizures, chorea, stroke)

Hematologic disorder

Leukopenia, Lymphopenia, Thrombocytopenia, AIHA

Immunologic disorder

dsDNA, Sm, APL Antibodies

Antinuclear antibodies

Any combination of 4 or more of 11 criteria, well-documented at any time during a patient's history, makes it likely that the patient has SLE (95% specificity; 75% sensitivity)

Tan EM, et al, Arthritis Rheum 1982

Clinical Case #1 – Alternative Scenario

General physical examination is unremarkable.
On musculoskeletal exam, you are unsure if there are

any swollen joints. Many joints are tender, particularly her PIP and MCP joints, her wrists and knees.

Skin exam is unremarkable

In the absence of clinical clues Are there diagnostic tests that will help identify the diagnosis?

Anti-Nuclear Antibody (ANA)? How does an ANA test help me to determine if the patient has “a rheum thing” (like SLE)?

SLIDE 7

7

How will an ANA test help me to determine if the patient has “a rheum thing” (like SLE)?

A. Although an ANA is not specific for any particular

autoimmune disease, the presence of the ANA does suggest the patient has a connective tissue disease.

B. A positive ANA indicates the patient has a defect in

tolerance mechanisms and will develop an autoimmune disease.

C. By examining the pattern of the ANA, you can

determine the diagnosis.

D. Testing for additional autoantibodies can increase

the specificity of testing.

How will an ANA test help me to determine if the patient has “a rheum thing” (like SLE)? ¡

A. ANA ¡presence ¡suggests ¡

disease ¡is ¡present ¡

B. ANA ¡suggests ¡will ¡

develop ¡disease ¡

C. ANA ¡pa7ern ¡is ¡diagnos8c ¡
D. Tes8ng ¡for ¡addi8onal ¡

autoan8bodies ¡is ¡helpful ¡ How will an ANA test help me to determine if the patient has “a rheum thing” (like SLE)?

A. ANA ¡presence ¡suggests ¡

disease ¡is ¡present ¡

B. ANA ¡suggests ¡will ¡

develop ¡disease ¡

C. ANA ¡pa7ern ¡is ¡

diagnos8c ¡

D. Tes8ng ¡for ¡addi8onal ¡

autoan8bodies ¡is ¡ helpful ¡ ANA is highly sensitive for Lupus & Somewhat sensitive for other autoimmune conditions

SLE

95-99%

Systemic Sclerosis

(Scleroderma) 60-80%

Sjögrens

40-70%

Polymyositis &

Dermatomyositis 30-80%

Rheumatoid

Arthritis 30-50%

Thyroid disease 30-50%
Multiple Sclerosis

25%

ITP

10-30%

Infectious diseases &

malignancies - varies widely

Kavanaugh A, et al, Arch Pathol Lab Med 2000

SLIDE 8

8

People without Autoimmune Disease can have a positive ANA

Fibromyalgia

15-25%

Relatives of SLE Pts 5-25%
Healthy People
>1:40

20-30%

>1:80

10-12%

>1:160

5%

>1:320

3%

Kavanaugh A, et al, Arch Pathol Lab Med 2000

ANA Frequencies

100% 0%

Lupus Healthy Scleroderma 1° relatives

f SLE Pts

Rheumatoid Arthritis & Thyroid Disease

50%

Fibromyalgia

Kavanaugh A, et al, Arch Pathol Lab Med 2000, PMID 10629135

Among 100,000 American Women Who has a positive ANA?

Data extrapolated from Kavanaugh A, et al, Arch Pathol Lab Med 2000 & Tan EM, et al, Arthritis Rheum 1997

Condition Number with condition per 100,000 ANA+ Calculated Prevalence of ANA+ people per 100,000 Women with SLE 50 99%

~50

Patients w/ Autoimmune Thyroid Dz 250 40%

~100

Women with Fibromyalgia 3500 20%

~700

Healthy women with ANA ≥1:160

5%

~5,000

ANA is not really helpful to screen for autoimmune disease

How will an ANA test help me to determine if the patient has “a rheum thing” (like SLE)?

a. Although an ANA is not specific for any particular

autoimmune disease, the presence of the ANA does suggest the patient has a connective tissue disease.

b. A positive ANA indicates the patient has a defect in

tolerance mechanisms and will develop an autoimmune disease.

c. By examining the pattern of the ANA, you can

determine the diagnosis.

d. Testing for additional autoantibodies can increase

the specificity of testing.

SLIDE 9

9 How about the ANA Pattern?

Speckled Cytoplasmic Nucleolar Centromere

Disease Suspicion: Scleroderma

Raynaud’s Phenomenon

1. Ischemia
2. Cyanosis
3. Hyperemia

Disease Suspicion: Scleroderma

Raynaud’s Phenomenon

TIP: Features of Raynauds’ Phenomenon that are predictive of CTD

Presence of ANA

http://www.skincosmos.com/img/raynauds_cold_hands.jpg

Disease Suspicion: Scleroderma

Raynaud’s Phenomenon

Women with Primary Raynaud’s: 15% ANA 1:160 in Healthy Women: 5%

∴ 1 in 133 women have Primary Raynaud’s & Positive ANA

1 in 5,000 women have Scleroderma

SLIDE 10

10 Disease Suspicion: Scleroderma

Raynaud’s Phenomenon

TIP: Features of Raynauds’ Phenomenon that are predictive of CTD

Presence of ANA
Prolonged (non-

remitting) episodes

Scar or Ulceration of

finger tips

Older age of onset
Esophogeal dysmotility

http://www.skincosmos.com/img/raynauds_cold_hands.jpg

Disease Suspicion: Scleroderma

useful lab tests:

Anti-Centromere Antibody

– CREST syndrome (limited SSc)

Calcinosis, Raynaud’s, esophogeal dysmotility,
sclerodactyly, telangectasia
Scl-70 (anti-topoisomerase)

– Systemic involvement with ILD

RNA polymerase III

– Systemic involvement

anti-RNP – mixed connective tissue disease

ANA patterns

ANA patterns are not highly predictive of:

– Disease Types – Autoantibody subsets

How will an ANA test help me to determine if the patient has “a rheum thing” (like SLE)?

a. Although an ANA is not specific for any particular

autoimmune disease, the presence of the ANA does suggest the patient has a connective tissue disease.

b. A positive ANA indicates the patient has a defect in

tolerance mechanisms and will develop an autoimmune disease.

c. By examining the pattern of the ANA, you can

determine the diagnosis.

d. Testing for additional autoantibodies can increase

the specificity of testing.

SLIDE 11

11 Disease Suspicion: SLE useful lab tests

Kavanaugh A, et al, Arch Pathol Lab Med 2000, PMID 10629135

Autoantibodies I do not routinely check

SLE

– ssDNA – Chromatin – Ribosomal-P – Neuronal – Ku

Systemic Sclerosis

– Fibrillarin (U3 RNP) – Th/To – Gu (RNA helicase) – Mitochondria

Walker JG, Fritzler MJ. Curr Opin Rheumatol 2007 Mimori T, et al. Curr Opin. Rheumatol 2007 Sawalha AH and Harley JB. Curr Opin Rheumatol 2007

Myositis

– PL-7 – PL-12 – EJ – OJ – KS – Zo – YRS – SRP – PM-Scl – Mi-2 – CADM-140 – p1.55/p1.40 – MJ

Autoantibodies Panels are problematic

The more tests you get, the more likely you will have

a false positive.

Order tests for diseases you suspect!

Back to Our Patient’s Diagnostic Testing

ESR 19 mm/hr (normal 0-15)
CRP 3.2 (nl <6.3)
ANA 1:160 speckled pattern
Anti-dsDNA, Sm, RNP - all negative
C3 69 (normal 71-159), C4 12 (normal 13-30)
WBC 3.2, lymphocytes 0.8, Hgb 11.1, PLT 104
Urine Analysis normal

This is consistent with mild SLE

SLIDE 12

12 Tips to help diagnose SLE

Search for CLINICAL CLUES!
Biopsy persistent skin rashes
Check complement levels
Check urine for hemoglobin & protein,

especially if the patient has dsDNA Ab

Look for lymphopenia and thrombocytopenia

SLE and Complement II

Hypocomplementemia in 62% of SLE patients.
Compared with patients with normal complement

values, those with hypocomplementemia showed:

– higher prevalence of female gender (P < 0.001), – fever (P = 0.021), – nephropathy (P < 0.001), – cutaneous vasculitis (P = 0.023), – positive anti-dsDNA antibodies (P = 0.012)

Ramos-Casals M, et al, Lupus (2004) 13:777-783

Causes of Hypocomplementemia

Immune Complex Disease

SLE
Cryoglobulinemia
Chronic Infection induced

GN or vasculitis

– Hepatitis viruses

Post-infectious GN
Sjogren’s
MPGN – Type I & III – 3
Rheumatoid Vasculitis
Chemotherapy for

Hematologic malignancies

Graves disease

Non-Immune Complex disease

Atheroembolic disease
HUS/TTP (C3 primarily)
Sepsis
Malnutrition
Hepatic Failure
Burns
Pancreatitis
Cardiopulmonary bypass
Hemodialysis
Porphyria

Herbet LA, Cosio FG and Neff JC. Kidney International, (1991), pp. 811—821

Autoantibodies I do not routinely check

SLE

– ssDNA – Chromatin – Ribosomal-P – Neuronal – Ku

Myositis

– PL-7 – PL-12 – EJ – OJ – KS – Zo – YRS – SRP – PM-Scl – Mi-2 – MJ

Walker JG, Fritzler MJ. Curr Opin Rheumatol 2007 Mimori T, et al. Curr Opin. Rheumatol 2007 Sawalha AH and Harley JB. Curr Opin Rheumatol 2007

Systemic Sclerosis

– Fibrillarin (U3 RNP) – Th/To – Gu (RNA helicase) – Mitochondria

SLIDE 13

13 Autoantibodies Panels are problematic

The more tests you get, the more likely you will have

a false positive.

Order tests for diseases you suspect!

Approach to Determining the Cause of a positive ANA

Review medications that can cause SLE:

Minocycline, Hydralazine, Procanamide,

isoniazide, methyldopa, anti-TNF agents

Check family history for connective tissue disease

ANA+ in 20% of 1° relatives of SLE patients

Clinical signs of autoimmune disease

(not just pain and fatigue) Classification Criteria for Systemic Lupus Erythematosus

Malar rash: Fixed erythema, flat or raised, over the malar eminences Discoid rash: Erythematous circular raised patches with adherent keratotic scaling and follicular plugging; atrophic scarring may occur Photosensitivity: Exposure to ultraviolet light causes rash Oral ulcers: Includes oral and nasopharyngeal ulcers, observed by physician Arthritis: Nonerosive arthritis of two or more peripheral joints, with tenderness, swelling, or effusion Serositis: Pleuritis or pericarditis documented by ECG or rub or evidence of effusion Renal disorder: Proteinuria >0.5 g/d or 3+, or cellular casts Neurologic disorder: Seizures or psychosis without other causes Hematologic disorder: Hemolytic anemia, leukopenia (<4000/L) or lymphopenia (<1500/L) or thrombocytopenia (<100,000/L) in the absence of offending drugs Immunologic disorder: Anti-dsDNA, anti-Sm, and/or anti-phospholipid Antinuclear antibodies: An abnormal titer of ANA by immunofluorescence or an equivalent assay in the absence of drugs known to induce ANAs

Any combination of 4 or more of 11 criteria, well-documented at any time during a patient's history, makes it likely that the patient has SLE (95% specificity; 75% sensitivity)

Clinical Case #2

52 year old woman with 5 months of

joint pain. Initially she had pain in her

hands. Over time, she developed pain

in her shoulders, knees and feet. It takes a couple of hours for her joint stiffness to improve in the mornings.

General physical examination is

unremarkable.

On musculoskeletal exam, you think a

few fingers and her right wrist might be

swollen. Many joints are tender,

particularly her PIP and MCP joints, her wrists and shoulders.

SLIDE 14

14 Approach to Arthritis

(clinical clues)

age
gender
family history
onset of disease (acute/chronic)
pattern of joint involvement

(& presence of enthesitis)

extra-articular manifestations
diagnostic testing

Lupus/MCTD/ scleroderma Rheumatoid Arthritis Peri-menopausal

steoarthritis

Psoriatic Arthritis

Part 2 – Patient’s Diagnostic Testing

WBC 7.1, Hgb 11.8, PLT 291
ESR 19 mm/hr
CRP 7.8 (nl <6.3)
ANA 1:40 speckled pattern
C3 128 (normal 71-159), C4 36 (normal 13-30)
Anti-dsDNA, Sm, RNP negative
Urine Analysis normal

Does not seem like Lupus or Scleroderma. Could this be Rheumatoid Arthritis?

Diagnostic Criteria for Rheumatoid Arthritis

Morning stiffness of >1 hour.
Arthritis of hand joints
Symmetric arthritis
Arthritis & soft-tissue swelling of >3 of 14 joints/joint groups
Subcutaneous nodules
Rheumatoid Factor (and anti-CCP antibody)
Radiological changes suggestive of joint erosion

Any combination of 4 or more of 7 criteria for >6 weeks, well-documented at any time during a patient's history, makes it likely that the patient has RA

Arnett FC, et al, Arthritis Rheum 1988

Diagnostic Criteria for Rheumatoid Arthritis

Morning stiffness of >1 hour.
Arthritis of hand joints
Symmetric arthritis
Arthritis & soft-tissue swelling of >3 of 14 joints/joint groups
Subcutaneous nodules
Rheumatoid Factor (and anti-CCP antibody)
Radiological changes suggestive of joint erosion

Any combination of 4 or more of 7 criteria for >6 weeks, well-documented at any time during a patient's history, makes it likely that the patient has RA

Arnett FC, et al, Arthritis Rheum 1988

SLIDE 15

15

The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis.

Criterion Definition

1. Morning stiffness

Morning stiffness in and around the joints, lasting at least 1 hour before maximal improvement

2. Arthritis of 3 or more joint areas

At least 3 joint areas simultaneously have had soft tissue swelling or fluid (not bony overgrowth alone) observed by a

physician. The 14 possible areas are right or left PIP, MCP,

wrist, elbow, knee, ankle, and MTP joints

3. Arthritis of hand joints

At least 1 area swollen (as defined above) in a wrist, MCP, or PIP joint

4. Symmetric arthritis

Simultaneous involvement of the same joint areas (as defined in 2) on both sides fo the body (bilateral involvement of PIPs, MCPs, or MTPs is acceptable without absolute symmetry)

5. Rheumatoid nodules

Subcutaneous nodules, over bony prominences, or extensor surfaces, or in juxtaarticular regions, observed by a physician

6. Serum rheumatoid factor

Demonstration of abnormal amounts of serum rheumatoid factor by any method for which the result has been positive in <5% of normal control subjects

7. Radiographic changes

Radiographic changes typical of rheumatoid arthritis on posteroanterior hand and wrist radiographs, which must include erosions or unequivocal bony decalcification localized in or most marked adjacent to the involved joints (osteoarthritis changes alone do not qualify)

For classification purposes, a patient shall be said to have rheumatoid arthritis if he/she has satisfied at least 4 or these 7 criteria.
Criteria 1 through 4 must have been present for at least 6 weeks.

Arnett FC, Edworthy SM, Bloch DA, McShane DJ, Fries JF, Cooper NS, et al. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum 1988;31:315---24.

How will Rheumatoid Factor & CCP Antibody help me to determine if the patient has Rheumatoid Arthritis?

Which is true?

A. A negative rheumatoid factor is helpful only if IgA,

IgM and IgG isotypes were tested.

B. Rheumatoid factor and CCP have similar

sensitivities for Rheumatoid Arthritis, but have very different levels of specificity

C. CCP is not commonly available and is not routinely

checked.

D. There is no additional value to checking anti-CCP

and rheumatoid factor

Which is true? ¡

A. For ¡RF, ¡test ¡IgM, ¡

IgG, ¡IgA ¡

B. RF ¡& ¡CCP ¡have ¡

different ¡specificity ¡

C. CCP ¡is ¡not ¡rou8nely ¡

checked ¡

D. No ¡need ¡for ¡both ¡RF ¡

& ¡CCP ¡

SLIDE 16

16

Which is true?

A. For ¡RF, ¡test ¡IgM, ¡

IgG, ¡IgA ¡

B. RF ¡& ¡CCP ¡have ¡

different ¡specificity ¡

C. CCP ¡is ¡not ¡rou8nely ¡

checked ¡

D. No ¡need ¡for ¡both ¡RF ¡

& ¡CCP ¡

Rheumatoid Factor

IgM directed against the Fc portion of IgG
Present in ~70% of patients with RA
Higher titers associated with more erosive disease

Rheumatoid Factor

False Positives

– 15% of normal persons over the age of 65 – Infections: Hepatitis C, Parvovirus, HIV, SBE – Neoplastic disease (especially hematogenous) – Autoimmune Disease: Sjogren’s, cryoglobulinemia,… – Chronic Inflammation

IgM directed against the Fc portion of IgG
Present in ~70% of patients with RA
Higher titers associated with more erosive disease

anti-CCP antibodies

(anti-Cyclic Citrullinated Peptide antibodies)

Sensitive (~70%)
Specific (92%-99%) for diagnosis of RA
Early marker for RA

Nishimura K, et al Ann Intern Med. 2007;146:797-808

SLIDE 17

17 Lab tests can help evaluate for RA

RF & CCP combined:
Sensitivity ~80%
Specificity (depends on which one is positive)

Lee DM, Schur P, Ann Rheum Dis. 2003

RF and CCP are helpful to evaluate

patients with joint pain for RA

Tests are limited by their sensitivity
RF is limited by its non-specificity

Which is true?

A. A negative rheumatoid factor is helpful only if IgA,

IgM and IgG isotypes were tested.

B. Rheumatoid factor and CCP have similar

sensitivities for Rheumatoid Arthritis, but have very different levels of specificity

C. CCP is not commonly available and is not routinely

checked.

D. There is no additional value to checking anti-CCP

and rheumatoid factor

Diagnostic Criteria for Rheumatoid Arthritis

Morning stiffness of >1 hour.
Arthritis of hand joints
Symmetric arthritis
Arthritis & soft-tissue swelling of >3 of 14 joints/joint groups
Subcutaneous nodules
Rheumatoid Factor (and anti-CCP antibody)
Radiological changes suggestive of joint erosion

Any combination of 4 or more of 7 criteria for >6 weeks, well-documented at any time during a patient's history, makes it likely that the patient has RA

Arnett FC, et al, Arthritis Rheum 1988

TIP:

Recognize the value of the plain x-ray

Erosions indicate inflammatory arthritis

– Rheumatoid Arthritis – Spondyloarthritis – Crystal Arthritis – Septic Arthritis (Tb)

SLIDE 18

18 RA Normal

X-rays can show early signs of RA

X-rays of the hands & Feet are insensitive but highly specific

Devauchelle-Pensec V, et al, Joint Bone Spine 2002, PMID 12477226

RA Normal

X-rays can show early signs of RA

X-rays of the hands & Feet are insensitive but highly specific

Devauchelle-Pensec V, et al, Joint Bone Spine 2002, PMID 12477226

Tips to help diagnose RA

Search for CLINICAL CLUES!
Prolonged morning stiffness
Check RF and CCP Antibodies
Check x-rays

Clinical Case #3

52 year old woman with 5 months of

worsening joint pain. Initially she had pain in her hands. Pain has developed in her shoulders, neck, lower back, knees and ankles. Pain and stiffness is most severe in the morning.

General physical examination is

unremarkable.

On musculoskeletal exam, are unsure

if there are any swollen joints. She is tender in many areas included over her joints and over some muscle groups.

SLIDE 19

19 Approach to Arthritis

(clinical clues)

age
gender
family history
onset of disease (acute/chronic)
pattern of joint involvement

(& presence of enthesitis)

extra-articular manifestations
diagnostic testing

Ankylosing Spondylitis Regional Pain syndromes Osteoarthritis Fibromyalgia Prevalence of Rheumatic Disorders in the USA (National Arthritis Data Workgroup)

Gout

3 million

Rheumatoid arthritis

1.3 million

Spondyloarthropathies

0.6 – 2.4 million

Polymyalgia rheumatica

0.7 million

Systemic lupus (SLE)

0.2 – 0.3 million

Giant cell arteritis

0.2 million

Lawrence et al Arthritis & Rheumatism 58(1), 26-35, 2008 Helmick et al Arthritis & Rheumatism 58(1), 15-25, 2008

Low back pain

59 million

Neck pain

30 million

Osteoarthritis

27 million

Fibromyalgia

5 million

What are the hallmarks of fibromyalgia? (choose 3)

a) Widespread pain b) Joint Pain c) Non-restful sleep d) Depression e) Fatigue f) Obesity What are the hallmarks of fibromyalgia? (Choose 3) ¡

a) Widespread pain b) Joint Pain c) Non-restful sleep d) Depression e) Fatigue f) Obesity

SLIDE 20

20

What are the hallmarks of fibromyalgia? (Choose 3) a) Widespread pain b) Joint Pain c) Non-restful sleep d) Depression e) Fatigue f) Obesity Diagnosis of Fibromyalgia

ACR classification criteria – Wolfe F, et al, Arthritis Rheum 1990 ACR diagnostic criteria – Wolfe F, et al, Arthritis Rheum 2010

www.ehow.com/about_5059501_fibromyalgia-diagnosis-symptoms.html

Diagnosis of Fibromyalgia

ACR classification criteria – Wolfe F, et al, Arthritis Rheum 1990 ACR diagnostic criteria – Wolfe F, et al, Arthritis Rheum 2010

Tender Point Exam

ACR fibromyalgia classification criteria: pain at 11 of 18 points

SLIDE 21

21

www.fibromyalgia- support.net/downloads/ NewFibroCriteriaSurvey.pdf

Fibromyalgia is present when: WPI score ≥7 SS score ≥5 Fibromyalgia Diagnostic Criteria

r

WPI = 3 – 6 SS score ≥9

Diagnosis of Fibromyalgia

ACR classification criteria – Wolfe F, et al, Arthritis Rheum 1990 ACR diagnostic criteria – Wolfe F, et al, Arthritis Rheum 2010

Work-‑up ¡

Laboratory ¡Tests ¡

– ESR, ¡CRP ¡ – CBC ¡w/ ¡diff ¡ – Comprehensive ¡ Metabolic ¡Panel ¡(inc. ¡ LFTs, ¡Calcium) ¡ – Fas8ng ¡Glucose ¡ – Hepa88s ¡B ¡& ¡C ¡ – TSH, ¡free ¡T4 ¡ – Vitamin ¡D ¡25-‑OH ¡ – CPK ¡(if ¡appropriate) ¡

– ANA ¡(rarely) ¡

X-‑rays ¡of ¡affected ¡

areas ¡to ¡inves8gate ¡ joint ¡damage ¡

Biopsy ¡8ssues ¡that ¡

appear ¡affected ¡(ie. ¡ skin ¡rashes) ¡

EMG ¡for ¡persistent ¡

neurologic ¡symptoms ¡ ¡

¡

Tip offs that suggest your patient may have fibromyalgia:

Multiple different pain complains

– Eg. Back pain, knee pain, neck pain

Activity has consequences

– Eg. If I do ____, I will be in bed for 2 days

No position relieves pain symptoms
The person has odd complaints – “my

body feels like it has tinnitus”

You walk into the room and the lights

are turned down (hypersensitivity).

“Pan-positive review of systems”
You feel exhausted after the interview

SLIDE 22

22 Fibromyalgia

Headache/Migraine TMJ disorder Dermatitis/ pruritis Chronic eye irritation/dryness Atypical chest pain Irritable bowel syndrome Polyuria/frequency (“interstitial cystitis”) Dyspareunia/ vulvodynia Paresthesia Chronic fatigue Muscle Cramps Dypsnea Multiple sensitivities

modified from Aaron LA, et al. Arch Int Med. 2000;160:221-227.

Costs Related to a Diagnose FMS and Failure to Diagnose FMS

Annemans et al, Arthritis Rheum 2008; 58:895 Annemans et al, Arthritis Rheum 2008; 58:895

Costs Related to a Diagnose FMS and Failure to Diagnose FMS

Summary

Use a systematic approach to evaluating a

patient with joint pain

Search for clinical clues
Obtain appropriate (targeted) laboratory

testing