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Rheumatology: OSTEOARTHRITIS RHEUMATOID ARTHRITIS Dr. Meg-angela Christi Amores OSTEOARTHRITIS • Most common type of arthritis • leading cause of disability in the elderly • Mostly affects >65 yrs old Osteoarthritis • Commonly affected joints: • cervical and lumbosacral spine, hip, knee, and first metatarsal phalangeal joint (MTP) • distal and proximal interphalangeal joints and the base of the thumb • Usually spared are the wrist, elbow, and ankle Osteoarthritis • Structural changes: • nearly universal by the elderly years • cartilage loss (seen as joint space loss on x-rays) and osteophytes Severe osteoarthritis in... • distal interphalangeal joints (Heberden's nodes) • proximal interphalangeal joints (Bouchard's nodes) Osteoarthritis • OA is joint failure – a disease in which all structures of the joint have undergone pathologic change – hyaline articular cartilage loss – increasing thickness and sclerosis of the subchondral bony plate, by outgrowth of osteophytes at the joint margin, by stretching of the articular capsule, by mild synovitis Joint protective mechanism • Joint protectors include: joint capsule and ligaments*, muscle, sensory afferents~, and underlying bone • *Fixing the range of joint motion • ~providing feedback , anticipating joint loading • Synovial fluid: major protector against friction-induced cartilage wear • depends on the molecule lubricin • concentration diminishes after joint injury Osteoarthritis • Major risk factors: – Joint vulnerability and joint loading – vulnerable joint whose protectors are dysfunctional can develop OA with minimal levels of loading – in a young joint with competent protectors, a major acute injury or long-term overloading is necessary to precipitate disease Osteoarthritis • Other risk factors: – Age (incidence of disease rising dramatically with age) – hormone loss with menopause – Highly heritable – Hip OA is rare in China, Knee OA is frequent – Major injuries to a joint : e.g. Fracture – Obesity – Repeated use of joint : e.g sports, farming, etc – Malalignment: e.g. varus, valgus • varus, in which the stress is placed across the medial compartment of the knee joint, and valgus, which places excess stress across the lateral compartment of the knee Clinical features: OA • Activity-related joint pain • during or just after joint use • knee or hip pain with going up or down stairs • pain in weight-bearing joints when walking • for hand OA, pain after cooking • Brief morning stiffness <30 mins Treatment • mild and intermittent symptoms may need only reassurance or nonpharmacologic treatments: • • • • altering loading across the painful joint avoid activities that precipitate pain Exercise Correction of malalignment • with ongoing, disabling pain are likely to need both nonpharmaco- and pharmacotherapy • Acetaminophen, Nonsteroidal Anti-Inflammatory Drugs (NSAIDs), and COX-2 Inhibitors Rheumatoid arthritis Rheumatoid Arthritis • chronic multisystem disease of unknown cause • persistent inflammatory synovitis, usually involving peripheral joints in a symmetric distribution • Hallmark: potential of the synovial inflammation to cause cartilage damage and bone erosions and subsequent changes in joint integrity Rheumatoid Arthritis • Epidemiology – prevalence of RA is ~0.8% of the population – Women > men ( 3:1 ) – seen throughout the world and affects all races – onset is most frequent during the fourth and fifth decades of life – genetic predisposition Rheumatoid Arthritis • Unknown cause • might be a manifestation of the response to an infectious agent in a genetically susceptible host • Mycoplasma, Epstein-Barr virus (EBV), cytomegalovirus, parvovirus, and rubella virus • but convincing evidence that these or other infectious agents cause RA has not emerged Rheumatoid Arthritis • propagation of RA is an immunologically mediated event • earliest event appears to be a nonspecific inflammatory response • cascade of cytokines produced in the synovium activates a variety of cells in the synovium, bone, and cartilage to produce effector molecules that can cause tissue damage Rheumatoid Arthritis Clinical features • chronic polyarthritis • begins insidiously with fatigue, anorexia, generalized weakness, and vague musculoskeletal symptoms • hands, wrists, knees, and feet, become affected in a symmetric fashion • by constitutional symptoms, including fever, lymphadenopathy, and splenomegaly (10%) Clinical features • • • • Prolonged morning stiffness (>1 hr) swelling, tenderness, and limitation of motion distal interphalangeal joints are rarely involved Synovitis of the wrist joints is a nearly uniform feature of RA Rhuematoid Arthritis- hand • “Z” deformity • radial deviation at the wrist with ulnar deviation of the digits, often with palmar subluxation of the proximal phalanges • swan-neck deformity • hyperextension of the proximal interphalangeal joints, with compensatory flexion of the distal interphalangeal joints • boutonnière deformity • flexion contracture of the proximal interphalangeal joints and extension of the distal interphalangeal joints Extraarticular manifestations • a systemic disease with a variety of extraarticular manifestations – Rheumatoid nodules – Clinical weakness and atrophy of skeletal muscle – Rheumatoid vasculitis – Pleuropulmonary manifestations – Felty's syndrome – Osteoporosis Laboratory tests • RF (rheumatoid factor) • 2/3 of patients • not specific for RA, present in 5% of healthy • • • • Anti-CCP Normochromic, normocytic anemia ESR increased Synovial fluid analysis • fluid is usually turbid, with reduced viscosity, increased protein content, and a slightly decreased or normal glucose concentration Treatment • Goals: – 1) relief of pain, (2) reduction of inflammation, (3) protection of articular structures, (4) maintenance of function, and (5) control of systemic involvement • Pain meds: – First line: NSAIDS – 2nd line: steroids (glucocorticoids) – 3rd line: DMARDS (methotrexate, gold) OA vs RA OSTEOARTHRITIS Age frequent Hand involvement Wrist involvement Onset of pain Morning stiffness Special features: RHEUMATOID ARTHRITIS