Overview of Rheumatology

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1 Overview of Rheumatology Griffin Hospital Mini Med School Stephen Moses, MD Valley Medical Associates 135 Division St. Ansonia, CT

2 Topics I. Anatomy of a Joint II. Osteoarthritis III. Rheumatoid Arthritis IV. Gout V. Infectious Arthritis VI. Psoriatic Arthritis, IBD Arthritis, Spondyloarthritis VII. Systemic Lupus Erythematosis VIII. Tendonitis/Bursitis Treatment

3 Joint Anatomy

4 Osteoarthritis

5 Osteoarthritis

6 Osteoarthritis

7 Osteoarthritis

8 Osteoarthritis

9 Rheumatoid Arthritis Affects more than two million Americans Direct and indirect cost reached $65 billion in 1992 More than 75 percent of RA patients are women Peak onset is between age 20 and 45 Osteoporosis is common in patients with RA

10 Rheumatoid Arthritis

11 Rheumatoid Arthritis Hand Deformities Rheumatoid Nodules

12 Rheumatoid Arthritis Hand Deformities

13 Rheumatoid Arthritis Foot Deformities

14 The Pathology of Rheumatoid Arthritis Feldmann M, et al. Annu Rev of Immuno. 1996; 14:

15 Diagnosing Rheumatoid Arthritis History Morning stiffness Symmetrical arthritis Physical Exam Swollen and tender joints Symmetrical involvement Laboratory Tests Rheumatoid Factor Sed Rate CRP Xrays Hands and feet Other involved joints

16 ACR Criteria for Classification of Rheumatoid Arthritis Morning stiffness Arthritis of 3 or more joint areas Arthritis of hand joints Symmetric arthritis Rheumatoid nodules Serum rheumatoid factor Radiographic changes Arnett FC, et al. Arthritis Rheum. 1988;31:

17 Rheumatoid Arthritis

18 Gout

19 Gout

20 Gout

21 Gout

22 Gout

23 Gout

24 Septic Arthritis Definition: Infection of the joint space Monoarticular Polyarticular Suppurative Nonsuppurative

25 Infectious Arthritis

26 Infectious Arthritis

27 Infectious Arthritis

28 Infectious Arthritis

29 Infectious Arthritis

30 Psoriatic Arthritis

31 Psoriatic Arthritis

32 Colitic Arthritis

33 Colitic Arthritis

34 S.L.E.

35 S.L.E.

36 S.L.E.

37 Systemic Lupus Erythematosus S.L.E. Chronic inflammatory connective tissue disease Probable autoimmune origin

38 S.L.E.

39 S.L.E.

40 S.L.E.

41 Tendonitis

42 Tendonitis

43 Tendonitis

44 Tendonitis

45 Tendonitis

46 Tendonitis

47 Tendonitis

48 Bursitis

49 Bursitis

50 Bursitis

51 Bursitis

52 Bursitis

53 Treatment I. II. III. IV. V. VI. Analgesics Anti Inflammatory Drugs (NSAIDS) DMARDS Steroid Injections Physical Therapy Unconventional Therapies

54 Traditional NSAIDs (Nonsteroidal Anti-inflammatory Drugs) Diclofenac (Voltaren) Etodolac (Lodine) Fenoprofen (Nalfon) Flurbiprofen (Ansaid) Indomethacin (Indocin) Ibuprofen (Motrin, Advil) Ketoprofen (Orudus, Oruvail) Nabumetome (Relafen) Naproxen (Naprosyn, Aleve) Oxaprozin (Daypro) Piroxicam (Feldene) Sulindac (Clinoril) Tolmetin (Tolectin)

55 Blocking Inflammation The Good Guy and the Bad Guy COX 1 (Good Guy) Protects the stomach Helps blood clotting Protects the kidneys COX 2 (Bad Guy) Causes inflammation Old NSAID s block both New NSAID s block only COX 2

56 Cox 2 Inhibitors--Advantages Safer in GI tract No effect on platelets Little or no interaction with blood thinners

57 Cox 2 Inhibitors Celecoxib (Celebrex) Vioxx (Rofecoxib) Bextra (Valdecoxib)

58 Ulcers Seen After Treatment With a Cox-2 Inhibitor 30% 26% 25% 20% 15% 10% 5% 4% 6%* 4%* 6%* 0% Placebo Naproxen Celecoxib Celecoxib Celecoxib 500 mg bid 100 mg bid 200 mg bid 400 mg bid Correlation between findings of endoscopic studies and relative incidence of clinically serious upper GI events not fully established. *P<0.001 vs naproxen. Simon et al. JAMA. 1999;282:

59 Goals of Therapy in RA Symptomatic relief of disease activity Improve physical function reduce physical disability Intervene in slowing/arresting progression of structural damage Guidelines for the Management of RA. Arthritis Rheum. 1996; 39:

60 Drugs for Rheumatoid Arthritis Sulfasalazine (Azulfidine) Minocycline Hydroxychloroquin (Plaquenil) Gold Salts Methotrexate Leflutamide (Arava) Etanercept (Enbrel) Inflixamab (Remicade) Adalimumab (Humira) Anikinra (Kineret)

61 Advantages of DMARDs (Disease Modifying Antirheumatic Drugs) Reduce signs and symptoms of RA Reduce functional disability Retard radiographic progression

62 Other Treatments Complementary Therapies Used in addition to traditional medical treatment Some published studies-often limited Biological plausibility Alternative Therapies Used in place of traditional medical treatments No published studies Effects and side effects unknown

63 Alternative Healing Systems Types Bee Venom Copper Bracelets Magnets No Nightshade Diet

64 Arthritis Quackery Snake Venom Dessicated Liver Pills Injection of Sex Hormones Lemon Juice Shark Cartilage Chelation Inductoscope Gin Soaked Raisins Chuifong Toukuwan Congo Kit Honey & Vinegar Arthritis Ease Capsules Copper bracelets DMSO Acu-Dot Submersion in Cow Manure New Zealand Greenlipped Muscle Extract

65 Exercise and Arthritis

66 Exercise

67 Exercise

68 Exercise

69 Questions?

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