Transcript Small Feedings of the Mind: Rheumatology

Small Feedings of the Mind:
Rheumatology
Brian J. Keroack, MD, FACP, FACR
Question #1: What do I REALLY need to know?
 English measured concordance rate between Rheumatologist and Internist
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before and 6 months after spending a day with a Rheumatologist.
Before 0.4 (F) after 0.9 (A-)
Two things stood out: First can you ask an intelligible question about
morning stiffness and Second can you find joint swelling (synovitis)
Inflammatory Arthritis is what you do not want to miss.
1.5% of the US has Rheumatoid Arthritis, others of note include Psoriatic
Arthritis, Ankylosing Spondylitis.
If you are to stand a chance there are certain TOOLS that you will need
NO NOT THE LAB!!!!
Location, Location, Location
DIP JOINTS
Second/third MCP
It takes me till 11AM to…or,
I just don’t get it I was
splitting wood 4 weeks ago
now I have trouble brushing
my teeth
I have all these bumps and
I cannot make a fist
anymore. If symptomatic;
use related
Progression of Rheumatoid Arthritis
Make the diagnosis HERE
SYNOVITIS
NOT HERE
What’s left after the fire
Listen to the patient—they will tell you the
diagnosis: William Osler
Age <40. Worst in AM. Pain
IMPROVED by exercise not relieved
by rest.
Need to file for disability
cannot even lift a gallon of
milk. Sharp/Mechanical
Symptoms—Please don’t
check HLA-B27
Case
 27 year old male has had back aching for 3
years. He states that the pain is worst in the
morning and occasionally wakes him at
night. He takes 600 mg Ibuprofen TID and
‘never misses a pill’. He almost cancelled
the appointment because changing jobs
from telemarketing to landscaping has
improved his symptoms
 Examination: Decreased side bend cervical
spine at 30 degrees. Schober=2.5 cm
(what is this?)
Most Psoriasis Patients Don’t have Psoriatic
Arthritis, But…
Nails
Dactylitis
Note Asymmetry
Tenosynovitis dominates in
Dactylitis
Clinical Enthesitis
(Spondyloarthropathy)
psoriasis
Achilles enthesitis
Psoriatic Arthritis “Enthesitis”
Gutierrez, Grassi: Clin Rheumatology: (2010) 29: 133-42
Achilles
+doppler
Erosion calcaneus
Medical Management: Immunosupressives
 80 year old female with Rheumatoid Arthritis on Enbrel.
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She presents to the ED with nausea having vomited once.
Afebrile, no other symptoms. She is alert. Presumed viral
gastroenteritis. 24 hours later she is delirious and has a BP
of 60/40 with a HR of 121.
Diagnosis
Gram Negative sepsis from Urinary tract infection
I’ve got at least 7 more stories like this
When these patients present they have a greater burden of
illness and FEWER symptoms
Plethora of ‘TOOLS”
 TNF-a Blockade
 IL-1 RA
 IL-6 Receptor Blocker
 IL-12/IL-23 (Stelara)
 IL-17 (coming soon)
 This category is associated with
standard bacterial infections
 However, when patients do present
they will be further along and will
have fewer (more subtle
symptoms)
 ?No Fever, ? No Cough, No
Dysuria—makes it much more
difficult
PREMIER
Change in Total Sharp Score
12
HUMIRA + MTX (n=268)
10
HUMIRA (n=274)
10.4
MTX (n=257)
8
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6
4
3.5
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2
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2.1
0.8
0
0
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5.5
5.7
26
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3.0
1.9
1.3
52
Weeks
78
104
OMG—If one is good TWO must be better!!! We see a 25% increase in remissions when we add
Methotrexate to ANYTHING---And we add it to EVERYTHING!
 Rituxan ‘Tags’ B-cells
 NK Cells Macrophages
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destroy them
Another system called
complement drills holes in
the rest
Remember not all antibody
producing cells are ‘bad’
So what does THIS mean
Vaccine TIMING is
everything
‘New’ Infection defenses
impared
Hyopgammaglobulinemia
Beyond Biologic Response Modifiers
XELJANZ
 Janus Kinase Inhibitor
 Cytokine hits receptor but
how does message get to
Nucleus?
 JAK-STAT System
 IL-6 (and others) Activates
JAK-STAT system
 Typical Infections
Take Home Message?
 Therapeutic ‘revolution’ has occurred in the management of
Rheumatoid Arthritis and other inflammatory syndromes
 Early diagnosis is the key—we need YOU!!!
 Wildly effective; wildly EXPENSIVE
 You will hear about some associations: ? Multiple Sclerosis,
Lymphoma—These are not relevant and only provide a
distraction to the real problems we face in patients on these
medications (population based data—no statistical link)
 Infection,
Infection, Infection