Small Feedings of the Mind Rheumatology Brian J

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 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 DIP JOINTS Second/third MCP It takes me till 11 AM 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-B 27

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. 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 Mean Change From Baseline Change in Total Sharp Score 12 HUMIRA + MTX (n=268) 10 HUMIRA (n=274) MTX (n=257) 8 6 * 5. 7 4 3. 5 * 2 † 2. 1 0. 8 0 0 . 10. 4 26 5. 5 * † † 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 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

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