What a Pain! Tales of Adult Arthritides (Ramirez, 3/31/2021)

Thank you to Dr. Vanessa Ramirez for her review of two very important inflammatory arthritides at Grand Rounds this week: psoriatic arthritis and gout.  I gleaned so many important pearls from her presentation. For those of you interested in seeing the full recording, it is available here. My summary notes are below:

Inflammatory arthritides

• infectious (septic)
• crystal induced (gout, pseudogout)
• immune related (RA, SLE, psoriatic arthritis, dermatomyositis, Sjogren's)
• reactive

Psoriatic arthritis (PsA) 

• PsA affects about 20% of people with psoriasis 
• skin changes can precede arthritis sx for years-- even up to 12 years
• skin changes and PsA flares are not necessarily temporally related, nor is disease severity necessarily correlated
• typically asymmetric arthritis (in one, several or multiple joints), sacroiliitis (30-78%) 
• historic definition of PsA: serological negative (i.e. negative rheumatoid factor) polyarticular arthritis in someone with psoriasis skin manifestations
• classification Criteria for Psoriatic Arthritis (CASPAR) (2006) may be helpful in making this clinical diagnosis (see image below)
• early identification and treatment prevents joint destruction
• anti-CCP may be elevated (usually mild) in 12% of patients with PsA
• more likely in higher numbers of involved joints
• Risk factors for PsA
• scalp psoriasis 4x risk, intergluteal/perianal 2.3x risk, nail involvement
• earlier age at dx with psoriasis, >3 body sites affected, family hx of PsA (first degree)
• ESR is superior to CRP as a marker of damage progression and mortality
• Treatment for PSA includes lifestyle modification (diet, smoking cessation, exercise), followed by symptomatic treatments (NSAID, steroids, injections) and then TNF alphas
• see images below from the 2018 ACR Guidelines
• also see AAFP image, which includes cost of these treatments

2018 ACR Guidelines for Treatment of PsA

https://www.rheumatology.org/Portals/0/Files/PsA-Guideline-2018.pdf

https://www.rheumatology.org/Portals/0/Files/PsA-Guideline-2018.pdf

AAFP Psoriasis (Am Family Physician 2013)

https://www.aafp.org/afp/2013/0501/p626.html

Gout 

• Gout is caused by deposition of monosodium urate crystals in the joint space, periarticular structures and soft tissues
• associated with obesity, htn, hyperlipidemia, DM, CKD, heart failure, thiazide diuretic 
• ACR online tool Clinical prediction (see image)

• 

  https://www.aafp.org/afp/2020/1101/p533.html

  
  
  
• Treatment Acute
• 2020 ACR Guidelines for Treatment of Gout Flare
• Naproxen 500 mg BID OR indomethacin 50 mg TID, ibuprofen 800mg TID
• Colchicine (low dose) 1.2mg PO, then 0.6mg 1 hour later, then BID until flare resolves
• Oral prednisone 0.5mg/kg (5-10 days full dose then stop OR 2-5 days full dose and then taper over 7-10 days)
• Treatment Chronic
• all patients with tophi, radiographic evidence or damage or 2+ flares/year
• goal is symptom relief AND maintenance of urate levels (<6)
• we should be titrating allopurinol based on checking uric acid levels
• Allopurinol is treatment of choice, lower doses preferred to start
• if on thiazide for BP, switch to losartan