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Arthritis (RA (Epidemiology (Female:male 2:1, Age 40-60, HLA-DR4 (4x risk)…

- - - - Morning Stiffness >1 hr
      - Improves w/ activity
      - Worsens w/ rest
  - - - DIP hyperextension, PIP flexion
    - - DIP flexion, PIP hyperextension
    - - Risk for paralysis/death w/ intubation!
    - - Rheumatoid nodules (25%)
      - Vasculitis
    - - Anemia (e.g. ACD b/o IL-6 effect on hepcidin) -- improves w/ talizumab before RA symps improve.
      - Thrombocytosis
      - Felty's Synd (1%)
        = neutropenia + splenomegaly (Treat by increasing immunosuppression, e.g. MTX)
  - - - Duration/distribution
      - Classic inflammatory symps
      - Tender, swollen joints
    - - RF (r/o mimickers like hepatitis)
      - Anti-CCP
      - Elevated ESR
      - Elevated CRP
    - - Hand/foot films
      - Periarticular osteopenia
      - Marginal erosions
      - Symmetric joint space narrowing
  - - - MTX
      - Hydroxychloroquine (Plaquenil) (safe in preggo)
      - Sulfasalazine (safe in preggo)
      - Leflunomide
    - - TNF-a inhibitors
      - Tocilizumab (IL-6 inhibitor)
      - Abatacept (target CTLA4 T cells)
      - Rituximab (target CD20 B cells)
      - Tofacitinib (JAK kinase inhibitor)
- - - - Morning stiffness < 30 mins
      - Worse w/ activity
    - - Larger wt bearing joints
      - DIPs, PIPs
      - CMC
      - MTP and mid-foot
  - - - Heberden nodules (DIPs)
      - Bouchard nodules (PIPs)
      - CMC squaring
  - - - Non-inflammatory synovial fluid (WBC<2000)
      - Labs typically not abnormal (note ESR and RF can rise w/ age)
    - - Central erosions
      - "Gull winging"
      - Changes only in DIP, PIP
  - - - Acetaminophen (1000 mg TID)
      - Steroid injections
      - Synvisc
      - Topical therapy (NSAIDs)
      - NSAIDs
    - - Exercise
      - Wt loss
      - Good footwear
      - Bracing/assist devices (e.g. medial wedge insoles for lateral compartment OA)
      - PT (especially quads strength)
      - Pt education
      - Joint replacement