Brian J. Keroack, MD, FACP, FACR

Small Feedings of the Mind: Rheumatology

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 needNO NOT THE LAB!!!!

Location, Location, Location

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

DIP JOINTS

Second/third MCP

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…

Note AsymmetryTenosynovitis dominates in Dactylitis

Dactylitis

Nails

Clinical Enthesitis (Spondyloarthropathy)

psoriasis

Achilles enthesitis

Psoriatic Arthritis “Enthesitis”Gutierrez, Grassi: Clin Rheumatology: (2010) 29: 133-42

Achilles

Erosion calcaneus+doppler

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.

DiagnosisGram Negative sepsis from Urinary tract

infectionI’ve got at least 7 more stories like thisWhen these patients present they have a

greater burden of illness and FEWER symptoms

Plethora of ‘TOOLS”TNF- BlockadeIL-1 RAIL-6 Receptor BlockerIL-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

Change in Total Sharp ScorePREMIER

.

1.9

5.5

10.4

1.30.8

3.02.1

5.7

3.5

0

2

4

6

8

10

12

0 26 52 78 104

HUMIRA + MTX (n=268)

HUMIRA (n=274)

MTX (n=257)

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WeeksOMG—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-cellsNK 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

Hyopgammaglobulinemia

Beyond Biologic Response Modifiers

XELJANZ

Janus Kinase InhibitorCytokine hits

receptor but how does message get to Nucleus?

JAK-STAT SystemIL-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 EXPENSIVEYou 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