•••••• • acofp••••••• INTENSIVE

UPDATE & BOARD REVIEW

AUGUST 25 - 27, 2017 Loews Chicago O'Hare Hotel

Rosemont, IL

INNOVATIVE • COMPREHENSIVE • HANDS-ON

acofp Am eric an College of

Osteopathi c

Family Physicians

The American College of Osteopathic Family Physicians is accredited by the

American Osteopathic Association Council to sponsor continuing medical

education for osteopathic physicians.

The American College of Osteopathic Family Physicians designates the lectures

and workshops for Category 1-A credits on an hour-for-hour basis, pending

approval by the AOA CCME, ACOFP is not responsible for the content.

Common Rheumatologic Presentations in Primary Care

Natalie A. Nevins, DO, MSHPE

ACOFP FULL DISCLOSURE FOR CME ACTIVITIES

Please check where applicable and sign below. Provide additional pages as necessary.

Name of CME Activity: ACOFP Intensive Update & Board Review in Family Medicine

Dates and Location of CME Activity: August 25 - 27, 2017, Loews Chicago O'Hare Hotel, Rosemont, IL, United States

Topic(s):

OMT Breakout Session #2: Lumbar Spine & Sacrum

Friday, 8/25/17 2:45-4:15pm

4:30-6:00pm

Saturday, 8/26/17 8:30-10:00am 10:15-11:45am

Basic OMT Demonstration Workshop

Friday, 8/25/17 8:00-9:30pm

Focused Topics in Rheumatology

Saturday, 8/26/17 3:00-3:30

Proctor- Test-Taking Skills Workshop: Review of Clinical Scenarios Utilizing a Hands-On Approach in Preparation for

Your Board Examination

Saturday, 8/26/17 6:00-9:00pm

OMT Case Reviews: Pre-Test Session

Thursday, 8/24/17 7:00-9:00pm

Name of Faculty/Moderator: Natalie A. Nevins, DO, MSHPE

DISCLOSURE OF FINANCIAL RELATIONSHIPS WITHIN 12 MONTHS OF DATE OF THIS FORMA. Neither I nor any member of my immediate family has a financial relationship or interest with any proprietary

entity producing health care goods or services.

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health care goods or services. Please check the relationship(s) that applies.

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Organization With Which Relationship Exists Clinical Area Involved

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4. 4.

*If you checked “Speakers’ Bureaus” in item B, please continue:

• Did you participate in company-provided speaker training related to your proposed topic? Yes: No:

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• Did the company provide you with slides of the presentation in which you were trained as a speaker? Yes: No:

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and/or lecture handout materials? Yes: No:

• Will your topic involve information or data obtained from commercial speaker training? Yes: No:

DISCLOSURE OF UNLABELED/INVESTIGATIONAL USES OF PRODUCTS

A. The content of my material(s)/presentation(s) in this CME activity will not include discussion of unapproved or

investigational uses of products or devices.

B. The content of my material(s)/presentation in this CME activity will include discussion of unapproved or

investigational uses of products or devices as indicated below:

I have read the ACOFP policy on full disclosure. If I have indicated a financial relationship or interest, I understand that this information will be

reviewed to determine whether a conflict of interest may exist, and I may be asked to provide additional information. I understand that failure or

refusal to disclose, false disclosure, or inability to resolve conflicts will require the ACOFP to identify a replacement.

Date:

Natalie A. Nevins, DO, MSHPE

Signature:

8/7/2017

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Natalie A. Nevins, D.O., MSHPE

Director of Clinical Education

Western University of Health Sciences

College of Osteopathic

Medicine of the Pacific

Common Rheumatologic Presentations in Primary CareACOFP Board Review 2017

• Is a chronic, systemic, inflammatory disorder of unknown etiology that primarily involves joints

• The most common inflammatory arthritis

• Arthritis is symmetrical, may lead to destruction of joints due to erosion of cartilage and bone which leads to deformity

• Extraarticular manifestations may be present (nodules, neuropathy, scleritis, pericarditis, splenomegaly)

• F>M 2:1, mean age 50-55 (peak age 35-55)

Rheumatoid Arthritis (RA)

ACR RA Diagnostic Criteria5 of 7: 1st 4 must be continuous > 6 wks

Morning stiffness > 1 hour

Arthritis of three or more joint groups with soft tissue swelling

Swelling involving 1 or more joint groups: wrist, proximal IPJ, MCP, MTP

Active symmetric joint swelling

Hand X-ray (usually normal for 1st two years) changes typical of RA that must include erosions or unequivocal bony decalcification

Subcutaneous nodules

+ Rheumatoid factor

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• The characteristic joint deformities appear in more established chronic RA. These findings include ulnar deviation swan neck or Boutonniere deformities of the fingers, or the “bow string” sign (prominence of the tendons in the extensor compartment of the hand)

• Occasional patients present with extensor tendon rupture, most commonly affecting the thumb, little or ring fingers of either hand

RA - Hands

Disease-Modifying

AntirheumaticDrugs

(DMARDS)

• DMARDS are divided into two categories: nonbiological and biological

• The nonbiological: methotrexate, sulfasalazine, lefunomide (Pyrimidine synthesis inhibitor), all primary options. Hyroxychloroquine: typically used in combination with the other DMARDS.

• The biological DMARDS: target specific cytokines or their receptors, such as tumor necrosis factor. Other types of biological DMARDS include B cell depleting agents and Tcellcostimulatory blockers. The use of biologic DMARDS has been referred to as “targeted therapy”

1st line for mild-moderate disease at

initial presentation

• Possible options:• Mild-moderate disease is usually

started on a single DMARD. MTX most common first line drug. Other options leflunomide (LEF), sulfasalazine (SSZ), and hydroxychloroquine (HCQ)

• The addition of ONE of the following agents to MTX:• tumor necrosis factor (TNF)

inhibitor: adalimumab, etanercept, or infliximab,

• abatacept (T cell costimulationblocker),

• rituximab (Pre-B cell depleter), • anakinra (interleukin-1 receptor

antagonist)

Treatment

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Juvenile Idiopathic Arthritis (JIA/JRA)• Most common form of chronic arthritis

in children

• Onset <16 y/o

• Pain, joint swelling, decreased rom > 6 weeks

• 3 subtypes (per ACR criteria):• Systemic: 10-20% fever, evanescent

rash• Polyarticular: 30-40%, > 4 joint

involvement (large and small)• Pauciarticular: 40-50%, <=4 joints

(large), risk for chronic uveitis in girls and axial skeleton in boys.

JRA

• ANA (baseline test)+ 40% (poly or pauci)

• RA factor (2 positive tests required for diagnosis of RF pos PA JIA) + 10-15%

• HLA-B27 + 70% of Pauci boys

• ESR (maybe normal or elevated) nonspecific

• Radiology: soft tissue swelling, periosteal reaction, juxta-articular demineralization

• First line PT and OT with lifestyle modifications in conjunction with Nsaids (effective in 50%)

• DMARDS if not responsive

A 32-year-old female presents with complaints of joint

stiffness over the last two months. She reports the pain is worse in the morning than at night. On physical exam, her wrists and MCP joints are red and erythematous as is her

right knee.What is the most likely

diagnosis?

A. Polymyalgia rheumatica

B. Lyme's disease

C. Parvovirus B19 infection

D. Rheumatoid arthritis

E. SLE

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A 3-year-old child presents with a fever, an evanescent

salmon-colored rash, arthritis,

hepatosplenomegaly, and a pericardial effusion. Lab

results show an elevated ESR and a CBC that reveals absolute neutrophilic

leukocytosis. What is the most likely diagnosis?

A. Polymyalgia rheumatica

B. Septic joint

C. Juvenile Idiopathic Arthritis (JIA/JRA)

D. Gout

E. Trauma

Systemic Lupus Erythematosus(SLE)• Multisystem, Autoimmune

inflammatory condition

• Genetic Markers: HLA-B8, HLA-DR2, HLA-DR3

• Risk factor Age 15-45, F>M 10:1

• Increased risk in African American, Hispanic, Asian and Native American

• Hereditary Compliment deficiency: C1q, C1r, C1s, C4 and C2

SLE Complications

• Fever

• Vasculitis

• Panniculitis

• Myositis

• Avascular Necorisis

• Endocarditis

• Ascites

• Venous thrombosis

• Pulmonary Fibrosis

• Renal failure

• Peripheral neuropathy

• Stroke syndromes

• Pancreatitis/ elevated LFT’s

• Infertility

• Seizures

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ACR Criteria for

SLEAny 4

manifestations of the

following 11

1. Malar rash (Butterfly)

2. Discoid rash

3. Photosensitivity rash

4. Oral ulcers

5. Arthritis: Nonerosive Involving 2 or more peripheral joints

6. Serositis: Pleuritis or Pericarditis a) Pleuritis

7. Renal Disorder a) Persistent proteinuria > 0.5 grams per day OR b) Cellular casts--may be red cell, hemoglobin, granular, tubular, or mixed

8. Neurologic Disorder a) Seizures OR b) Psychosis

9. Hematologic Disorder a) Hemolytic anemia--with reticulocytosis OR b) Leukopenia < 4,000/mm3 on ≥ 2 occasions OR c) Lymphopenia--< 1,500/ mm3 on ≥ 2 occasions OR d) Thrombocytopenia--<100,000/ mm3

10. Immunologic Disorder a) Anti-DNA: antibody to native DNA in abnormal titer OR b) Anti-Sm: presence of antibody to Sm nuclear antigen OR c) Positive finding of antiphospholipid antibodies on: an abnormal serum level of IgG or IgM anticardiolipin antibodies, a positive test result for lupus anticoagulant using a standard method, or a false-positive test result for at least 6 months confirmed by Treponema pallidum immobilization or fluorescent treponemal antibody absorption test.

11. Positive Antinuclear Antibody An abnormal titer of antinuclear antibody by immunofluorescence or an equivalent assay at any point in time and in the absence of drugs

2012 Systemic Lupus International Collaborating Clinics (SLICC) criteria for the classification of SLE4 of 17 criteria, including at least one clinical criterion and one immunologic criterion; OR biopsy-proven lupus nephritis)

• Adds: Nonscarring alopecia

• Low complement

• Direct Coombs' test

• Subdivides:

• Acute vs chronic cutaneous lupus

• Oral or nasal ulcers

• Hemolytic anemia/ Leukopenia or lymphopenia/ Thrombocytopenia

• Anti-dsDNA/ Anti-Sm/ Antiphospholipid antibody

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Labs• + ANA (15% false pos in

elderly)

• Anti-DS DNA

• Anti-SM

• False + VDRL

• + LE Prep

• Increased creatinine

• + Coombs test

• Sed Rate (nonspecific)

• Anemia

• Anticardiolipin AB

• Leukopenia/Lymphopenia/thrombo-cytopenia

• Proteinuria

• Activated PTT (prolonged with anti phos AB)

Gout

• Inflammatory reaction to URATE crystals in joints, bones and subcutaneous structures

• Crystals in joint fluid is pathognomonic

• Hyperacute arthritis• Primary: Most common, under-

excretion or overproduction of uric acid

• Secondary: related to myloproliferative DZ, treatments inducing hyperuricemia, renal failure/tubluar disorders, glycogen storage dz

Gout

• Age 30-60, M>F 20:1

• Risks: ETOH, Fam hx, MEDS (diuretics induce 20% of secondary gout), obesity/HTN (50%), diet

• S/S: <24 hour onset of severe joint/soft tissue: pain, swelling, redness/warmth in 1-2 joints. 75% monoarticular, 1st MTP in 50% of 1st attack.

• Sub q or interosseous nodules 20%, called tophi

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Gout

• X-ray normal 1st year

• Chronic gout gets “punched out” erosions with “overhanging edge” of periostium over the erosion.

• Arthrocentesis with synovial fluid analysis, Wet mount: synovial fluid strongly negatively birefringent urate crystals on the polarizing exam

• Uric acid: get 2 weeks after attack

Resolves, may be false low or normal during attack (>7mg/dl men, >6mg/dl women)

• Risk of kidney stones

Gout Treatment

Avoid

Avoid foods high in purines, such as liver and other organ meats, veal, turkey, and some types of fish, including anchovies, shrimp, mackerel, and scallops.

Stop

Stop drinking large amounts of alcohol. Alcohol interferes with excretion of uric acid, and alcoholic beverages contain purines

Lose

Lose Weight

Gout Treatment

Acute: NSAIDs (first line) for 10-14 days

Treatment of gout should be initiated with an NSAIDs to control acute inflammation. At the maximum recommended doses, NSAIDs effectively treat arthritis caused by crystals.

Unlike the newer, equally effective NSAIDs, indomethacin frequently causes dyspepsia and can cause central nervous system side effects such as headache and mental status changes

Antigout Agents

Colchicine (second line), may be helpful with patients who cannot tolerate or have contraindications to NSAIDs and corticosteroids.

With the availability of other agents, however, there is little role for colchicine in the treatment of acute gout, particularly in elderly patients.

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Gout Treatment

• Recurrent Gout: 2-3 weeks post acute episode

• First line: Urate lowering agent

• Allopurinol, Febuxostat

FDA Approved for Gout

Naproxen

Ibuprofen

Diclofenac Potassium

Meloxicam

Celecoxib

Febuxostat

Triamcinolone acetonide

Prednisone/methylpred/

Indomethacin

Probenecid

Sulindac

Allopurinol

Colchicine

Pseudogout

Acute inflammatory arthritic disease usually involving large joints

Arthrocentesis Synovial fluid

Calcium pyrophosphate dihydrate crystal (CPPD) deposition disease

Associated with chondrocalcinosis

80% > 60 y/o

Knee involved 50% of all attacks

50% with fever

Elevated sed rate, leukocytosis (may have left shift)

Treatment: Nsaids

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A 21-year-old African-American female presents to the clinic complaining of weakness and

malaise, which has grown worse over the last month. She has lost 9 lb despite maintaining her regular diet. She reports that whenever she goes into the sun she gets a

painful rash on her face. She has a fever. Laboratory results reveal

that she is ANA positive.What is the most likely diagnosis?

A. Lymphoma

B. SLE

C. HIV/AIDS

D. Leukemia

E. Bacterial Endocarditis

Reactive Arthritis (formerly known as Reiter’s Syndrome)

• Triad of Arthritis, conjunctivitis and either urethritis or cervicitis. 4th feature may be buccal ulceration or balanitis

• Sterile joint inflammation with infection starting at non-articular site

• 2 forms:

• Sexually transmitted: S/S emerge 7-14 days after sex (Chlamydia usual organism)

• Postdysenteric (shigella, salmonella, yersina, campylobacter). More common in Women, children and elderly.

Reactive Arthritis

HLA-B27 in 60-80%

20-40 y/o M>F

Ankylosing spondylitis develops in 30-50% in those + for HLA-B27

Asymmetric arthritis (knees, ankles, MTP)

Enthsopathy

Urogenital tract: Urethritis/prostatitisetc.

Eye: Conjunctivitis/scleritis/keratitis

Skin: mucocutaneous ulcers

Constitutional: fever, malaise, wt loss

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Reactive Arthritis

• most common presentation is an asymmetric arthritis, usually a large or medium sized joint of the lower extremities after an infection that the patient may or may not remember

• WBC: 10-20,000

• Increased neutrophils

• Increased sed rate

• Normochromic anemia

• Hypergammaglobulinemia

Polyarteritis Nodosa

Ongoing segmental inflammatory, systemic necrotizing vasculitis within the media of medium sized muscular arteries

Multisystem involvement: fever, wt loss, malaise, Skin (livedo reticularis), CNS (HA, sz), Renal, MSK, GI, Lung, Cardiac

Labs: nonspecific, may have RF, endothelial cell AB, high neutrophil, anemia, elevated sed rate & C-reactive protein. Hepatitis surface antigen + in 10-50% of cases. Negative ANA and RF

BX of involved organs: necrotizing vasculitis

Angiogram with aneurysmal changes

Treatment (Non-HBV related):

Good Prognosis: Prednisone

Poor Prognosis: Prednisone and DMARD

Severe disease: is treated with cyclophosphamide

ACR Diagnosis of

PNAt least 3 of

the 10criteria are

present

1. Weight loss: of 4 kg or more of body weight since illness began, not due to dieting or other factors

2. Livedo reticularis

3. Testicular pain or tenderness Pain or tenderness of the testicles

4. Myalgias, weakness or leg tenderness Diffuse myalgias (excluding shoulder and hip girdle) or weakness of muscles or tenderness of leg muscles

5. Mononeuropathy or polyneuropathy Development of mononeuropathy, multiple mononeuropathys, or polyneuropathy

6. Diastolic BP >90 mm Hg Development of hypertension with diastolic BP higher than 90 mm Hg

7. Elevated BUN or creatinine Elevation of BUN >40 mg/dl or creatinine >1.5 mg/dl

8. Hepatitis B virus Presence of hepatitis B surface antigen or antibody in serum

9. Arteriographic abnormality Arteriogram showing aneurysms or occlusions of the visceral arteries, not due to arteriosclerosis, fibromuscular dysplasia, or other noninflammatory causes

10. Biopsy of small or medium-sized artery containing PMN Histologic changes showing the presence of granulocytes or granulocytes and mononuclear leukocytes in the artery wall

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A 32-year-old business man returns from a trip abroad. He presents to his primary care

physician a few days later complaining of pain on urination. His physician notes that he has a

slight limp and severe uveitis.What is the most likely diagnosis?

A. Psoriasis

B. SLE

C. Rheumatoid arthritis

D. Ankylosing spondylitis

E. Reactive Arthritis / Reiter's Syndrome

Fibromyalgia: A Clinical DiagnosisSymptoms

Widespread pain

Stiffness

Poor sleep

Fatigue

Swelling in soft tissue (especially hands)

Numbness in the extremities

Headaches

Restless Leg Syndrome

Diarrhea

Abdominal pain

Tender joints

Limited range of motion

Jaw pain

Memory impairment

Menstrual cramping

Dizziness

Skin and chemical sensitivities

Fibromyalgia: Diagnosis

• Restless sleep and fatigue

• Hx of widespread pain & Pain in 11 of 18 tender point sites on digital palpation for at least 3 months

Occiput: Bilateral, at the suboccipital muscle insertions. Low cervical: bilateral, at the anterior aspects of the intertransverse spaces at C5-C7.Trapezius: bilateral, at the midpoint of the upper border. Supraspinatus: bilateral, at origins, above the scapula spine near the medial border.Second rib: bilateral, at the second costochondral junctions, just lateral to the junctions on upper surfaces.Lateral epicondyle: bilateral, 2 cm distal to the epicondyles. Gluteal: bilateral, in upper outer quadrants of buttocks in anterior fold of muscle.Greater trochanter: bilateral, posterior to the trochanteric prominence.Knee: bilateral, at the medial fat pad proximal to the joint line.

80-95% are women

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Treatment

First Line: Graded Aerobic Exercise: Walking,

Pool, Strength training Cognitive - behavior therapy Good sleep hygiene

Second line: Mind-Body Therapies: Biofeedback,

Guided Imagery, hypnosis

FDA Approved Meds:◦ Tricyclic Antidepresants◦ Cymbalta (Duloxetine HCl)◦ Lyrica (Pregabalin )◦ Savella (Milnacipran HCl)

Thank you!