Tuesday, 12 Nov 2019

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The Best Kind of Arthritis …..Revisited

I was recently asked “what is the best kind of arthritis to have?”

Only a rheumatologist would ruminate on such a quandary and recall many patients who were easily diagnosed and treated and some who were not. There are some rheumatoids who are recalcitrant and impossibly hard to manage, and there are other challenging conditions like scleroderma, ANCA+ vasculitis or fibromyalgia. But, there are many patients with arthritis who are easy to diagnose and manage, even if you’re not a keen-eyed rheumatologist.

To fairly answer this question, I have three criteria: 1) the diagnosis should be easily and readily made (by rheumatologists and others) on clinical more so than laboratory findings; 2) the chance for remission and avoidance of damage must be high; and 3) drug exposure and risk is limited. Based on these guidelines here are my top five answers. 

1. Polymyalgia Rheumatica – also called PMR, this condition affects nearly 400,000 geriatricians in the USA. It almost exclusively occurs in Caucasians over the age of 60, with most being over 70 years old. This is a great diagnosis because a) the symptom onset is rapid and distinctive as these patients just feel miserable, achy, sore, stiff in the shoulders and legs; b) the ESR and C-reactive protein are dramatically high; and (the best part) C) the response to low to modest doses of prednisone (10-15 mg per day) is equally dramatic. With a correct diagnosis these geriatricians turn from weeks or months of misery (losing weight, achy joints, new anemia) to a quick return to function and can be seen playing frisbee and running under sprinklers. The only down side here is that it often takes up to five years to get off the prednisone.

More good news comes with the publication of ACR/EULAR recommendations on the management of PMR (Citation source http://buff.ly/1jRGALL).  This includes 1) assess patient as necessary, including wise use of ANCA, ANA, ACPA testing if indicated; 2) steroids are preferred over NSAIDs; 3) starting minumum effective dose of prednisone 12.5-25 mg/day; 4) taper prednisone to 10 mg/day within 4-8 weeks; and 5) use methotrexate (not TNF inhibitors) as steroid sparing therapy when necessary. 

2. Gout – Gout affects 8.1 million Americans, making it 8x more common than RA and 50% more common than fibromyalgia. Why then do I see tons more FM and RA than I do gout? Wait…I know why…most gout occurs in men and men are clearly the invincible imbeciles of healthcare. Instead of tackling their health issues, men tend to backslide into adolescent wishful-thinking when it comes to their future medical plans. 

Nevertheless, all MDs believe they can diagnose and treat gout. IF the diagnosis of gout was entirely dependent on elevated uric acid level then every stethoscope would be one lab order away from a timely diagnosis of gout.  Unfortunately, ~50% of all acute attacks will present with a normal serum uric acid and only after the attack will the hyperuricemia be revealed. Gout remains an easy diagnosis because once gout starts it is likely to recur and gives the doc more than once chance to get it right. What’s great about gout is that once diagnosed it can be prevented (by lifestyle or drug) or easily managed. Another amazing observation is that as long as you do something to treat gout, the patient will benefit – whether NSAIDs, steroids or colchicine for the acute attack or any urate-lowering therapy (allopurinol or febuxostat) for the worrisome hyperuricemic periods in between. Lastly, gout is a condition that gives you what you deserve. If you don’t smarten up and manage it, your neglect will be rewarded with a gimpy gait, shoes with cut out holes to accommodate that damn big toe and the promise of damaged, deformed, foot-stool dependant foot to accompany you into old age.  

A few new pearls on gout management include evidence that you can either start urate-lowering therapy or continue ULT during the acute attack. Renal insufficiency mandates dose adjustment if using colchicine, but is not necessarily required if using allopurinol. Lastly, despite a flurry research and drug development for new drugs and biologics to treat acute gout or hyperuricemia, rheumatologists and other physicians are still conservative and under-using allopurinol.  Most studies show 300 mg is the top dose in nearly all prescribers, when in fact the dose could be as high as 800 mg per day. Nevertheless, more research and new drugs should create more education and better management of gout.

3. Bursitis or Tendinitis – What most people and physicians don’t know is that most “joint pain” does not come from arthritis or the joints, but instead comes from bursitis or tendinitis. These two conditions often coexist, involving adjacent structures and hence these can be considered together as the culprits underlying many common complaints. In this category are conditions like rotator cuff syndrome (shoulder), trochanteric bursitis (hip), deQuervains tenosynovitis (wrist) and anserine bursitis (knee). Bursae and tendons are supportive structures  that lie in close proximity to the joints and often bear much of the strain or trauma when a joint is stressed. These structures become painful when used repetitively (overuse or repetitive movement syndromes), thereby leading to inflammatory or degenerative changes. Infection and overt damage (strains, tears) are less frequent but more dramatic causes of bursitis/tendinitis. The frequency of bursitis/tendinitis is not officially known but is felt to affect nearly everyone in their lifetime. Knowledge of anatomy, common sites of bursal or tendon inflammation can facilitate a rapid diagnosis. These disorders benefit greatly from the Graucho Marx Medical Edict of “hurts when I do this”, “then don’t do this”. Overuse aggravates, while time and rest is often curative.  Some will benefit from ice applications, immobilization/splinting or the use of steroid injections to hasten the relief and repair.

Most of the management of these periarticular syndromes is done by primary care and orthopedic physicians.  The clue here is when the patient says, "doc, it hurts when I do this". Meaning the specific movements are needed to invoke the action of that tendon or bursa.  As long as therapy involves rest & avoidance of "when I do this", pain relief, ice, injection or physical therapy - most will resolve with time.  (see http://buff.ly/1jz44Ww)

4. Pauciarticular Juvenile Arthritis – This is also known as oligoarticular (meaning few joints involved – usually less than four) juvenile idiopathic arthritis. This form of JIA is the most common form and accounts for over half of all children with JIA.  It may occur as they enter school years or late into their teens. The onset of 1, 2 or 3 swollen joints, even when associated with some inflammatory tests or antinuclear antibodies, may be distressing to the parents and child, but the good news is that many of these children will go into remission and thus the risk of chronic disease, damage or long term drug use is favorably low. These swollen joints still need to be treated aggressively so as to avoid damage and growth disturbances. 

5. “No arthritis at all” – This answer comes from a wise friend who may have been trying to be a “wise guy”.  But while this answer may seem flippant or impossble according to what we currently don’t know, the notion of prevention should be one that doctors discuss with their patients – especially those who have concerns based on bad genes or bad luck. 

Rheumatologists are frequently asked how to avoid arthritis or how to prevent it from getting any worse. There are no proven formulas for this challenge. Instead there is a large amount of population-based lifestyle research that says the following: a) reduce weight and avoid obesity – it’s a risk factor for many kinds of arthritis and increases the odds of non-response to medications; b) stop or avoid smoking – it promotes gingivitis, systemic inflammation and is another risk or amplifying factor for arthritis; c) avoid gingivitis – on this one, your mother was right, brush your teeth, floss and see the dentist; d) consider an anti-inflammatory diet (low/no carbs, low/no gluten); and e) use good footwear – even if not preventative or curative, you’ll look good!

Disclosures: 
The author has no conflicts of interest to disclose related to this subject
Dr. Cush is the Director of Clinical Rheumatology at the Baylor Research Institute and a Professor of Medicine and Rheumatology at Baylor University Medical Center in Dallas, TX. He a Professor of Clinical Medicine at the University of Texas Southwestern Medical School.
 
Dr. Cush is the Executive Editor of RheumNow.com and also Co-Edits the online textbook RheumaKnowledgy.com. 
 
Dr. Cush's research and interests include novel drug development, rheumatoid arthritis, spondyloarthritis, drug safety, pregnancy and Still's disease/autoinflammatory syndromes. He has published over 140 articles and 2 books in rheumatology.
He can be followed on twitter: @RheumNow.