QD94 - When It's Not RA Save
QD Clinic - Lessons from the clinic
What to do when its no longer RA or is "burnt-out" RA
Features Dr. Jack Cush
Transcription
Welcome to QD Clinic. Hi. I'm doctor Jack Cush with RheumNow. This episode is brought to you by RheumNow's virtual coverage of ACR twenty twenty reporting, analysis, and perspective. That's what we're gonna do on the website.
Be sure to check it out. Today's case, what to do when it's not RA. So I saw this patient last week, 70 year old gal who had been diagnosed twenty years ago with rheumatoid arthritis. At the time, the patient had bilateral swollen wrists. Sounds like RA.
It was inflammatory. It didn't respond to whatever treatment she got, she didn't remember, but she did get bilateral synovectomies, which were inconclusive, meaning that's kind of what you get when you do a synovial biopsy in RA, it's chronic inflammation and, you know, you don't usually see germinal centers or things that are truly diagnostic. So she was treated as someone who had rheumatoid arthritis. Oh, and her rheumatoid tests were supposedly positive. She says that early on she got, a TNF inhibitor that was infused and, boy, fabulous response.
She also got methotrexate and when she could no longer afford the infusible TNF inhibitor, she was maintained on methotrexate and, gee, that was almost good enough. And then six months ago, she, ran out of methotrexate. Her doc you know, why why do you stop drugs? Well, you know, the doctor retired, lost the prescription, COVID nineteen, you know, dog ate my homework, a million and one reasons why people stopped their medicine. She stopped her medicines, and she thinks that since then she's gotten worse.
The thing is, when you examine the patient, she's got fairly normal looking hands, except she's got scars over both wrists and limitation of motion where she really can't flex and extend as she should, suggesting there's damage there. What from? I don't know. But the rest of the exam, pretty much normal. Tender a few tender points, and that's really the source of her pain.
She does sleep blousy, but RA synovitis? No. RA deformities? No. MTP possibilities, not a chance.
Nodules don't exist. It's not RA, at least not now. So, that's sort of the first discussion. Patient comes in with a firm belief that it's rheumatoid arthritis and it no longer is. I think, I always take the tact, I wasn't there twenty years ago when you had all this going on, and gee, it sure sounded like rheumatoid arthritis.
The good news is that it's no longer a problem. You don't have to have rheumatoid arthritis for the rest for your whole life. RA does burn out after twenty or thirty years, seldom after five years, and maybe this is a case of burnt out RA. Well, she had lab tests done, and she is in fact zero negative for rheumatoid factor, CCP, ANA. Uric acid was normal.
Got a fairly normal looking lab. No signs of chronic inflammation or hypoalbuminemia or hyper, anything or l o LFT elevation. They're all normal. So, again, the good news is RA is not in play, but you do have pain. We do know that it's myofascial.
You may have some degenerative damage and or mechanical damage to whatever you did in your wrist. So first question is explaining how RA can go away, and RA does burn out. The second question is, what is going on? And I think that the longer someone has a history like this, the more you're calling it maybe now difficult or refractory disease, or you maybe you've gone through and tried a number of DMARDs, and tried a number of biologics, or tried a number of small molecule targeted synthetic DMARDs, and you're not getting better, you should now start to rethink that this is no longer immune mediated or inflammatory. And you should be thinking that, number one, the problem could be structural.
And I think if that's the case, then imaging usually is, going to give you the most, telltale answers on what to do and how to proceed. Next, that the problem could be periarticular. That's really evident in cases of shoulder and knee where you can quite commonly have in these burnt out patients, you know, rotator cuff disease and or meniscal tears and other periarticular damage. The same could exist also in the feet and in the hands, and you may need to involve specialists. You need to exclude weakness as the cause for pain, especially as people burn out and get older.
So I tend to rely in such patients on imaging, orthopedic and physical medicine referrals, and PT when necessary when dealing with the issue of, weakness. If you're not strong, you're gonna hurt. If you hurt, you're gonna get weak. If you weak get weak, you're gonna hurt more. Again, there's a spiral of weakness and pain.
And of course, can have, as this patient did, myofascial pain or fibromyalgia related to poor sleep. Interestingly, a colleague of mine had a similar question at a recent grand rounds that I did on, changing paradigms, where I, was saying that, you know, what I do in managing people, and the question that she put forward to me is, in someone who I think has burnt out RA, what do you do? When do you use a DMARD? Well, do what I just said. I think structural, I think weakness, I think periarticular, ortho imaging, PM and R as my solutions rather than DMARDs.
When would I use a DMARD? I use a DMARD when I can prove by exam or by imaging that synovitis, tenosynovitis, synovial flu synovial fluid effusions is something that a DMARD might be indicated. I don't use DMARDs for pain. I don't use DMARDs for elevated sed rate and CRP. I don't use DMARDs for X rays.
X rays are gonna change. X rays are what you have X-ray findings of erosions and damage is damaged. The damage is already done. And, again again, you have to be clear about what the goal of DMAR therapy and DMAR initiation is going to be. So what do you do when it's not RA?
Well, number one, make the decision it's not RA, and number two, move on to these other options. Again, reporting, analysis, perspectives. Follow us at RheumNow during ACR twenty twenty. Take care.
Be sure to check it out. Today's case, what to do when it's not RA. So I saw this patient last week, 70 year old gal who had been diagnosed twenty years ago with rheumatoid arthritis. At the time, the patient had bilateral swollen wrists. Sounds like RA.
It was inflammatory. It didn't respond to whatever treatment she got, she didn't remember, but she did get bilateral synovectomies, which were inconclusive, meaning that's kind of what you get when you do a synovial biopsy in RA, it's chronic inflammation and, you know, you don't usually see germinal centers or things that are truly diagnostic. So she was treated as someone who had rheumatoid arthritis. Oh, and her rheumatoid tests were supposedly positive. She says that early on she got, a TNF inhibitor that was infused and, boy, fabulous response.
She also got methotrexate and when she could no longer afford the infusible TNF inhibitor, she was maintained on methotrexate and, gee, that was almost good enough. And then six months ago, she, ran out of methotrexate. Her doc you know, why why do you stop drugs? Well, you know, the doctor retired, lost the prescription, COVID nineteen, you know, dog ate my homework, a million and one reasons why people stopped their medicine. She stopped her medicines, and she thinks that since then she's gotten worse.
The thing is, when you examine the patient, she's got fairly normal looking hands, except she's got scars over both wrists and limitation of motion where she really can't flex and extend as she should, suggesting there's damage there. What from? I don't know. But the rest of the exam, pretty much normal. Tender a few tender points, and that's really the source of her pain.
She does sleep blousy, but RA synovitis? No. RA deformities? No. MTP possibilities, not a chance.
Nodules don't exist. It's not RA, at least not now. So, that's sort of the first discussion. Patient comes in with a firm belief that it's rheumatoid arthritis and it no longer is. I think, I always take the tact, I wasn't there twenty years ago when you had all this going on, and gee, it sure sounded like rheumatoid arthritis.
The good news is that it's no longer a problem. You don't have to have rheumatoid arthritis for the rest for your whole life. RA does burn out after twenty or thirty years, seldom after five years, and maybe this is a case of burnt out RA. Well, she had lab tests done, and she is in fact zero negative for rheumatoid factor, CCP, ANA. Uric acid was normal.
Got a fairly normal looking lab. No signs of chronic inflammation or hypoalbuminemia or hyper, anything or l o LFT elevation. They're all normal. So, again, the good news is RA is not in play, but you do have pain. We do know that it's myofascial.
You may have some degenerative damage and or mechanical damage to whatever you did in your wrist. So first question is explaining how RA can go away, and RA does burn out. The second question is, what is going on? And I think that the longer someone has a history like this, the more you're calling it maybe now difficult or refractory disease, or you maybe you've gone through and tried a number of DMARDs, and tried a number of biologics, or tried a number of small molecule targeted synthetic DMARDs, and you're not getting better, you should now start to rethink that this is no longer immune mediated or inflammatory. And you should be thinking that, number one, the problem could be structural.
And I think if that's the case, then imaging usually is, going to give you the most, telltale answers on what to do and how to proceed. Next, that the problem could be periarticular. That's really evident in cases of shoulder and knee where you can quite commonly have in these burnt out patients, you know, rotator cuff disease and or meniscal tears and other periarticular damage. The same could exist also in the feet and in the hands, and you may need to involve specialists. You need to exclude weakness as the cause for pain, especially as people burn out and get older.
So I tend to rely in such patients on imaging, orthopedic and physical medicine referrals, and PT when necessary when dealing with the issue of, weakness. If you're not strong, you're gonna hurt. If you hurt, you're gonna get weak. If you weak get weak, you're gonna hurt more. Again, there's a spiral of weakness and pain.
And of course, can have, as this patient did, myofascial pain or fibromyalgia related to poor sleep. Interestingly, a colleague of mine had a similar question at a recent grand rounds that I did on, changing paradigms, where I, was saying that, you know, what I do in managing people, and the question that she put forward to me is, in someone who I think has burnt out RA, what do you do? When do you use a DMARD? Well, do what I just said. I think structural, I think weakness, I think periarticular, ortho imaging, PM and R as my solutions rather than DMARDs.
When would I use a DMARD? I use a DMARD when I can prove by exam or by imaging that synovitis, tenosynovitis, synovial flu synovial fluid effusions is something that a DMARD might be indicated. I don't use DMARDs for pain. I don't use DMARDs for elevated sed rate and CRP. I don't use DMARDs for X rays.
X rays are gonna change. X rays are what you have X-ray findings of erosions and damage is damaged. The damage is already done. And, again again, you have to be clear about what the goal of DMAR therapy and DMAR initiation is going to be. So what do you do when it's not RA?
Well, number one, make the decision it's not RA, and number two, move on to these other options. Again, reporting, analysis, perspectives. Follow us at RheumNow during ACR twenty twenty. Take care.
If you are a health practitioner, you may Login/Register to comment.
Due to the nature of these comment forums, only health practitioners are allowed to comment at this time.