Inflammatory Arthritides
Gout
 • Diagnosis: Arthrocentesis: ...
791
Description

Inflammatory Arthritides

Gout

 • Diagnosis: Arthrocentesis: Negatively birefringent needle-shaped crystals, 10k<WBC<100k, diagnostic score; culture as septic arthritis can co-exist. If any suspicion for septic arthritis, start empirical abx until Cx negative.

 • Treatment: Acute: Rx depends on pt’s comorbidities. Colchicine (1.2mgx1, 0.6mg 1h later, then 0.6mg QD until 2-3d after resolu), PO GC (pred 40mg until resolu., then taper), NSAIDs (until 1-2d after resolu. [usu. 5-7d]), or intra-articular GC injection Chronic: Urate lowering if: ≥2 attacks/yr, CKD, urate nephrolithiasis, tophi (urate goal <6); Δdiet; d/c diuretics. Do not stop urate lowering therapy during acute attack.

CPPD

 • Diagnosis: Arthrocentesis: Small pos. birefringent rhomboid crystals, 10k<WBC<100k; XR: chondrocalcinosis, crowned dens

 • Treatment: Acute: ≤2 joints → intra-articular GC injection 1st line; 2nd is same as gout (prefer colchicine w/in 24h of sx onset) Chronic: Consider HCQ, low-dose GC, MTX

RA

 • Diagnosis: Exclude other dz (esp. psoriatic, viral, polyarticular gout/CPPD, SLE). RF (70% sn, 85% sp), anti-CCP (75% sn, 95% sp), 30% ANA+; extremity XRs.

 • Treatment: Acute/flares: GC or NSAIDs and initiate DMARD if not on. Chronic: DMARD (MTX > HCQ, SSZ, leflunomide); if pt fails monotherapy, consider combination; if fails combo, transition to biologic (infliximab, abatacept, tocilizumab)

Ankylosing spondylitis

 • Diagnosis: Sacroiliitis (XR or MRI), LBP, ↑ESR/CRP, HLA-B27 (90% sn/sp)

 • Treatment: NSAIDs 1st line, no GC, DMARDs not effective TNFα inh. 2nd (infliximab, etanercept, adalimumab) 

Psoriatic arthritis

 • Diagnosis: Clinical dx, ↑ ESR/CRP (40%), HLAB27, CASPAR criteria (91%sn;99%sp)

 • Treatment: NSAIDs 1st line; if mod/sev, MTX > SSZ, leflunomide. Sev. and erosive: TNFα inh (inflix, adalimumab, golimumab)

Enteropathic arthritis

 • Diagnosis: Joint pain, LBP, always exclude septic arthritis, HLA-B27 (50-75%)

 • Treatment: Usually improves w/ Rx of IBD. NSAIDs 1st line, d/w GI as can ↑IBD inflam. 2nd SSZ > MTX, azathioprine. 3rd TNFα inh.

Reactive arthritis

 • Diagnosis: Presence of preceding infection, arthrocentesis, stool culture, GC/Chla

 • Treatment: Treat GU infxn; GI infxn may not need Rx. Acute: 1st NSAIDs, 2nd intra-articular GC, 3rd PO GC. Chronic: >6mo, SSZ>MTX

Septic arthritis 

 • Diagnosis: Arthrocent: Fluid GS/Cx, joint WBC usually 50-150k

 • Treatment: Antibiotics (3-4 wks) and joint drainage/wash out (ortho c/s)

Osteoarthritis 

 • Diagnosis: Clinical, age>45, AM stiff <30m, slow progression, no warmth, musc wasting

 • Treatment: PT, braces, PRN NSAIDs, consider duloxetine (60-120mg), intra-articular GC injection, severe sx → refer to ortho



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