1. PsA (2-15%) 2. systemic onset (10-15%) Stills 3. RF+ polyarticular onset (5-10%) 4. RF- polyarticular onset (10-30%) 5. HLA-B27+ oligoarticular onset 6. ANA+ oligoarticular onset (30-60%)

B6.037 Oligoarthritis Flashcards by Lauren Sinik

definition of oligoarthritis

1-4 joints
not just arthritis; inflammation/synovitis is present
>6 weeks duration
almost always asymmetric
lower extremity predominant

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what is JIA

juvenile idiopathic arthritis

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age of JIA patients

especially 1-4 years

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race of JIA patients

typically white

northern European

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different courses of JIA after 6 months

first 6 months: 1-4 joints
persistent (50%) = stays 4 or less
extended (50%) = >4 joints after 6 months

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sex of JIA patients

3:1 girls: boys

in Asia, more boys

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negative blood tests in JIA

IgG anti-CCP (ACPA)

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blood tests that has 8% chance of being positive in JIA

HLA-B27

prevalence in the general white population

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autoantibody positive in 75-85% of JIA patients

ANA

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common joints affected by JIA

knee > ankle > others

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what might be an associated skin complication of JIA?

psoriasis

esp if the patient has wrist involvement

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what is the uveal tract

pigmented part of the eye

choroid, ciliary body, and iris

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symptoms of acute anterior uveitis

pain
photophobia
blurred vision
redness

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in which JIA patients would you expect ocular inflammation

ANA+
oligoarticular-onset
25% get inflammatory eye disease, but few present with symptoms

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what monitoring is done for patients with ANA+, oligoarticular onset, LE predominant arthritis

slit lap screening

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do ANA- JIA patients have ocular involvement

no often

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potential long term ocular complications in ANA+ JIA patients

synechiae
cataracts
glaucoma
band keratopathy

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what is synechiae

iris attaches to cornea or attaches to lens

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initial pharmacotherapy for JIA

intra articular glucocorticoid

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second step of therapy for JIA

NSAIDs
motrin = ibuprofen
Naprosyn = naproxen
tolectin = tolmetin
Mobic = meloxicam
Celebrex = celecoxib

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third step of therapy for JIA

methotrexate

TNF a or abatacept

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-cept suffix meaning

protected from rapid degradation by attachment to Fc receptor

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6 forms of JIA

PsA (2-15%)
systemic onset (10-15%) Stills
RF+ polyarticular onset (5-10%)
RF- polyarticular onset (10-30%)
HLA-B27+ oligoarticular onset
ANA+ oligoarticular onset (30-60%)

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what is PsA

psoriatic arthritis

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what is systemic onset JIA (Stills)

presents with serious symptoms that resemble leukemia or a horrible infection

what is RF+ polyarticular onset JIA

adult RA presenting in kids typically a negative prognosis for joints tends to occur in slightly older kids

what is RF- polyarticular onset JIA

children are younger than in RF+ and have a better prognosis for joints

what is HLA-B27+ oligoarticular onset JIA

ankylosing spondylitis more common in males around 9-13 peripheral arthritis initially, with back complaints much later

how often does PsA accompany psoriasis?

25% of the time

how often do patients have psoriasis prior to being diagnoses with PsA?

70%

how often does PsA precede a diagnosis of psoriasis?

15% | other 15% coincident onset or undiagnosed psoriasis

CASPAR criteria for PsA

>3 points, 99% spec/92% sens - 2 pts psoriasis - 1 pt past psoriasis or FH - 1 pt psoriatic nail changes - 1 pt RF- - 1 pt dactylitis - 1 pt radiographic juxtaarticular new bone

where is psoriasis most common

scalp, retroaural, EACs extensor extremities umbilicus, gluteal cleft/perianal

racial predilection of PsA

whites 2:1

sex of PsA patients?

equal overall males: axial (3:1) and classical (vide infra) females: RA-like

age of onset of psoriasis in PsA

mid-teens-20s

age of onset of joint complaints in PsA if there was prior skin involvement

a decade after skin involvement

genetic influences on PsA

35-70% monozygotic concordance 12-20% dizygotic concordance 1st degree relatives of PsA 27-50x greater risk

specific genes found in PsA

HLA-B27 + in only axial pts (50%) | HLA-B38 and B39 in general PsA

categories of PsA (not mutually exclusive)

``` asymmetric, oligoarticular (15-20%) symmetric, polyarticular (50-60%) "classical" (2-5%) isolated axial (2-5%) arthritis mutilans (5%) ```

asymmetric, oligoarticular PsA

associated with dactylitis / ray involvement

symmetric, polyarticular PsA

``` RA like usually seronegative (95% of the time) ```

classical PsA

uncommon predominant DIP involvement dactylitis present nail involvement

isolated axial PsA

only SI joint involvement (asymmetric) +/- spinal involvement syndesmophytes large /nonmarginal

what are syndesmophytes

vertical bony spurs | like dripping wax down the spine?

arthritis mutilans

very dysmorphic hands very little bone growth can pull fingers out to a normal length, but they shrink back

what is enthesitis

inflammation of a tendon/ligament insertion into bone

what is dactylitis

sausage fingers/toes

common extraarticular manifestations of PsA

``` enthesitis dactylitis nail pitting other nail changes (onycholysis, onychodystrophy) conjunctivitis acute iritis ```

rare extraarticular manifestations of PsA

stomatitis urethritis nonspecific colitis dilation of aortic arch base

treatment of PsA

``` NSAIDs intraarticular steroids methotrexate leflunomide apremilast TNFa inhib anti-IL17 anti-IL12/23 JAK inhibitor costim blockade ```

use of methotrexate in PsA

``` oral, 7.5-25 mg once a week subQ same dosage; better bioavailability take w 1 mg folic acid daily can help both skin and joints not helpful for spine or nails ```

use of leflunomide in PsA

pyrimidine antagonist 20 mg qd side effects similar to mtx less helpful for skin than mtx

use of apremilast in PsA

pde4 inhibitor 30 mg bid approved for skin and joints excellent safety profile

use of TNFa inhibitors in PsA

4 subQ doses per week 1 IV dose every 4-8 weeks more risky/ greater payoff

use of anti-IL17 in PsA

secukinumab approved for PsA | every 4 weeks subQ after a 5 shot weekly loading phase

use of anti-IL12/23 in PsA

ustekinumab | every 12 weeks subQ after 2 loading doses 4 weeks apart

use of janus kinase inhibitor in PsA

tofacitinib | 11 mg oral qd

drugs to avoid in PsA

prednisone | hydroxychloroquine

use of abatacept in PsA

costimulatory blockade | subQ weekly or IV every 4

MAINSTAYS of therpay in PsA

glucocorticoids and NSAIDs almost always insufficient | mainstays: mtx and TNFa inhib

B6.037 Oligoarthritis Flashcards

(61 cards)