Wann denke ich an Rheuma 1. Lernen im Internet 2. Beschwerden, Diagnostik, Therapie 3. Rheumatoide ArthritisRA 4. SpondylarthritisSpA 5. PsoriasisarthritisPsA 6. OsteoarthritisOA 7.OsteoporoseOpor PK MD 8/13

1. Lernen im Internet A)Lesezeichen B)Adressen C)Google Bilder D)Screendump./. Power Point E)Downloads If you want to learn, just teach !

A) Lesezeichen

B) Adressen M M

2. Beschwerden, Diagnostik, Therapie DiagnoseBeschwerdenTherapie______ RAschmerzhaft geschwollene Fingergelenke; TJC SJC NSAR, NSAID`s SpA 3Mon, morgensteif, Rückenschmerz, Colitis, Uveitis DEMARDS: MTX, PsAPsoriasis, Arthritis Sulfosalazin,... milde bis schwere Schuppenflechte plus Gelenkentzündung Biologicals: OABewegungsschmerz der GelenkeMonoklonale nach Trauma oder VerschleißAntikörper Oposkeine Beschwerden bis FX WK Verdacht bei Postmenopause

Dosierung von NSAID`s in SpA

Halbwertszeitmax mg/Tag Ibuprofen1,8 - 3, Ketoprofen1,5 - 2, Aceclofenac 4200 Diclofenac° 2 Celecoxib Etoricoxibca Meloxicamca Piroxicam Naproxen Indomethacin Phenylbutazon

DEMARD`s: Disease Modifying Anti Rheumatic Drugs DosierungAbk. Methotrexat mg s.c. p.o.MTX Azathioprin2 - 2,5 mg / kg KG Sulfasalazin mg wtl. Steiger.SSZ Cloroquin100 mg / Tag Hydroxycloroquin Leflunomid mg / Tag CyclophosphamidD-Penicillamin Ciclosporin2 x 100 mg Gold: z.B. Auranofin2 x 50 mg / Monat

Biologicals: Monoclonale Antikörper Abatacept (Orencia)Bristol-Mey. Squ TNF alpha Blocker: Adalimumab (Humira)AbbVie Ltd. Etanercept (Enbrel)Pfizer Infliximab (Remicade)Centocor CD 20 Antikörper: Rituximab (Rituxan)Biogen / Roche BAFF Inhibitor Belumimab (Benlysta)GlaxoSmithKline IL-1 Rezeptorantagonist: Anakinra(Kineret)Swed. Orph. Biov

3. RA Rheumatoide Arthritis Wann denke ich an RA Beschwerden der Patienten DiagnostikKlassifikationTherapie

Beschwerden bei V.a. RA schmerzhaft geschwollene Fingergelenke, die morgens geschwollen sind, die Beschwerden lassen nach 2 – 3 h nach. mehr als 2 Fingergelenke betroffen und das länger als 6 Wochen

3. Rheumatoide ArthritisRA WIN und HOT what is new how to treat personal account: EULAR Madrid 2013 Beschwerden des Patienten DiagnostikTherapie

Target Population of the Criteria

2010 ACR/EULAR Classification Criteria for RA JOINT DISTRIBUTION (0-5) 1 large joint large joints1 1-3 small joints (large joints not counted) small joints (large joints not counted)3 >10 joints (at least one small joint) 5 SEROLOGY (0-3) Negative RF AND negative ACPA0 Low positive RF OR low positive ACPA2 High positive RF OR high positive ACPA3 SYMPTOM DURATION (0-1) <6 weeks0 ≥6 weeks1 ACUTE PHASE REACTANTS (0-1) Normal CRP AND normal ESR0 Abnormal CRP OR abnormal ESR1 ≥6 = definite RA What if the score is <6? Patient might fulfill the criteria…  Prospectively over time (cumulatively)  Retrospectively if data on all four domains have been adequately recorded in the past

Classification vs. Diagnosis We don’t have diagnostic criteria for RA Typically in rheumatic diseases, criteria are labeled as “classification” criteria – These are helpful in defining homogeneous treatment populations for study purposes A clinical “diagnosis” has to be established by the physician (rheumatologist) – It includes many more aspects than can be included in formal criteria – Formal classification criteria might be a guide to establish a clinical diagnosis

Definitions ≥6 = definite RA JOINT DISTRIBUTION (0-5) 1 large joint large joints small joints (large joints not counted) small joints (large joints not counted)3 >10 joints (at least one small joint) 5 SEROLOGY (0-3) Negative RF AND negative ACPA0 Low positive RF OR low positive ACPA2 High positive RF OR high positive ACPA3 SYMPTOM DURATION (0-1) <6 weeks0 ≥6 weeks1 ACUTE PHASE REACTANTS (0-1) Normal CRP AND normal ESR0 Abnormal CRP OR abnormal ESR1 Definition of “JOINT INVOLVEMENT” - Any swollen or tender joint (excluding DIP of hand and feet, 1st MTP, 1st CMC) - Additional evidence from MRI / US may be used for confirmation of the clinical findings

Definitions JOINT DISTRIBUTION (0-5) 1 large joint large joints small joints (large joints not counted) small joints (large joints not counted)3 >10 joints (at least one small joint) 5 SEROLOGY (0-3) Negative RF AND negative ACPA0 Low positive RF OR low positive ACPA2 High positive RF OR high positive ACPA3 SYMPTOM DURATION (0-1) <6 weeks0 ≥6 weeks1 ACUTE PHASE REACTANTS (0-1) Normal CRP AND normal ESR0 Abnormal CRP OR abnormal ESR1 ≥6 = definite RA Definition of “SMALL JOINT” MCP, PIP, MTP 2-5, thumb IP, wrist NOT: DIP, 1 st CMC, 1 st MTP

Definitions JOINT DISTRIBUTION (0-5) 1 large joint large joints small joints (large joints not counted) small joints (large joints not counted)3 >10 joints (at least one small joint) 5 SEROLOGY (0-3) Negative RF AND negative ACPA0 Low positive RF OR low positive ACPA2 High positive RF OR high positive ACPA3 SYMPTOM DURATION (0-1) <6 weeks0 ≥6 weeks1 ACUTE PHASE REACTANTS (0-1) Normal CRP AND normal ESR0 Abnormal CRP OR abnormal ESR1 ≥6 = definite RA Definition of “SMALL JOINT” MCP, PIP, MTP 2-5, thumb IP, wrist NOT: DIP, 1 st CMC, 1 st MTP

Definitions ≥6 = definite RA JOINT DISTRIBUTION (0-5) 1 large joint large joints small joints (large joints not counted) small joints (large joints not counted)3 >10 joints (at least one small joint) 5 SEROLOGY (0-3) Negative RF AND negative ACPA0 Low positive RF OR low positive ACPA2 High positive RF OR high positive ACPA3 SYMPTOM DURATION (0-1) <6 weeks0 ≥6 weeks1 ACUTE PHASE REACTANTS (0-1) Normal CRP AND normal ESR0 Abnormal CRP OR abnormal ESR1 Definition of “LARGE JOINT” Shoulder, elbow, hip, knee, ankles

JOINT DISTRIBUTION (0-5) 1 large joint large joints small joints (large joints not counted) small joints (large joints not counted)3 >10 joints (at least one small joint) 5 SEROLOGY (0-3) Negative RF AND negative ACPA0 Low positive RF OR low positive ACPA2 High positive RF OR high positive ACPA3 SYMPTOM DURATION (0-1) <6 weeks0 ≥6 weeks1 ACUTE PHASE REACTANTS (0-1) Normal CRP AND normal ESR0 Abnormal CRP OR abnormal ESR1 ≥6 = definite RA Definition of “>10 JOINTS” -At least one small joint -Additional joints include: temporomandibular, sternoclavicular, acromioclavicular, and others (reasonably expected in RA) Definitions

≥6 = definite RA JOINT DISTRIBUTION (0-5) 1 large joint large joints small joints (large joints not counted) small joints (large joints not counted) 3 >10 joints (at least one small joint) 5 SEROLOGY (0-3) Negative RF AND negative ACPA0 Low positive RF OR low positive ACPA2 High positive RF OR high positive ACPA3 SYMPTOM DURATION (0-1) <6 weeks0 ≥6 weeks1 ACUTE PHASE REACTANTS (0-1) Normal CRP AND normal ESR0 Abnormal CRP OR abnormal ESR1 Definition of “SEROLOGY” Negative: ≤ULN (for the respective lab) Low positive: >ULN but ≤3xULN High positive: >3xULN

Definitions ≥6 = definite RA JOINT DISTRIBUTION (0-5) 1 large joint large joints small joints (large joints not counted) small joints (large joints not counted)3 >10 joints (at least one small joint) 5 SEROLOGY (0-3) Negative RF AND negative ACPA0 Low positive RF OR low positive ACPA2 High positive RF OR high positive ACPA3 SYMPTOM DURATION (0-1) <6 weeks0 ≥6 weeks1 ACUTE PHASE REACTANTS (0-1) Normal CRP AND normal ESR0 Abnormal CRP OR abnormal ESR1 Definition of “SYMPTOM DURATION” Refers to the patient’s self-report on the maximum duration of signs and symptoms of any joint that is clinically involved at the time of assessment.

RA Diagnostik Inspektion und Palpation der Fingergelenke, wenn diese schmerzhaft geschwollen sind Rö Hände und Füße bei V.a. RA Labor: BB, CRP, CCP, ENA, ANA, dsDNA, AK Borrelien, Yersinien, Clamydien

2010 ACR/EULAR Classification Criteria for RA JOINT DISTRIBUTION (0-5) 1 large joint large joints1 1-3 small joints (large joints not counted) small joints (large joints not counted)3 >10 joints (at least one small joint) 5 SEROLOGY (0-3) Negative RF AND negative ACPA0 Low positive RF OR low positive ACPA2 High positive RF OR high positive ACPA3 SYMPTOM DURATION (0-1) <6 weeks0 ≥6 weeks1 ACUTE PHASE REACTANTS (0-1) Normal CRP AND normal ESR0 Abnormal CRP OR abnormal ESR1 ≥6 = definite RA What if the score is <6? Patient might fulfill the criteria…  Prospectively over time (cumulatively)  Retrospectively if data on all four domains have been adequately recorded in the past

RA Therpie Feuer sofort und dauerhaft löschen, jeder Schub zerstört Gelenkstrukturen ! NSAID `sCortison, Lyrica DEMARDSBiologicals

4. SpondylarthritisSpA Wann denke ich an Spondylarthritis Beschwerden der Patienten DiagnostikKlassifikationTherapie

Klagen der Patienten Nächtlicher Rückenschmerz, Schlafstörung Morgentlicher Schmerz / Steifigkeit der WS Besserung in Verlauf des Morgens Fragen des Doktors Wurstförmige Finger / Zehen:Daktylitis Fersen schmerzh. Geschw.:Enthesitis Urethritis / Cervizitis M. Crohn, Blanitis, Uveitis

SPA Diagnostik Anamnese, Anamnese, Anamnese; MRI: ISG bds. STIR (bei V.a. Sakroiliitis) Labor:CRP, BSG; (HLA B27) U Ortho:FBA, Schober; WS Rot. / Neig.; lumb. Muskulatur tasten periphere Gelenke, Achillessehne Haut, Harnröhre, Uvea

SpA Therapie Multimodal es droht Erwerbsunfähigkeit ! Aufklärung, Beratung Physikalische Therapie: Mikrowelle, Reizstrom, Neuraltherapie, Reha Sport, „Kur beantragen“ Krankenkasse, Arbeitsamt, Rententräger Pharmakotherapie

Beispiel:

SpA Klassifikation Axiale Spondylarthritis Periphere Spondylarthritis

5. Psoriasis ArthritisPsA Wann denke ich an Psoriasisarthritis Beschwerden der Patienten Diagnostik CASPAR Kriterien Therapie

Beispiel: Kr, Val; W ich Schmerzen Bein re, 2 Jahre Operation: Fragen:ganz genau: welches Gelenk, wann schmerzhaft, in Ruhe oder nach Bewegung; Schuppenflechte: vor 1J Hautarzt, Cortis. Augenentzündung x 2 in 3J Befund:Z.n. Psoriasis und Uveitis; seit 2 Mon Knie re, OSG re schmerz. gesch

Autoimmunerkrankungen Rheumatische Begleiterkrankungen Morbus Crohn, Colitis ulcerosa UveitisDactylitisPsoriasis Rheumatische (chron. entz.) Autoimmunerkrankg RA, SpA, PsA, SLE, Vaskulitiden, JRA,

PsA Google Bilder

CASPAR Kriterien in PsA Um die diagnostischen Kriterien der PsA zu erfüllen, muss der Patient eine entzündliche Gelenkerkrankung haben und > 3 von max. 9 Punkten aus 5 Kategorien aufweisen Punkte 1. Nachweis einer Psoriasis entweder akut vorhanden oder pos. Fam. Anamnese und Psoriasis Vorgeschichte Psoriatische Nageldystrophie (Pitting, Onychclyse, Hyperkeratose) 1 3. Rheumafaktor negativ (LABOR) 1 4.Dactylitis akute, entzündliche Schwellung eines ganzen Fingers Dactylitis in der Anamnese 1 5.Radiologische Zeichen einer periartikulaeren Knochenbildung (auf Roe Hand/Fuss undeutliche Ossifikation an Gelenkraendern) 1

Therapie der SpA

6. OsteoarthritisOA Wann denke ich an OA Beschwerden der Patienten DiagnostikTherapie

7. OsteoporoseOpor Wann denke ich an Osteoporose Beschwerden der Patienten DiagnostikTherapie

Wann denke ich an Osteoporose 1.Bei Frauen nach der Menopause 2.Bei Dauertherapie mit Cortison 3.Bei Z.n. Wirbelkörperfraktur 4.Bei Z.n. OS-Halsfraktur älterer Patienten

Beschwerden / Diagnostik Beschwerden:vor einer Fx WK oder OSH 0 Diagnostik:Rö BWS, LWS; Osteodensitometrie Vit. D Spiegel ? Therapie:Vit. D plus Ca 1000/ ResorptionshemmerOsteoblastenstimulationRaloxifen Strontium ?

Beschwerden / Diagnostik Beschwerden: keine Diagnostik:Rö Hüften, Wirbelkörper Osteodensitometrie Vitamin D Spiegel Therapie:Aufklärung / Beratung LebenswandelMedikamente

Zusammenfassung take home message 1.RA: autoimmune Entzündung der kleinen Fingergelenke kleinen Fingergelenke 2. SpA:autoimmune Entzündung der WS mit / ohne Gelenkbeteiligung 3. PsA:autoimmune Erkrankung der Haut und chaotischer Gelenkbeteiligung 4. OA:Verschleiß der „Organs“ Gelenk 5. OsPo:aktivitäts- und hormonell bedingter Verlust von Knochenmasse