CASE SCENARIOS IN JOINT

DISEASE- PART1

Presenter
Dr Souradip

Sr moderator
Dr Jayshree Faculty Preceptor
Dr Ved Prakash
Dr Prayas Sethi
Dr Ranjan Gupta
 CASE 1

• New patient – Age: 26 yrs, F

• Pain and swelling in multiple joints in B/L hands, wrists, ankles
• Symptom duration: 2 years - taking ibuprofen - some relief
• Early morning stiffness (EMS) - 2–3 hours
• No h/o - rash, fever, chest pain, oral ulcers, red eye

What is your most likely diagnosis?

 PRESCRIPTION 1

Inflammtory arthritis: ?cause

• Rx:

• Inv: • Tab Naproxen 500 mg BD after meal for 2

weeks
o CBC
• Tab Pantoprazole 40 mg in morning empty
o LFT stomach
o RFT • Review after 2weeks with reports
o ESR, CRP
o RA factor, Anti CCP
o ANA
 2 WEEKS LATER (1 S T FOLLOW UP)

• Dx: Rheumatoid arthritis with severe disease activity

• CBC/LFT/KFT : WNL (CDAI-28)

• CRP/ESR: raised
• RA factor +ve • Rx:

• ACPA +ve • Tab Methotrexate 15 mg once weekly (Saturday) in morning

empty stomach
• Tab ondansetron 4 mg once weekly before taking MTx
Should we add steroid?? • Tab Folic Acid 5 mg once weekly (Sunday)
• Tab Naproxen 500 mg SOS (if severe pain)
• Tab Pantoprazole 40 mg empty stomach in morning
• Review after 3 months with KFT,LFT, CBC,ESR and CRP
report
 RHEUMATOID ARTHRITIS
5

◻ Most common form of chronic inflammatory disease

◻ Synovial inflammation& hyperplasia
◻ Auto antibody production(RF& ACPA)
◻ Cartilage & bone destruction--- deformity
◻ Systemic features

Ian B McInnes: The Pathogenesis of Rheumatoid Arthritis;NEJM 365:23 Dec 8 2011

PATTERN OF JOINT INVOLVEMENT IN
RA
 EXTRA ARTICULAR MANIFESTATIONS
7
 DEFORMITIES
8

◻ Swan neck deformity

◻ Boutonnaire deformity
◻ Trigger finger
◻ Z line deformity
◻ Piano key sign
◻ Pes planovalgus
◻ Atlanto axial subluxation
 2010 ACR/EULAR
Classification Criteria for RA
JOINT DISTRIBUTION (0-5)
1 large joint
2-10 large joints
0
1
≥6 = definite RA
1-3 small joints (large joints not counted) 2
4-10 small joints (large joints not counted) 3
>10 joints (at least one small joint) 5
Definition of “SMALL JOINT” What if the score is <6?
SEROLOGY (0-3)
MCP, PIP, MTP 2-5, thumb0 IP, wrist
Negative RF AND negative ACPA Patient might fulfill the criteria…
Low positive RF OR low positive ACPA 2
NOT: DIP, 1 CMC, 1 MTP
High positive RF OR high positive ACPA
st
3
st
🡪 Prospectively over time
SYMPTOM DURATION (0-1) (cumulatively)
<6 weeks 0
≥6 weeks 1 🡪 Retrospectively if data on all four
ACUTE PHASE REACTANTS (0-1) domains have been adequately
Normal CRP AND normal ESR 0 recorded in the past
Abnormal CRP OR abnormal ESR 1

9
 Radiographic Assessment
WHEN TO PERFORM HOW TO USE
GENERAL PRINCIPLES • The presence of typical erosions allow
classification of RA even without
•Radiographs are not required in the fulfillment of the scoring system
ACR/EULAR 2010 classification criteria
• The scoring result should nevertheless be
•Radiographs should not be taken for the
documented in clinical studies/trials
mere purpose of classification
EXCEPTIONS • Currently, there is no exact definition of
“typical erosions”
1.Radiographs should be taken in the
unclassified patient in whom longstanding
inactive disease is suspected (likely failed
classification falsely)
2.If radiographs are already available in an
early arthritis patient, their information can be
used for classification purposes.
(e.g., radiographs taken by GP before referral)
10
 X-RAY IN RHEUMATOID ARTHRITIS
11

◻ Soft tissue swelling  -fusiform and periarticular. (combination of joint effusion,

oedema and tenosynovitis)
◻ Osteoporosis- initially juxta-articular
◻ Joint space narrowing - symmetrical or concentric
◻ Marginal erosions - due to erosion by pannus of the bony “bare areas”.
 X-RAY IN RHEUMATOID ARTHRITIS
12

◻ Increased predilection-PIP and MCP joints (especially 2nd and 3rd MCP), ulnar

styloid, triquetrum
◻ DIP joints are spared
◻ Late changes- subchondral cysts, subluxation, deformity, ankylosis
 USG IN RHEUMATOID ARTHRITIS
13

◻ Sonography - assess the soft tissue manifestations of RA

◻ Synovial proliferation and inflammation of the superficial joints
◻ Tenosynovitis - extensor carpi ulnaris tendon involvement is common in early
disease, and may lead to erosion of the ulnar styloid 
◻ Bursitis
 MANAGEMENT
14

DMARDs

SYNTHETIC DMARDs BIOLOGICAL DMARDs

TNF
CONVENTIONA INHIBITOR,TCE
TARGETED
L LL
STIMULATOR
etc
 SDMARDS
15

Conventional sDMARDs Targeted sDMARDs

◻ Methotrexate ◻ Tofacitinib
◻ Sulfasalazine ◻ JAK-kinase inhibitor
◻ Leflunamide
 METHOTREXATE
16

◻ DHFR inhibitor
◻ Stimulate adenosine release from
cells- anti inflammatory effect
◻ 10-25 mg/week orally or
subcutaneous
Initial evaluation- CBC,
◻ Hepatotoxicity
◻
LFT, Viral hepatitis panel,
Myelosuppression
chest Xray
Monitor CBC, creatinine,
LFTs every 2-3 months Price: 140 rs/10 tabs
 SULFASALAZINE
17

◻ Initial dose 500mg twice daily

◻ Maintenance dose 1000-1500mg
twice daily
Initial evaluation –CBC,
LFT, G6PD levels

Monitoring –CBC every 74 rs/15 tabs

◻ Granulocytopenia
◻ Hemolytic anemia( with
2-4 weeks for first 3
G6PD deficiency) months and then every 3
◻ Nausea months
◻ Diarrhoea
◻ Headache
 LEFLUNAMIDE
18

◻ 10-20mg /day
◻ Hepatotoxicity
◻ Myelosuppression Initial evaluation-
◻ Infection CBC, LFT, viral
◻ Alopecia hepatitis panel
◻ Diarrhoea

Monitor –CBC,
Creatinine, LFTs 100 rs/10 tabs
every 2-3 months
 HYDROXY CHLOROQUINE
19

◻ 200-400 mg/d orally

◻ Irreversible retinal damage
◻ Cardiotoxicity
◻ Blood dyscrasia Initial evaluation-
◻ Nausea eye examination if >
◻ Diarrhoea
40 years old or prior
◻ Headache
◻ Rash
ocular disease

Monitoring 100 rs/15 tabs

Fundoscopy and
visual field testing
every 12 months
 BIOLOGICAL SDMARDS
20

Anti B cell agent

TNF inhibitors
◻ Rituximab
◻ Adalimumab
◻ Certolizumab pegol
IL6-R blocking agents
◻ Etanercept
◻ Tocilizumab
◻ Golimumab
◻ Infliximab
IL 1 inhibitor
◻ Anakinra
T cell costimulation inhibitor
◻ Abatacept
Biosimilars
◻ Bs-infliximab
 TNF INHIBITORS
21

◻ Adalimumab ◻ Risk bacterial, fungal infections

◻ Certolizumab pegol ◻ Reactivation of latent TB
◻ Etanercept ◻ Lymphoma risk (controversial)
◻ Golimumab ◻ Drug-induced lupus
◻ Infliximab ◻ Neurologic deficits
Initial evaluation-
◻ Infusion reaction

Mantoux skin test

Monitoring - LFTs
SCORING SYSTEM USED IN RA
 DAS 28 SCORE
23

◻ How many joints in the hands, wrists, elbows, shoulders, and knees are swollen
and/or tender
◻ The erythrocyte sedimentation rate (ESR) or C reactive protein (CRP) in the blood
to measure the degree of inflammation 
◻ The patient’s Visual Analogue Score (a simple scale) to assess how they are feeling
on that day from 0 (very good) to 10 (very bad) 

Arthritis & Rheumatism; volume 57, no 2; march 2007

 DAS-28 SCORE
24

◻ <2.6: Disease remission

◻ 2.6 – 3.2: Low disease activity
◻ 3.2 – 5.1: Moderate disease activity
◻ >5.1: High disease activity i

Arthritis & Rheumatism; volume 57, no 2; march 2007

 SIMPLIFIED DISEASE ACTIVITY
INDEX(SDAI)
25

◻ Sum of a tender joint and a swollen joint (using 28 joints), patient global
assessment(0-10 scale), physician global assessment(0-10) and CRP (mg/dl)

Arthritis & Rheumatism; volume 57, no 2; march 2007

 CDAI (CLINICAL DISEASE ACTIVITY
INDEX)
26

◻ CDAI = SJC(28) + TJC(28) + PGA + EGA

◻ Remission                        CDAI ≤ 2.8
◻ Low Disease Activity        CDAI > 2.8 and ≤ 10
◻ Moderate Disease Activity    CDAI > 10 and ≤ 22
◻ High Disease Activity            CDAI > 22
◻ Does not include the ankles / feet
◻ Does not include inflammatory markers (although this is what makes it a quick and
useful clinical tool)

SJC= swollen joint count; TJC= tender joint count; PGA= patients global assessment; EGA= examiners global assessment
 BACK TO OUR CASE, 3 MONTHS LATER

• Dx: Rheumatoid arthritis with low disease activity

• CBC/LFT/KFT :
WNL
• Rx:
• CRP/ESR: Normal
• Tab Methotrexate 15 mg once weekly (Saturday) in morning
• CDAI- 5
empty stomach
• Tab Ondansetron 4 mg once weekly before taking MTx
• Tab Folic Acid 5 mg once weekly (Sunday)
• Tab Prednisolone 5 mg once daily X 2weeks then stop
• Tab Naproxen 500 mg SOS (if severe pain)
• Tab Pantop 40 mg empty stomach in morning
• Review after 3 months with KFT,LFT, CBC,ESR and CRP
report
 2 YEARS LATER

• Same patient : Doing well

• Now says that her marriage is planned 1 month later
 WHAT TO DO NEXT?

1. STOP MTX
2. Asked the patient not to get married
3. Continue MTX, we wiil see what will
happen
4. None of the above

Any special advice to mention?

contraception
 REVISED TREATMENT

Investigations:
Urgent G6PD Rx:
level 1. STOP METHOTREAXATE
2. To start Sulfasalazine after
G6PD level
 9 MOTHS LATER

• Delivered a healthy male child.

गठिया की दवाएं बच्चे के

लिए हानिकारक हैं
• Patient was reassured and was advised to continue Sulfasalazine and she can
safely breastfeed .
 ANOTHER YEAR PASSED

• Doing well for 1 year. Compliant

• Now has flare of disease for ;last 3 months
• Last time- Methotrexate- severe nausea- not willing to take again

?
 NEW PRESCRIPTION

Rx

• Tab leflunomide 10 mg once daily in morning

• Sulfasalazine 1gm twice daily
• Continue other medication a advised before

Patient doing well, complaint to medication

 2 YEAR LATER

• 2 year later , patient plan pregnancy again.

What will we do now??

• Cholestyramine washout- 8 gm TID for 11days.
• Leflunomide level <0.02 mcg/ml on two measurements spaced at least 2
weeks apart

Cholestyramine washout:
• LEF persistence depends upon enterohepatic circulation of active metabolites
• Cholestyramine binds to bile salts and prevents enterohepatic recirculation
 WHAT SHOULD WE DO NEXT??

• Patient is started on Infliximab at 3 mg/kg dose and continued on sulfasalazine

1000 mg 1 tab BD.

• Patient is followed up, she is complaint to medicine.

• Disease activity reduced, patient doing well
 15 YEARS LATER

left shoulder joint osteoarthritis

Other joints normal
On low dose of infliximab (3 mg/kg) and Sulfasalazine

What will you do with biologics? What dose?

Patient was referred to orthopedic surgeon for shoulder

replacement
 20 MORE YEARS PASSED

• Grandmother
• Grandchildren 16 yrs/M
• Intermittent Pain in some joints in hand.
• No swelling of joint
• No morning stiffness.

MCQ: what all investigation to do

a. ESR, b. CRP, c. RA factor, d. anti CCP, e. all of the above, f. none of the
above
EULAR GUIDELINE ON MANAGEMENT
OF RA
GUIDELINE
CONTD
CONTD
 POOR PROGNOSTIC FACTORS IN
RHEUMATOID ARTHRITIS (EULAR 2019)
44

◻ Persistently high or moderate disease activity despite conventional synthetic

DMARD (csDMARD) therapy according to composite measures including joint
counts
◻ High acute phase reactants
◻ High swollen joint count
◻ Presence of RF and or acpa especially at high levels
◻ Presence of early erosions
◻ Failure of two or more csDMARDs

Seith L Feigenbaum ;prognosis of rheumatoid arthritis

 REMISSION – ACR/EULAR DEFINITION
45

◻ At any point of time, patient must satisfy all of the following

◻ Tender joint count≤1
◻ Swollen joint count≤ 1
◻ CRP≤1mg/dl
◻ Patient global assessment ≤1 (on a 0-10 scale)
OR
◻ At any point patient must have simplified disease activity score≤3.3
THANK YOU
 CASE SCENARIOS IN JOINT
DISEASE -2

Presenter : Dr Ravi Kumar

SR moderator : Dr Jayashree
Faculty Preceptor: Dr Ved Prakash, Department of Medicine
Dr Prayas Sethi, Department of Medicine
Dr Ranjan Gupta, Department of Rheumatology
 CASE

• A 36 yrs old man , smoker

• gradually progressive low back and hip pain x 5 months
• associated with morning stiffening which improved on activity.
• aggravated during sleep leading to awakening from sleep .
• swelling and tenderness in his fingers x 2 months
• heel pain for last 1 month.
• pain , redness and blurring of vision in the right eye x 4 days.
• No history of trauma, skin rash , oral ulcers, steroid intake .
• Past history of pulmonary tuberculosis 3yrs back which was treated with 6
month ATT.
 ON EXAMINATION

• Vitals- normal range.

• General physical examination -pallor.
• Musculoskeletal examination revealed restriction of
lateral and anterior flexion of lumbar spine.
• His chest expansion was 2.4cm .
• Modified Schober test - 2cm increase on flexion.
 DEFINITION

The spondyloarthritides are a group of overlapping disorders that share certain

clinical features and genetic associations (HLA-B27).
Includes:
• Ankylosing spondylitis
• Psoriatic arthritis
• Reactive arthritis
• Enteropathic arthritis
• Juvenile onset spondyloarthritis
• Undifferentiated spondyloarthritis

Usually, rheumatoid factor (RF) assay is negative in spondyloarthritides. Hence,

they are also referred to as seronegative arthritis.
 2 BROAD
CATEGORIES
 CARDINAL FEATURES

Involvement of sacroiliac joint and/or lumbar spine

Asymmetric peripheral arthritis
Familial occurrence
Enthesitis or Dactylitis
Extra-articular features-skin, eye, gut, urogenitals
Negative autoantibody tests (RF, anti-CCP, ANA)
High association with HLA-B27
 Cervical mobility
Occiput-to-wall distance
Tragus-to-wall distance
Cervical rotation
Thoracic mobility
T E ST A N D
M EA S U REME N T Chest expansion
Lumber mobility
Modified Schober test
Finger-to-floor distance
Lumber lateral flexion
 OCCIPUT-TO-
WALL
DISTANCE

• To measure severity of cervical

flexion deformity (Flesche
test).
• Patient’s heels and back rest
against the wall.
• Chin at usual carrying level.
• Maximal effort to touch the
head against the wall.
• Report the better of two tries in
cm.
 CERVICAL ROTATION

• The patient sits straight on a chair, chin level, hands on the

knees.
• A goniometer is placed at the top of the head in line with the
nose (A).
• The patient is asked to rotate the neck maximally to the left and
the angle is recorded between the sagittal plane and the new
plane after rotation (B).
• A second reading is taken and the better of the two is recorded
for the left side.
• The procedure is repeated for the right side.
• The mean of left and right is recorded in degrees.
 MODIFIED
SCHOBER TEST

• Patient must be standing erect.

• Mark an imaginary line connecting
both posterior superior iliac spines
(A).
• The next mark is placed 10 cm above
(B).
• The patient bends forward maximally:
measure the difference (C).
• Report the increase (in cm to the
nearest 0.1 cm).
• The better of two tries is recorded.
 L ATE RA L S P I N A L
F L EX I O N T ES T

• Patient’s heels and back rest against

the wall. No flexion in the knees, no
bending forward.
• Measure the distance between the
patient’s middle fingertip and the
floor before (B1) and after bending
sideways (B2), and record the
difference.
• The better of two tries is recorded
for left and right separately. The
mean of left and right is reported for
lateral spinal flexion.
• Normally >10 cm.
 CHEST
EXPANSION

• The patient has his hands

resting on or behind the
head.
• Measure at fourth intercostal
level anteriorly.
• Difference between
maximal inspiration and
expiration in cm is recorded
• Normal chest expansion is
≥5 cm.
 PRESCRIPTION

Diagnosis: Inflammatory arthritis likely Spondyloarthritis

INVESTIGATIONS
• CBC, LFT, RFT
• ESR , CRP
• RA Factor, Anti CCP , ANA
• X-Ray SPINE with Sacroiliac joint
• MRI L-S spine
• HLA B-27
 PRESCRIPTION

• TREATMENT
Non Pharmacological
• Patient education- about nature of disease and need for a life long exercise and posture
training programme and importance of regular follow up.
• Smoking cessation
• Physical Therapy – posture training , range of motion exercises , stretching, recreational
activities

Pharmacotherapy
• NSAIDs – Indomethacin 150 mg OD after meals for 14 days
• Sulfasalazine – 1000mg BD for 14 days
• PPI- Pantoprazole 40 mg OD before meals for 14 days
• Local Application of Volini gel/spray

Ophthalmology consultation for evaluation of eyes.

Follow up after 14 days

 FOLLOW UP: 2 WEEKS

• Patient was not having much symptomatic relief with the medication
started.
• He still had complaints of early morning severe back pain associated
with tenderness.
• On examination tenderness was present over sacroiliac joints and joints
of the fingers along with swelling.
 FOLLOW UP: 2 WEEKS

• Lab tests showed normochromic normocytic anaemia (Hb 9.8gm %)

• WBC count of 8700/mm3.
• LFT and RFT was in normal limits
• ESR -46mm/hr , CRP- 24 mg/L.
• ANA, Anti CCP and RA factor was negative.
• The human leukocyte antigen (HLA) typing was positive for HLA B27
• Ophthalmology evaluation - acute anterior uveitis.
 RADIOGRAPH

• Xray L-S spine showed bilateral

sacroiliitis
 CRITERIA

✔️
✔️
✔️
✔️
✔️
✔️

✔️
✔️
 Predominantly
Involves Spine
Pelvis
Thoracic cage
Root Joint arthritis
AXIAL (Hip joint, shoulder joint)
S PO N D Y LO A RT H R I TI Includes
S Ankylosing Spondylitis

Non-Radiographic Axial SpA.

(Patients with clinical ax-SpA that do
not have radiologic criteria for AS)
APPROACH
 ANKYLOSING SPONDYLITIS
Axial skeleton
• Sacroiliitis
◦ Unknown cause, 0.9-1.4% prevalence • Enthesitis
• Hip and Shoulder joint
◦ Late adolescence and early adulthood
(mid twenties), rarely >40 years in <5%
◦ More common in Males
◦ Females: Ankylosing
Spondylitis
◦ Non radiographic Axial Spondyloarthritis
Peripheral Extra articular manifestation
◦ Less frequency of total spine ankylosis manifestation • Eye
• Enthesitis • Bowel
◦ Cervical ankylosis and peripheral arthritis • Dactylitis • Cardiac

◦ Pregnancy- no consistent effect

 EXTRA-ARTICULAR
MANIFESTATION

• The most common extraarticular manifestation of ankylosing spondylitis

(AS) is anterior uveitis.
• Presents with unilateral pain, photophobia and increased lacrimation.
• Also associated with other spondyloarthritides like reactive arthritis,
psoriatic arthritis and enteropathic arthritis.
• Other extra-articular manifestations of AS include:
• GIT: ileitis, colitis, inflammatory bowel disease
• Cardiovascular: increased risk of IHD, aortic insufficiency, heart block.
• Respiratory: upper lobe fibrosis
• Neurological: cauda equina syndrome.
• Skin: acne fulminans, hidradenitis suppurativa
 D I S E A S E A C T I V I T Y: B A S D A I Q U E S T I O N N A I R E

◦ BASDAI questionnaire (Bath Ankylosing Spondylitis Disease Activity Index) regarding

subjective symptoms during the week prior to answering the questions.

1. How would you describe the overall level of fatigue/tiredness you have experienced?
2. How would you describe the overall level of AS neck, back, or hip pain you have had?
3. How would you describe the overall level of pain/swelling in joints other than neck, back, hips
you have had?
4. How would you describe the level of discomfort you have had from an area tender to touch or
pressure?
5. How would you describe the level of morning stiffness you have had from the time you wake
up?
6. How long does your morning stiffness last from the time you wake up?

Each question is scored on a scale of 0 to 10. Aside from the last question, 0 indicates none and 10
indicate very severe. For the last question, 0 is 0 hours, 5 is one hour, and 10 is two or more hours.

BASDAI = ((Q1 + Q2 + Q3 + Q4) + ((Q5 + Q6) / 2)) / 5

 DISEASE ACTIVITY: ASDAS SCORE

◦ ASDAS score (Ankylosing Spondylitis Disease Activity Score)

ASDAS-CRP =0.12 x Back Pain + 0.06 x Duration of Morning Stiffness + 0.11
x Patient Global + 0.07 x Peripheral Pain/Swelling + 0.58 x Ln(CRP+1)
 PRESCRIPTION : 2 WEEKS

Diagnosis: Ankylosing Spondylitis

• Continue non pharmacological management

• Stop Indomethacin.
• Start on Naproxen 500 mg BD for 14 days
• Rest continue same treatment.
• Follow up after 14 days with CRP and ESR test .
 FOLLOW UP @ 4 WEEKS

• Patient came with complaints of presistance of back ache and

inability to do his day to day activities.
• Patient was complaint with the medications.
• His BASDAI score and ASDAS score was 4.5 and 2.6 respectively.
• Patient was then planned to be started on biologicals (TNF
Inhibitors).
• Patient had a past history of tuberculosis 3 years back.
 INDICATION OF BIOLOGICS?

Evidence of inflammation
Active disease
CRP
ASDAS ≥ 2.1 or BASDAI ≥ 4
MRI evidence of inflammation

Failure of NSAIDS (atleast 2) over 4

weeks
 WHICH TO CHOOSE?

• TNFi preferred over IL-17i

If IBD or Uveitis:
• Available options :
Use only monoclonal
TNFi

TNFi
• Infliximab IL17i
• Adalimuab TNFi monoclonal • Ixekizumab
• Golimumab antibodies • Secukinumab
• Certolizumab
• Etanercept
HOW LONG TO CONTINUE?

Continue bDMARDS for atleast 3

months

Improvement in ASAS ≥ 1.1

OR
BASDAI ≥ 2

Consider tapering/ spacing

TNF INHIBITORS IN POST TB INFECTION

Symptoms suggest active

TB/previous h/o TB /
abnormal chest radiograph?
Investigation
confirms
Active TB?
yes no
6 months treatment, Adequate
Start TNFi after chemotherapy in past?
atleast 2 months no yes
Activity of joint Monitor and
assess if
disease
symptoms
develop

Inactive:
Delay anti TNFi
until completed
Active disease chemoprophylaxis

Ormerod, Milburn, Gillespie, et al ,BTS recommendations for assessing risk and for managing
Mycobacterium tuberculosis infection and disease inpatients due to start anti-TNF-a treatment
 PRESCRIPTION @ 4 WEEKS

• Continue non pharmacological management.

• Inj. Adalimumab 40 mg subcutaneous injection every alternate week.
• Tab Naproxen 500 mg SOS for 30days
• Rest continue same treatment.
• Follow up after 30 days.
 FOLLOW UP @ 12 MONTHS

• Patient was on monthly follow-up on the previous medications.

• Patient started having relief toms after 2 months of initiation of
Adalimumab and was doing well for the initial 9 months.
• Patient now complaints of recurrence of backache impairing his
daily activities for the last 2 months.
Secondary Non response

Recurrence of AS activity after

initial improvement

Alternative TNFi
 PRESCRIPTION @ 12 MONTHS

Diagnosis: Ankylosing Spondylitis

• Continue non pharmacological management.

• Stop Adalimumab.
• Inj Infliximab 300 mg IV infusion over 2 hours after premedication.
• Tab Naproxen 500 mg BD for 14 days
• Rest continue same treatment.
• Follow up after 30 days.
 FOLLOW UP @ 18 MONTHS

• Patient comes again unsatisfied with the treatment.

• He complaints of progression of his symptoms and no relief at
all after changing to Infliximab.
• Asks to restart the previous medication only as according to him
the change in medication didn’t benefit him at all.
Primary Non response

Absence of meaning
improvement over 3-6 months

IL 17i
 PRESCRIPTION @ 18 MONTHS

Diagnosis: Ankylosing Spondylitis

• Continue non pharmacological management.

• Stop Infliximab.
• Inj. Secukinumab 150 mg subcutaneous injection every 4
weeks.
• Tab Naproxen 500 mg BD for 14 days
• Rest continue same treatment.
• Follow up after 30 days.
GUIDELINES
TREATMENT – 1ST LINE
TREATMENT – 2ND LINE
TREATMENT – 3RD LINE
THANK YOU
CASE SCENARIOS IN JOINT
DISEASE-3
Presenter: Dr Saurabh Kumar Singh
SR moderator: Dr Amit Sehgal
Faculty preceptors: Dr Prayas Sethi, Dept. of Medicine
Dr Ranjan Gupta, Dept of Rheumatology
 CASE 1

• 28 yr old male
• B/L Polyarticular pain and swelling of small joint for past 6
weeks
• Early Morning stiffness : 1hour, relief with exercise
• o/e : polyarthritis with tenderness; nails normal, skin normal
• CRP : elevated

?
• RA factor/Anti CCP was negative
 PRESCRIPTION 1

• Dx: Symmetric poly arthritis : sero neg RA

• Rx:
• Tab Naproxen 500 mg SOS
• Tab Methotrexate 15 mg (Saturday)
• Tab Folic Acid 5 mg (Sunday)
• Review after 6 weeks
 FOLLOW UP

• 2 years later: IBP + nail changes

Nail pitting
Subungal hyperkeratosis
 SERONEGATIVE ARTHRITIS

Psoriatic arthritis
• Mother had h/o palmoplantar Ps
• Now pt has nail changes
• No history of diarrhoea/ STDs/ urethrititis 4 weeks Reactive arthritis
preceding onset
• No history of chronic bloody diarrhea
Enteropathic arthritis
• No history of chronic IBP
• No history of skin and nail involvement in past
Axial
spondyloarthritis
History of present / past skin involvement
Nail examination
Family history of psoriasis, IBP or other spA
PSORIATIC ARTHRITIS
 Mono arthritis

Dactylitis Oligo arthritis

Disease
spectrum-
musculoskeleta
l

Enthesitis Poly arthtritis

Axial
spondyloarhtritis
PATTERNS OF JOINT INVOLVEMENT
 Mono arthritis

Dactylitis Oligo arthritis

Disease
spectrum-
musculoskeletal

Enthesitis Poly arthtritis

Axial
spondyloarhtritis
 DACTYLITIS

• Also known as sausage digit

• Inflammation of an entire digit (a finger or toe)

• Associated commonly with

1. Psoriatic SpA
2. Reactive SpA
3. Enteropathic SpA, occasionally
 Mono arthritis

Dactylitis Oligo arthritis

Disease
spectrum-
musculoskeleta
l

Enthesitis Poly arthtritis

Axial
spondyloarhtritis
 ENTHESITIS
• Highly vascular and are susceptible to
bacterial and antigen deposition 

• Most common sites

1. Achilles tendon region
2. plantar fascia

• Diagnosis mainly clinical (i.e. tenderness,

Limits movement)

• USG and MRI helps in delination

 IBD

Non Uveiti
Nail musculoskeleta
l
s

Skin
 LAB INVESTIGATION

◦ There are no laboratory tests diagnostic of PsA.

◦ ESR and CRP are often elevated. A small percentage of patients may have low
titers of rheumatoid factor or ANAs, anti-CCP antibodies.
◦ Uric acid may be elevated in the presence of extensive psoriasis.
◦ HLAB27 is found in 50–70% of patients with axial disease, but in ≤20% of
patients with only peripheral joint involvement.
 RADIOLOGY
◦ Peripheral PsA :
◦ DIP involvement
◦ “Pencil-in-cup” deformity; marginal erosions with
adjacent bony proliferation (“whiskering”)
◦ Small-joint ankylosis
◦ osteolysis with telescoping of digits
◦ periostitis and proliferative new bone at sites of enthesitis
◦ “Ray” distribution of lesions.

◦ Axial PsA:
◦ Asymmetric sacroiliitis; severe cervical spine
involvement, with a tendency to atlantoaxial subluxation
 DIAGNOSIS:
◦ CASPAR criteria 2006:
-Sensitivity of 99%, Specificity of 91%
◦ Psoriasiform lesions should be sought in the scalp, ears,
✔️
umbilicus, and gluteal folds in addition to more accessible ✔️
sites; the finger and toe nails should also be carefully ✔️
examined.

Differentials:
◦ all other forms of arthritis
◦ DIP involvement: Osteoarthritis (Heberden’s nodes);
multicentric reticulo-histiocytosis and inflammatory
osteoarthritis.
TREATMENT
 CASE 2

• 28 yr old female with history of psoriasis

• B/L polyarticular pain and swelling of small joint
• Early Morning stiffness : 1hour, relief with exercise
• o/e : symmetric polyarthritis with tenderness; nails normal, skin normal
• CRP : elevated
• RA factor was negative

?
 PRESCRIPTION 2

• Rx:
• Tab Naproxen 500 mg SOS
• Tab Methotrexate 15 mg (Saturday)
• Tab Folic Acid 5 mg (Sunday)
• Review after 6 weeks

?
 CASE 3

• 29 year old female with history of psoriasis

• Pain in left 2nd DIP in morning; EMS >30 min
• Skin normal
• Nail normal
• Left 2nd DIP swelling and tenderness
• RA -ve
 PRESCRIPTION 3

• Dx: psoriatic mono arthritis

• Rx:
• Tab Naproxen 500 mg SOS
• Tab Pantop 40 mg BBF
• Review after 4 weeks
 FOLLOW UP

After 4 weeks….. • Rx:

No relief on NSAIDS
• Inj. Methylprednisolone 20 mg I/A
stat
• Tab Naproxen 500 mg SOS
• Tab Pantop 40 mg BBF
• Review after 2 months
 CASE 4

• 2 months later……
• 29 year old female with history of psoriasis
• Pain in left 2nd finger in morning; EMS >30 min
• Skin normal
• Left 2nd DIP swelling and tenderness
• RA -ve
 PRESCRIPTION 4

• Dx: psoriatic monoarthritis with nail involvement

• Rx:
• Tab Naproxen 500 mg SOS
• Tab Methotrexate 15 mg (Saturday)
• Tab Folic acid 5 mg (Sunday)
• Review after 6 weeks
 POOR PROGNOSTIC FEATURES

• Nail involvement
• Dactylitis
• Raised ESR/CRP
• Early erosions
GUIDELINE-1 S T LINE
 CASE 5

• 3 months later………
• 28 yr old female on MTX for last 3 months at 25 mg weekly
• multiple polyarticular pain and swelling of small joint
• Early Morning stiffness : 1hour, relief with exercise
• CRP : elevated
• RA factor was negative
• o/e : polyarthritis with tenderness; skin normal
 PRESCRIPTION-5

• Psoriatic Poly arthritis with 1st line t/t failure

Combination csDMARDs bDMARDS

 PRESCRIPTION-5

• Rx:
1. Inj. MP 80 mg i.m. stat/week for 3-4 weeks
2. NSAIDs sos
3. Tab Methotrexate 25 mg (Saturday)
4. Tab Folic acid 5 mg (Sunday)
Alternative:
5. Tab Leflunamide 20 mg Sulfasalazine
6. Review after 4 weeks Cyclosorine
Apremilast
 CASE 6

• After 3 months:
• 28 yr old female on MTX for last 3 months at 25 mg weekly
• multiple polyarticular pain and swelling of small joint
• Early Morning stiffness : 1hour, relief with exercise
• CRP : elevated
• RA factor was negative
• o/e : polyarthritis with tenderness; skin normal
What next ?

BIOLOGICS
BEFORE BIOLOGICS
 PRETREATMENT INVESTIGATIONS

• CBC
• LFT:
• ALT/AST, Albumin
• KFT
• Immunoglobins (Ig A, G, M)
• Indicated if pt receiving B cell delpleting agent (Rituximab)
• Lipid profile
• If TCZ indicated
 SCREEN FOR INFECTIONS

• Hep B &C screening

• Hepatitis B surface antigen (HBsAg).
• Hepatitis C antibody.
• HIV screening.
• Screening for latent tuberculosis (TB).
• Mantoux test, IGRA (interferon-gamma release assay)
• Chest radiograph
Handa R, et al. Int J
Rheum Dis. 2017; 20:1313–1325
 COMORBIDITIES: INFECTION

• Latent TB: • HIV:

• Start prophylactic anti TB drugs • Less risk if CD >200, Viral load undectable
• Biologics may be started after 1 month • Anti- TNF and HAART can be given together
• And skip loading dose of TNFi
• Active TB
• Biologics after 3 months of anti TB drugs
• HBV ⊕ ve
• Biologics safe with antiviral
• HCV⊕ ve
• No studies showed detrimental effect on HCV
• Still use with caution
 COMORBIDITIES: MALIGNANCY

• C/I in patient with malignancy Basal cell carcinoma is not C/I

 PREGNANCY

Rheumatology 2016;55:1693􏰀1697 doi:10.1093/rheumatology/kev404

 COMORBIDITIES: CVS

• Use in caution in class III/IV NYHA

 COMORBIDITIES: ILD

RITUXIMAB/ABETACEPT:
• Biologics not C/I 1st line in pt with ILD
• Use with caution
 VACCINATION

• Influenza and pneumococcal pneumonia

• COVID vaccine
• HBV
• Herpes zoster
• Age >50 years
• JAK ⊖
 CONTRA INDICATIONS

• Active infection
• If requiring IV antibiotics/hospitalization
• Active malignancy
Basal cell carcinoma is not C/I
• MS and other demyelinating disease
• TNF α ⊖ C/I
• SLE or other AI disease
• TNF α ⊖ C/I
• Diverticular disease
• TOCILIZUMAB C/I
 PRESCRIPTION-6

• Workup: • Rx:
• 1. Monteaux test; CXR 1. Inj. MP 80 mg i.m. stat/week
• 2. CBC, LFT/KFT 2. Tab Naproxen 500 mg SOS
• 3.Lipid profile 3. Tab Methotrexate 25 mg (Saturday)
• 4. Viral markers 4. Tab Folic acid 5 mg (Sunday)
5. Tab Leflunamide 20 mg OD
6. Review after 1 week
 PRESCRIPTION-6

CBC, LFT, KFT: WNL

Viral marker :-ve
 WHICH ONE TO CHOOSE

• Choose based on cost and availability

• Available options :

TNFi
• Infliximab IL17i JAKi
• IxeKizumab
IL12/23i
• Adalimuab • Ustekinumab • Tofacitinib
• Golimumab • Secukinumab • upadacitinib
• Certolizumab
• Etanercept
 WHICH BIOLOGICS TO CHOOSE?

TNFi IL17i JAKi

• Infliximab • IxeKizumab IL12/23i
• Tofacitinib
• Adalimuab TNFi monoclonal • Secukinumab • Ustekinumab
• upadacitinib
• Golimumab antibodies
• Certolizumab
• Etanercept

If IBD or Uveitis: If significant skin

If predominant axial If predominant axial
1. Monoclonal involvement
1. IL 17i + skin
TNFi 1. IL 17i
2. TNFi 1. IL 17i
2. IL 12/23i 2. IL 12/23i
 PRESCRIPTION-6

• Rx:
• Tab Naproxen 500 mg SOS
• Tab Methotrexate 10 mg (Saturday)
• Tab Folic acid 5 mg (Sunday)
• S/C inj Secukinumab 150 mg at 0,1,2,3,4 week
• Followed by 150 mg every month X 3 months
• Review after 1 month
 PRESCRIPTION-7

• She lost her job

• Now can not afford her medications ?

Now what?
Drug MOA Dose Side effects Cost/ 6 month

1. Infliximab TNFi m/c ab Loading dose: IV Infusion rxn, ₹2,40,000

5mg/kg @0,2,6 weeks reactivation of
Maintainence: 5 mg/kg every TB, Drug
2 weeks induced lupus

2. Adalimumab TNFi m/c ab 40 mg s/c every 2 weekly -do- ₹1,32,000

3. Etanercept TNFi 50 mg s/c every weekly -do- ₹84,000

4. Secukinumab IL17i Loading :S/C inj Secukinumab Infection, IBD ₹1,25,000
150 mg at 0,1,2,3,4 week
Maintainence:150 mg every
month

5. Ustekinumab IL23i Loading dose: 40 mg s/c at 0, 4 Infection, ₹8,00,000

weeks diarrhea
Maintainence: 40 mg every 3
monthly
6. Tofacitinib JAKi 5 mg BD Herpes zoster ₹ 6500
 PRESCRIPTION-7

• Tab Tofacitinib 5 mg BD X 1month Contraindications

• Tab Methotrexate 25 mg BBF (Saturday) X 1month

Absolute lymphocyte count <500
• Tab folic Acid 5 mg (Sunday) X 1 month cells/mm3
• Tab Naproxen 500 mg SOS ANC <1,000 cells/mm3
Hb <9 g/dL
• Review after 1 month
HAPPY BIRTHDAY SOURADIP