good evening and welcome to doctors on call I'm Dr Peter nen professor and head of the Department of Family Medicine and biobehavioral health and Associate Dean for Rural medicine at the University of Minnesota medical school duth campus I'm your host for our program tonight on rheumatoid art arthritis tendonitis and btis the success of this program is very dependent on you the viewer so please call in your questions or email them to ask pbsn north.org the telephone numbers can be found at the bottom of your screen our panelists this evening include Dr vishu deala a rheumatologist with Essentia Health Dr Wasim Khan a rheumatologist with with St Luke's Rheumatology Associates and Dr Paul Sanford an internal medicine specialist with St Luke's Internal Medicine Associates our medical students answering the phones tonight are Kai akimoto from tamuning Guam Anika liberg of Jackson Minnesota and Walker toron from Fairmont Minnesota and now on to tonight's program on rheumatoid arthritis tendinitis and btis and uh Dr Sanford the first question is for you what makes btis painful well inflammation is just where something's happening that your body and connective tissue doesn't like and so the Bersa sack which is like a shock absorber here or over the hip will swell and be painful and it can happen from trauma or just overuse wear and tear thank thank you and uh Dr KH uh for tendinitis how do you distinguish between tendonitis and btis well itis is just a genetic term meaning inflammation so inflammation of the Bersa is btis inflammation of the tendon is tendonitis Bas like Dr Sanford said are these tiny pouches which Nature has designed at different spots in our body where there's friction so the hip elbow bow shoulder and tendon tendons are Senus that attach your muscles to your bone so when the tendon gets inflam we call it tendonitis when a Bersa gets inflamed we call it btis when a joint gets inflamed we call it arthritis and so on thank you Dr dalala what is the importance of the test called ana um so Ana stands for anti-nuclear antibodies and and um they're we're still kind of in the process of really understanding them um they can be very common about 5% of the population can make these antibodies um I'll simplify like the the term we use the uh which is positive predictive value so how uh important is that test so um that test tells us that out of a 100 times the Ana is posi positive um one or two times it might mean that you might have a underlying connective tissue disease or an autoimmune disease so um it's an so to simplify it's an antib body that a lot of folks uh make and uh about uh 99 TS out of a 100 it doesn't really mean much that one time out of a 100 it may mean that you're dealing with the uh an in inflammatory condition are there other tests you might order with it or after it yes so that's uh typically we use that test as a Gateway test and uh now we have to interpret that test in context you know we have to make sure there are other things that are going on that uh um uh warrant additional testing but typically yes when the patients have joint pain or a rash or other things going on we use that test as a Gateway and uh it usually does lead to additional testing Dr KH how about uh patients who might be reviewing their own records or their own bills if they see CRP uh can you tell us about that test well the CRP or C reactive protein is a protein in our body uh that the body makes in response to inflammation so it generally signifies inflammation it's not a very specific test it doesn't tell you whe whether the inflammation is due to an infection or a disease like rheumatoid or lupus or sometimes even malignancy so it's basically a marker for inflammation thank you Dr Sanford this question is about uh timing or age when do most people develop rheumatologic disease oh my goodness yeah it can happen in children it can happen probably less often after age 70 but there are some subtypes of inflammatory arthritis or connected tissue disease that could happen at any time thank you and uh Dr deala What treatments are there for people with arthritis who have been on antibiotics for three months um this is for What treatments are there for people with arthritis who've been on antibiotics for three months perhaps uh after three months of antibiotics for septic joint perhaps I see um maybe they're referring to Lyme disease uh but uh you know it really depends on the cause of the infection and um it uh so for typically when you do have a joint infection you do kind of have to treat uh for a long term afterwards it really depends on their symptoms um if the infection is gone and they still have joint pain then we tend to focus on physical therapy uh and things like that um and uh so yeah I would it really depends on what's Happening after the antibiotics are gone if the infection is gone or if if it's just the pain that we are dealing with or instability and those kinds of things Dr Sanford what are indications for joint replace replacement referrals for evaluation well I'm I'm an old Geyer doctor and joint replacement for me is the last resort if people literally cannot walk because their knee or hip is making it untenable then it's time for replacement but before that I want to have them go through aggressive Physical Therapy build up their quadriceps build up their muscles endurance you know just practicing getting up and down from a chair which for a lot of people is almost impossible but if if they diligently do physical therapy and they still are just in agony from the bone on bone arthritis then it's time to visit with your friendly neighborhood orthopedic surgeon to replace the Joint Dr KH could you tell us about the relationship between rheumatoid arthritis and gold therapy and whether it's still used oh gold therapy I think it was probably it hasn't been I haven't used it in 25 years that I've been practicing Rheumatology so we don't use gold therapy anymore it was used in the 80s and ' 90s when a lot of our current treatments um were not in Vogue um I tell people 80% of the drugs we use for rheumatoid arthritis today weren't around 20 years ago so we've come a long way and gold I think should be sort of um put in a museum someplace as a sort of a relic of the past Dr dalala um how is stic arthritis different from rheumatoid arthritis um so there there are a lot of similarities between the two but uh stic arthritis can uh it tends to involve the larger joints it can cause more joint pain in the knees ankles um hips um but really in um uh in practice we see that there there are a lot of similarities it can look like uh rheumatoid arthritis um and uh but the main difference I would say is uh it tends to affect the large joints and rheumatoid arthritis tends to um affect the smaller joints of the hands the feet um so that would say that's the biggest difference thank you Dr Sanford a call a viewer asks um how do you how do you or how does one know whether to exercise or rest for joint pain oh my uh that's an interesting question it's I've never had a patient who didn't exercise enough um basically if you're sitting still you know hopefully it's when you're reading or getting ready to go to bed but otherwise during the day I ask my patients to walk even or dance or roller skate for 30 minutes every single day that's the one thing that all my hundred-year-old patients have in common that and they had one meal a day as a family and they stayed passionate about something like stamp collecting or eating cheeseburgers so yeah but movement is the key Dr Khan uh this question is about joints that get infected uh which joints are susceptible to infection and why do those occur most of the joint infection in occur um due to spread from a skin infection or people who use intravenous drugs uh so it could be for that matter it could be any joint usually the large joints are commonly affected but um any part of the body can be affected by an infection including the heart valves which can spread infection to to the joints so it's it's more in the realm of infectious disease and our infectious disease colleagues we involve them very commonly when we are dealing with this situation Dr deala is lupus considered a rheumatologic disease and what symptoms do those patients experience uh yes it it is a rogic disease and you know lupus is a is a tough one because um there's quite a lot of it's a broad spectrum of symptoms they could have you know usually joint pain and rash uh are very common uh symptoms usually uh they'll have Sun sensitivity um these folks when they spend time outside in the sun will develop a rash um and they'll typically feel very tired you know really fatigued um and uh they can have quite a lot of other manifestations also but for the most part you know rash joint pain uh joint swelling um um feeling kind of fatigued weak and another common uh um symptom we come across is called rods um which is um when your fingertips turn blue or purple purple or white when they're exposed to cold temperatures um rods tends to be very common but uh in the in the context of all of these other symptoms then we we kind of think of Lupus thank you Dr Sanford can btis actually be treated or cured yeah you know when you have any inflammation of any Vera Sac shock absorber you know usually stretching maybe a corticosteroid injection hot packs cold packs but yeah usually will'll we go away it's not a life-threatening thing although it can be uncomfortable thank you and also for you Dr Sanford would you explain for us symptoms and treatments of Achilles tendinitis yeah the Achilles tendon that hooks up the back of the calf where those muscles are with your heel so that you can stand on your tiptoes um sometimes will get inflamed and stretching is the best way to treat it it's a big tendon at the amount of work that it does you know is phenomenal the amount of weight that it has to handle so rest elevation hot cold ibuprofen a leave if you have a bleeding ulcer don't do that if you're on a blood thinner don't do that but they're it's just tender loving care we try not to inject tendons because sometimes they bust and that can ruin your whole day Dr KH what might be some nondrug management protocols for rheumatoid arthritis uh that area has been looked into I would say if you're um staying um natural um and a lot of our patients are interested in those things the the first and foremost thing would be not to smoke smokers rheumatoid arthritis is always more difficult to control and it's more aggressive there is some evidence that omega-3 fatty acids have a role um I would say it's a minor role if someone has a rip roaring rheumatoid arthritis they need to be on the drugs um so avoiding uh smoking Omega three fatty acids and just taking overall good you know good uh taking good care of your overall all Health thank you Dr dalala how does the experience of rheumatoid arthritis vary for patients across the globe yeah so um you know it yes it can vary quite a bit um now there's some evidence that people in warmer climates tend to have less inflammation okay less disease activity um so a in the colder climates here you could you might have more joint pain more stiffness um and uh it it tends to be a little bit more common in the northern hemisphere of the globe also um so we're not sure why that is um and uh so yes it does vary and it warm weather uh I wouldn't put too much weight on it but warm weather tends to help a little bit good to know Dr Sanford how would you compare or contrast gout and pseudo gout okay gout and pseudogout are both where you have crystals that will form in the fluid where the bones um meet and calcium pyrophosphate is the crystal that you get with pseudogout and then uric acid is with regular gout they act like sandpaper in the joint and you try to move the joint and it's just h hurts so the way you treat it is you you can use a host of different things to treat either one of them and you know then try to keep for gout uric acid levels low using something like alopurinol and for pseudogout dietary things and lots of hydration drink at least two quarts of water or any fluid a day thank you Dr KH could you tell us a little about uh the node or bumps that appear on patients hands with forms of arthritis okay that's an interesting question so there's osteoarthritis and then there's rheumatoid arthritis and although they are both arthritis they are like chalk and cheese you know one is wear and tear aging the other is inflammation so generally speaking if you look at the hand osteoarthritis tends to affect these Knuckles or these Knuckles and they are called The Bard's node and the hean nodes while rheumatoid affects these Knuckles and these Knuckles it never affects these Knuckles so that's how you tell one disease from another and stic arthritis was mentioned it can affect all three so it's a pattern you so when you when you are looking at a patient and diagnosing it you look at the pattern of joint involvement the blood tests the x-rays and all that goes into sort of the diagnostic process Dr dalala could you tell us the perhaps the top way you use Imaging in your evaluation of patients with arthritis in the hands so I would say the most common um Imaging modality we use are X-rays um and x-rays can kind of help us differentiate between wear and tear arthritis and rheumatoid arthritis um we see specific changes you know uh uh joint space loss um and uh you'll hear the term bone on bone often um these are findings that we see on X-rays and that can tell us about um um osteoarthritis and now in advanced cases uh rheumatoid arthritis can cause um a particular kind of joint damage that we call erosions um so we can use x-rays to kind of look for those uh and you know so X-rays I would say we we use most of often and you know in uh rare cases we do use MRIs uh that uh MRIs tend to be a little bit more sensitive and they can pick up inflammation and that can help us uh uh figure out if there's a component of rheumatoid arthritis there but yeah so be typically um lean towards x-rays Dr Khan in the course of your career what have been uh one or two of the uh leading breakthroughs or changes in rheumatologic care that you can now offer oh my I mean it's a if you walked into our um our waiting room in the '90s you would see half our patients with rheumatoid in wheelchairs or disabilities and deformities we don't see that anymore our rheumatoid patients provided they are diagnosed early and treated appropriately can uh hope to live very normal active fulfilling lives we have patients who are teachers surgeons um er docs n ICU nurses who are living full lives as with rheumatoid arthritis so like I said 80% of our drugs weren't around 20 years ago so it has come a long long way how have those classes of drugs changed um the major breakthrough has been the the introduction of biologic drugs in rheumatoid arthritis and there are different classes of biologics so there are about a dozen different drugs it's not one category and we get asked that question often you know how come you know we have so many drugs for a single disease because it it is not a single disease everyone's rheumatoid arthritis is being driven by a different part of the immune system so it's a it's a it's a it's about five six different diseases under one umbrella and the Art and Science and challenge is picking out which is the best drug for each individual because all rheumatoid isn't created equal Dr Sanford is there any relationship between osteoporosis and osteoarthritis not really osteoporosis is where you lose the density of the bone and you're the bone becomes more spongy or at higher risk of a fracture osteoarthritis can happen to anybody whether they have strong bones or not from trauma just wear and tear you know it's it's just a wear and tear injury where osteoporosis is a biochemical issue where people decalcify their bones and have a significant increase risk of a broken bone just standing up Dr deala what are some uh examples of injections used in rheumatologic practice that are perhaps other than steroids uh you know in terms of our um outside of steroids uh we in some practices they do um trigger point injections um where if there are certain painful areas we use uh Lidocaine with which is a numbing agent um and we'll inject that into the area and uh there's hyaluronic acid ID um which is the simk um that can be injected into joints so there are um not too many other options outside of steroids but uh usually lidocaine and uh simis and things like that that we use Dr Sanford regarding gout um why might it be important to treat gout rather than simply tolerated well gout can become very disfiguring there's when you get enough Uric a it building up in a joint it can swell it's called tophus and it can cause skin der rupture you can get an infected joint and then you can lose the finger you know ever since I think even Moses and rameses II used culine one of the oldest medicines in our Arsenal and it's remarkably effective in melting away uric acid crystals so if it's good enough for Moses it's good enough for me terrific um Dr KH could you uh tell us about the um information that it's helpful to have when a patient is referred to your practice I didn't understand the question like for a physician referring physician yes referring a patient into the rheumatologist just basically is there's some initial workup that you expect the uh patient to have already experienced okay so when you send a patient to a rheumatologist uh the basic question that you need to address is whether this is a mechanical problem or an autoimmune or inflammatory problem which is where V rheumatologists come in so um if someone has swollen joints or the disease is uh new onset or acute then there are blood tests like a rheumatoid Factor CCP deala mentioned the Ana test which is probably U being U utilized too much uh but that can be appropriate in the correct setting and then markers for inflammation like the sedimentation rate C reactive protein so those are the usual basic tests but um the key is to order them in the right clinical context because if you order a blood test in someone who does whose likelihood of having that disease is low if it's positive it does it may not mean much and Dr dalala what are some Le leading reasons that a uh patient patient might need a Rheumatology consult within the hospital um well you know we're we're blessed in our field that to you know we don't have too many emergencies um but I would say if uh uh a condition called vasculitis um and uh it's inflammation of the blood vessels that can affect uh um organs like your kidneys your heart so those would be the cases that uh we would need to be called in the hospital because that patient they tend to be very sick and um and uh we need to act in a timely manner to get it under control thank you well we're uh very pleased with the activity of our panelists and the answers this evening and the uh number of questions coming in I want to thank our panelists Dr vishu deala Dr Wasim Khan and Dr Paul sanfred and our medical student volunteers Kai akamoto anaka liberg and Walker tson please join Dr Ray Christensen next week for a program on Diabetes when his panelists will be Dr David Hutchinson Dr Ken rip and Dr Umar sadiki thank you for watching good night 1 2 3 4 5 67 8 9 10 sound are you able to see a timer yes okay are you guys comfortable with that can you keep going please 1 2 three four five I really like that right there it's easy to see so thank you for having that up do you need me to keep talking or do you have the sound on there uh the timer will not the timer will not start until you start answering or start talking take a breath it won't be during everything good I'm going to head upstairs have a show and it's straight through for an hour right 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