Case-Based Approach for the Management of Rheumatic Diseases - Episode 5
Transcript: Madelaine A. Feldman, MD: Hi, this is Madelaine A. Feldman, MD. I’m on the clinical faculty in medicine at Tulane University School of Medicine. I’m a rheumatologist in private practice in New Orleans, Louisiana. Welcome to this HCPLive® Insights titled “Case-Based Approach for the Management of Rheumatic Diseases.”
Our case today is of a 48-year-old gentleman who initially presented to his primary care physician with a 9-month history of pain, swelling, and stiffness in his hands, wrists, and ankles in the morning. This stiffness would last for several hours. He presented to his primary care doctor, who started him on 800 mg of ibuprofen 3 times a day. Despite this very good dose of an anti-inflammatory, it eventually lost its effectiveness. And so he presented to a rheumatologist.
He has no past medical history. He was on no other medicines, other than the ibuprofen. On physical exam, he has active bilateral synovitis in both hands, wrists, and ankles. And importantly, he’s got nodules on his left elbow. A CDAI [Clinical Disease Activity Index] score was calculated and was 38. Remember that CDAI is the number of swollen and tender joints. We look at 28 joints. We look at the shoulders, the elbows, the wrists, the MCP [metacarpophalangeal] joints, the PIP [proximal interphalangeal] joints, and the thumbs. Remember, the ankles and feet are not included in the CDAI.
There’s a patient global assessment as well as a physician global assessment, and high disease activity in the CDAI is over 22. This patient was at 36, so he demonstrated very high disease activity. That was also confirmed by his laboratory results. His CRP [C-reactive protein] level was 62. He had a sedimentation rate of 42, a rheumatoid factor of 44, and a highly elevated CCP [cyclic citrullinated peptide] level.
X-rays showed no erosions, but there was joint space narrowing and some periarticular osteopenia. At that time, oral methotrexate was recommended at 10 mg a week. And over the next 4 weeks, it was increased to 15 mg.
He returned to the rheumatologist’s office after 3 months and continued to complain about stiffness, pain, and swelling in his wrists. The CRP level and sedimentation rate continued to be elevated. At this point, his productivity and his general mobility were really being affected by his joint pain. His CDAI score had come down to 22, but it was still demonstrating very high disease activity.
Transcript Edited for Clarity