Rheumatoid Arthritis¶
Raeann Whitney
Background¶
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Inflammation and proliferation of synovial tissue, loss of articular cartilage, erosion of juxtarticular bone
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Female predominant (~3:1), mostly child-bearing age at onset
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Chronic, inflammatory polyarthritis affecting the small joints of the hands (MCPs, PIPs, classically spares DIPs), wrists, feet, ankles - typically symmetric
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Ulnar deviation, swan neck, boutonniere deformities are late findings of untreated disease
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Morning stiffness lasting >30 min (often 1 hr+) suggests inflammatory arthritis (not specific)
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Extra-articular manifestations include: sicca symptoms, scleritis, ILD, pulm nodules, serositis, constrictive pericarditis, anemia, mononeuritis multiplex, rheumatoid nodules, rheumatoid vasculitis. Increased risk of lymphoma, osteoporosis
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C1-C2 instability: pts need evaluation with imaging prior to surgical procedure/intubation
Evaluation¶
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Clinical diagnosis + positive RF, anti-CCP. Note up to 15-20% patients have seronegative RA
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RF is more sensitive but not specific; can be + in HBV/HCV, cryoglobulinemia
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CCP is less sensitive but more specific
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CBC, CMP, CRP, ESR, HIV, Hepatitis B and C screening; Quantiferon Gold (biologics)
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Obtain hand and foot films to assess for periarticular osteopenia & typical marginal erosions
Management¶
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The majority of joint damage occurs early in the disease so early treatment paramount
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DMARDs: typically start with MTX; may require biologics such as TNF inhibitors
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MTX dosed weekly; required daily 1 mg folic acid supplement
- Toxicities: oral ulcers, bone marrow suppression, liver toxicity, pneumonitis, teratogenic (contraception required)
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Symptomatic/Flare treatment (no impact on disease progression):
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Steroids at low-moderate dosage (e.g., prednisone 15-20mg/day); NSAIDs (high doses required for anti-inflammatory effects)