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Rheumatoid Arthritis

Raeann Whitney


  • Inflammation and proliferation of synovial tissue, loss of articular cartilage, erosion of juxtarticular bone

  • Female predominant (~3:1), mostly child-bearing age at onset

  • Chronic, inflammatory polyarthritis affecting the small joints of the hands (MCPs, PIPs, classically spares DIPs), wrists, feet, ankles - typically symmetric

  • Ulnar deviation, swan neck, boutonniere deformities are late findings of untreated disease

  • Morning stiffness lasting >30 min (often 1 hr+) suggests inflammatory arthritis (not specific)

  • 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

  • C1-C2 instability: pts need evaluation with imaging prior to surgical procedure/intubation


  • Clinical diagnosis + positive RF, anti-CCP. Note up to 15-20% patients have seronegative RA

    • RF is more sensitive but not specific; can be + in HBV/HCV, cryoglobulinemia

    • CCP is less sensitive but more specific

  • CBC, CMP, CRP, ESR, HIV, Hepatitis B and C screening; Quantiferon Gold (biologics)

  • Obtain hand and foot films to assess for periarticular osteopenia & typical marginal erosions


  • The majority of joint damage occurs early in the disease so early treatment paramount

  • DMARDs: typically start with MTX; may require biologics such as TNF inhibitors

    • MTX dosed weekly; required daily 1 mg folic acid supplement

      • Toxicities: oral ulcers, bone marrow suppression, liver toxicity, pneumonitis, teratogenic (contraception required)
  • Symptomatic/Flare treatment (no impact on disease progression):

  • Steroids at low-moderate dosage (e.g., prednisone 15-20mg/day); NSAIDs (high doses required for anti-inflammatory effects)

Last update: 2022-06-26 16:42:46