MSK History

Rheumatoid arthritis



    • Ask About

    • Diagnosis - when rheumatoid arthritis was diagnosed, presentation, duration of symptoms
    • Family history of rheumatoid arthritis
    • Manifestations - extent / severity of articular involvement, extra-articular disease
    • Functional impact
    • Management - non-pharmacologic, steroids, DMARDs
    • Risk Factors for Rheumatoid Arthritis

    • Female sex
    • Family history of rheumatoid arthritis
    • Infections - EBV, CMV, E coli, periodontal disease (Porphyromonas gingivalis)
    • Smoking


    • Manifestations of Rheumatoid Arthritis

    • Articular

    • Symmetrical inflammatory polyarthropathy with sparing of the distal interphalangeal (DIP) joints
    • Tendon rupture
    • Atlantoaxial instability (severe cases)
    • Extra-Articular

    • Rheumatoid nodules
    • Systemic - fatigue, weight loss
    • Skin - rheumatoid nodules
    • Ocular - sicca symptoms, scleritis, episcleritis, scleromalacia, scleromalacia perforans
    • Vasculitis - pulmonary hypertension, palpable purpura, distal gangrene
    • Neurologic - compressive neuropathies (e.g. carpal tunnel syndrome), mononeuritis multiplex
    • Cardiovascular - pericarditis
    • Respiratory - interstitial lung disease, pleurisy, lung nodules
    • Haematologic - Felty’s syndrome (arthritis, splenomegaly and neutropaenia)


    • Ask About

    • Disease-modifying anti-rheumatic drugs (DMARDs) - effectiveness, adverse effects
    • Steroids - duration, continuous / intermittent, maximum dose, adverse effects, osteoporosis screening
    • Management Options

    • Non-Pharmacologic

    • Smoking cessation
    • Pharmacologic

    • Steroids (for acute flares or bridging therapy only)
    • Conventional DMARDs - methotrexate, sulfasalazine, leflunomide, hydroxychloroquine
    • Targetted DMARDs - JAK inhibitors
    • Biologic DMARDs - TNF blockers, IL-6 blockers, CTLA4-Ig, rituximab
    • Pearls

    • Start treatment as early as possible
    • Aim for sustained remission or low disease activity
    • Monitor patients frequently
    • Change medications if they are not working
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 Baker DG, Schumacher Jr HR. Acute monoarthritis. New England Journal of Medicine. 1993 Sep 30;329(14):1013-20.
Bengtsson AA, Rylander L, Hagmar L, Nived O, Sturfelt G. Risk factors for developing systemic lupus erythematosus: a case–control study in southern Sweden. Rheumatology. 2002 May 1;41(5):563-71.
Cooper GS, Dooley MA, Treadwell EL, St Clair EW, Gilkeson GS. Risk factors for development of systemic lupus erythematosus: allergies, infections, and family history. Journal of clinical epidemiology. 2002 Oct 1;55(10):982-9.
Dacre JE, Worrall JG. The rheumatological history. Medicine. 2010 Mar 31;38(3):129-32.
de l’Escalopier N, Anract P, Biau D. Surgical treatments for osteoarthritis. Annals of physical and rehabilitation medicine. 2016 Jun 1;59(3):227-33.
Fransen M, Nairn L, Winstanley J, Lam P, Edmonds J. Physical activity for osteoarthritis management: a randomized controlled clinical trial evaluating hydrotherapy or Tai Chi classes. Arthritis Care & Research. 2007 Apr 15;57(3):407-14.
Heidari B. Knee osteoarthritis prevalence, risk factors, pathogenesis and features: Part I. Caspian journal of internal medicine. 2011;2(2):205.
Herrick A. Diagnosis and management of scleroderma peripheral vascular disease. Rheumatic Disease Clinics of North America. 2008 Feb 1;34(1):89-114.
Hummers LK, Wigley FM. Management of Raynaud's phenomenon and digital ischemic lesions in scleroderma. Rheumatic diseases clinics of North America. 2003 May;29(2):293-313.
Hunzelmann N, Scharffetter KK, Hager C, Krieg T. Management of localized scleroderma. InSeminars in cutaneous medicine and surgery 1998 Mar (Vol. 17, No. 1, pp. 34-40).
Katz JN, Earp BE, Gomoll AH. Surgical management of osteoarthritis. Arthritis care & research. 2010 Sep;62(9):1220-8.
 Majithia V, Geraci SA. Rheumatoid arthritis: diagnosis and management. The American journal of medicine. 2007 Nov 30;120(11):936-9.
McInnes IB, Schett G. The pathogenesis of rheumatoid arthritis. New England Journal of Medicine. 2011 Dec 8;365(23):2205-19.
Nelson AE, Allen KD, Golightly YM, Goode AP, Jordan JM. A systematic review of recommendations and guidelines for the management of osteoarthritis: the chronic osteoarthritis management initiative of the US bone and joint initiative. InSeminars in arthritis and rheumatism 2014 Jun 1 (Vol. 43, No. 6, pp. 701-712). WB Saunders.
Puttick MP. Rheumatology: 11. Evaluation of the patient with pain all over. Cmaj. 2001 Jan 23;164(2):223-7.
Sallam H, McNearney TA, Chen JZ. Systematic review: pathophysiology and management of gastrointestinal dysmotility in systemic sclerosis (scleroderma). Alimentary pharmacology & therapeutics. 2006 Mar;23(6):691-712.
Shah AA, Wigley FM. My approach to the treatment of scleroderma. InMayo Clinic Proceedings 2013 Apr 1 (Vol. 88, No. 4, pp. 377-393). Elsevier.
Smolen JS, Landewé R, Bijlsma J, Burmester G, Chatzidionysiou K, Dougados M, Nam J, Ramiro S, Voshaar M, Van Vollenhoven R, Aletaha D. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2016 update. Annals of the rheumatic diseases. 2017 Jun 1;76(6):960-77.
Squance ML, Reeves GE, Bridgman H. The lived experience of lupus flares: features, triggers, and management in an Australian female cohort. International journal of chronic diseases. 2014;2014.
Turesson C, O’fallon WM, Crowson CS, Gabriel SE, Matteson EL. Extra-articular disease manifestations in rheumatoid arthritis: incidence trends and risk factors over 46 years. Annals of the rheumatic diseases. 2003 Aug 1;62(8):722-7.
Vasoo S. Drug-induced lupus: an update. Lupus. 2006 Nov;15(11):757-61.
Young A, Koduri G. Extra-articular manifestations and complications of rheumatoid arthritis. Best practice & research Clinical rheumatology. 2007 Oct 1;21(5):907-27.