MSK History
 

Rheumatoid arthritis

 
 
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Overview

    • 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

    • 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)

Management

    • 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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