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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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