Overview
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- 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
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- 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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