Rheumatoid Arthritis Management

Aka: Rheumatoid Arthritis Management

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II. Approach

  1. Assess Current disease activity
    1. Morning Stiffness
    2. Synovitis
    3. Fatigue
    4. C-Reactive Protein
  2. Document Joint Damage
    1. Joint Range of motion and deformities
    2. XRay joint space narrowing and erosions
    3. Functional status
  3. Document Joint Extra-articular manifestations
    1. Nodules
    2. Pulmonary fibrosis
    3. Vasculitis
  4. Scales to grade current Rheumatoid Arthritis Severity
    1. Clinical Disease Activity Index (CDAI)
    2. Simplified Disease Activity Index (SDAI)

III. Management: General

  1. Non-Pharmacologic
    1. Systemic and articular rest
    2. Tobacco Cessation
      1. Tobacco Smoking is associated with more severe RA-related articular and extraarticular disease
      2. Cardiovascular Risk is significantly increased in RA
        1. Overall Cardiovascular Risk Reduction is critical
    3. Physiotherapy
      1. Physical therapy and hand therapy for joint protection techniques
      2. Local Heat Therapy
      3. Local Cold Therapy
    4. Exercises
      1. Range of Motion
      2. Conditioning
      3. Strengthening Exercises
      4. Tai Chi
    5. Assistive Devices
    6. Patient Education Materials
      1. Arthritis Foundation
      2. American College Rheumatology
      3. Bob and Brad (Youtube)
        1. General Exercises
          1. https://www.youtube.com/watch?v=sVHJy24JjHo
        2. Hand Exercises
          1. https://www.youtube.com/watch?v=TdhvUFFv1_A
  2. Rheumatoid Arthritis Remittive Medications (DMARDs)
    1. Most important agents in Rheumatoid Arthritis
    2. Methotrexate is first-line preferred agent
      1. Alternatives include Leflunomide, Sulfasalazine, Plaquenil
    3. Biologic and TNF agents are third-line agents in refractory cases
    4. Consider tapering DMARD if in remission for at least 6 months (esp. if anti-citrullinated Protein negative)
      1. In some cases DMARDs may be tapered off with maintained remission
      2. Haschka (2016) Ann Rheum Dis 75(1):45-51 [PubMed]
  3. Rheumatoid Arthritis Antiinflammatory Medications (NSAIDs, COX2 Inhibitors)
    1. Used in combination with DMARDs
    2. Limit use of NSAIDs and COX2 Inhibitors once on DMARD >1 month
      1. Decrease to lowest effective dose (preferably use only as needed)
      2. Best use is limiting NSAIDS and COX2 Inhibitors for exacerbations
  4. Other medications
    1. Atorvastatin
      1. Showed modest benefit in clinical improvement
      2. McCarey (2004) Lancet 363:2015-21 [PubMed]
  5. Joint Replacement
    1. Consider for severe joint damage with pain refractory to medical management

IV. Management: Initial protocol

  1. Indications: New moderate to severe seropositive Rheumatoid Arthritis
  2. Protocol: Start
    1. Prednisone
      1. Low dose protocol (preferred if adequate)
        1. Prednisone 5-10 mg orally daily for 4-6 weeks
      2. High dose tapering protocol
        1. Prednisone 60 mg daily tapered weekly by 10 mg each week
    2. Methotrexate
      1. Start at 7.5-10 mg weekly and titrate to 15 mg weekly in the first 4-6 weeks
    3. Folic Acid 1 mg daily
  3. References
    1. Michet (2012) Mayo POIM Conference, Rochester

V. Management: Emergency Department

  1. Cardiopulmonary presentations
    1. Myocardial Infarction risk (RR 3)
    2. Congestive Heart Failure (RR 2)
    3. Atrial Fibrillation (RR 1.4)
    4. Pulmonary fibrosis, Pulmonary Hypertension and Right Heart Failure
    5. Pulmonary Embolism
    6. Pericardial Effusion
    7. Pleural Effusion
    8. Methotrexate induced pulmonary toxicity
  2. Infectious disease presentations
    1. Immunosuppression due to RA alone, in addition to medications (e.g. TNF agents, Corticosteroids)
    2. Pneumonia (including opportunistic lung infections, Fungal Infections, Legionella, Tuberculosis)
  3. Joint Pain presentation
    1. Exclude Septic Arthritis!
      1. Diagnosis is often delayed in Rheumatoid Arthritis
      2. Immunocompromised state results in underwhelming signs (afebrile, minimally Inflamed joint)
      3. Aspirate suspected joints
    2. Rheumatoid Arthritis flare (after excluding Septic Joint)
      1. Prednisone taper from 60 mg to 10 mg over 2 weeks
  4. Endotracheal Intubation
    1. Atlantoaxial subluxation risk
      1. Risk of secondary cervicomedullary compression and respiratory arrest
    2. Temporomandibular Joint Arthritis
      1. Decreased mouth opening (see LEMON Mnemonic)
    3. Intubation Approach
      1. Maintain inline cervical stabilization during intubation
      2. Use videolarygnoscopy or fiberoptics to aid intubation
  5. References
    1. Herbert, Orman, Berman in Herbert (2018) EM:Rap 18(4): 6

VI. References

  1. Pincus (1993) Rheum Dis Clin North Am 19:123-151 [PubMed]
  2. Scott (2010) Lancet 376(9746):1094-108 [PubMed]
  3. Wasserman (2011) Am Fam Physician 84(11): 1245-52 [PubMed]
  4. Wasserman (2018) Am Fam Physician 97(7): 455-62 [PubMed]

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