Rheumatology Book


Rheumatoid Arthritis Management

Aka: Rheumatoid Arthritis Management
  1. See Also
    1. Rheumatoid Arthritis
    2. Rheumatoid Arthritis Diagnosis
    3. Rheumatoid Arthritis Articular Signs
    4. Rheumatoid Arthritis Extra-articular Signs
    5. Felty's Syndrome
    6. Rheumatoid Arthritis Antiinflammatory Medications
    7. Rheumatoid Arthritis Remittive Agents
  2. Approach
    1. Assess Current disease activity
      1. Morning Stiffness
      2. Synovitis
      3. Fatigue
      4. Erythrocyte Sedimentation Rate
    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
  3. Management: General
    1. Non-Pharmacologic
      1. Systemic and articular rest
      2. Physiotherapy
        1. Local Heat Therapy
        2. Local Cold Theraoy
      3. Exercises
        1. Range of Motion
        2. Conditioning
        3. Strengthening Exercises
        4. Tai Chi
      4. Assistive Devices
      5. Patient Education Materials
        1. Arthritis Foundation
        2. American College Rheumatology
    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
  4. 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
  5. 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 JointArthritis
        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
  6. 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]

Rheumatoid Arthritis (C0003873)

Definition (MEDLINEPLUS)

Rheumatoid arthritis (RA) is a form of arthritis that causes pain, swelling, stiffness and loss of function in your joints. It can affect any joint but is common in the wrist and fingers.

More women than men get rheumatoid arthritis. It often starts in middle age and is most common in older people. But children and young adults can also get it. You might have the disease for only a short time, or symptoms might come and go. The severe form can last a lifetime.

Rheumatoid arthritis is different from osteoarthritis, the common arthritis that often comes with older age. RA can affect body parts besides joints, such as your eyes, mouth and lungs. RA is an autoimmune disease, which means the arthritis results from your immune system attacking your body's own tissues.

No one knows what causes rheumatoid arthritis. Genes, environment and hormones might contribute. Treatments include medicine, lifestyle changes and surgery. These can slow or stop joint damage and reduce pain and swelling.

NIH: National Institute of Arthritis and Musculoskeletal and Skin Diseases

Definition (NCI_NCI-GLOSS) An autoimmune disease that causes pain, swelling, and stiffness in the joints, and may cause severe joint damage, loss of function, and disability. The disease may last from months to a lifetime, and symptoms may improve and worsen over time.
Definition (NCI) A chronic systemic disease, primarily of the joints, marked by inflammatory changes in the synovial membranes and articular structures, widespread fibrinoid degeneration of the collagen fibers in mesenchymal tissues, and by atrophy and rarefaction of bony structures. Etiology is unknown, but autoimmune mechanisms have been implicated.
Definition (MSH) A chronic systemic disease, primarily of the joints, marked by inflammatory changes in the synovial membranes and articular structures, widespread fibrinoid degeneration of the collagen fibers in mesenchymal tissues, and by atrophy and rarefaction of bony structures. Etiology is unknown, but autoimmune mechanisms have been implicated.
Definition (CSP) chronic systemic disease, primarily of the joints, marked by inflammatory changes in the synovial membranes and articular structures, widespread fibrinoid degeneration of the collagen fibers in mesenchymal tissues, and by atrophy and rarefaction of bony structures; etiology is unknown, but autoimmune mechanisms have been implicated.
Concepts Disease or Syndrome (T047)
MSH D001172
ICD9 714.0
ICD10 M06.9, M06.99
SnomedCT 156471009, 287010008, 156481008, 69896004
LNC LP30644-6, LA15161-5
English Arthritis, Rheumatoid, ARTHRITIS RHEUMATOID, Rheumatoid Arthritis, Rheumatoid arthritis, unspecified, RHEUMATOID ARTHRITIS, RHEUMATOID ARTHRITIS, SUSCEPTIBILITY TO, Rheumatoid arthritis NOS, rheumatoid arthritis, RA (rheumatoid arthritis), rheumatoid arthritis (diagnosis), R arthritis, Rh arthritis, Arthritis rheumatoid, Systemic rheumatoid arthritis, RA, Arthritis, Rheumatoid [Disease/Finding], Rheumatoid arthritis, unspecified, site unspecified, rheumatoid arthritis systemic, gout rheumatic, proliferative arthritis, atrophic arthritis, Rheumatoid arthritis NOS (disorder), ARTHRITIS, RHEUMATOID, Rheumatoid arthritis, Atrophic arthritis, Chronic rheumatic arthritis, Rheumatic gout, RA - Rheumatoid arthritis, RhA - Rheumatoid arthritis, Rheumatoid disease, Rheumatoid arthritis (disorder), atrophic; arthritis, rheumatoid; arthritis, arthritis; atrophic, arthritis; rheumatoid, Atrophic Arthritis, Arthritis or polyarthritis, atrophic, Arthritis or polyarthritis, rheumatic
Portuguese ARTRITE REUMATOIDE, Artrite reactiva reumatóide, Artrite atrófica, Artrite reumatóide sistémica, Artrite Reumatoide, Artrite reumatóide
Spanish ARTRITIS REUMATOIDE, Artritis reumatoide sistémica, Artritis R, Artritis Re, Artritis atrófica, AR, Artritis Reumatoidea, artritis reumatoide, SAI, Rheumatoid arthritis NOS, artritis reumatoide, SAI (trastorno), artritis atrófica, artritis reumatoide (trastorno), artritis reumatoide, artritis reumática crónica, gota reumática, Artritis reumatoide, Artritis Reumatoide
Dutch systemische reumatoïde artritis, atrofische artritis, RA, reumatische artritis, artritis; atrofisch, artritis; reumatoïd, atrofisch; artritis, reumatoïd; artritis, Reumatoïde artritis, niet gespecificeerd, reumatoïde artritis, Artritis, reumatoïde, Reumatoïde artritis
French Arthrite d, Arthrite rhumatoïde systémique, AR, Polyarthrite rh, ARTHRITE RHUMATOIDE, Polyarthrite rhumatismale, PCE (Polyarthrite Chronique Évolutive), Polyarthrite chronique évolutive, Polyarthrite rhumatoïde, PR (Polyarthrite Rhumatoïde)
German systemische rheumatische Arthritis, atrophische Arthritis, Rh Arthritis, RA, R Arthritis, ARTHRITIS RHEUMATOID, Chronische Polyarthritis, nicht naeher bezeichnet, rheumatoide Arthritis, Arthritis, rheumatoide, Rheumatoide Arthritis, PcP (Primär-chronische Polyarthritis), Polyarthritis, primär chronische, Primär-chronische Polyarthritis
Italian Artrite reumatoide sistemica, AR, Artrite atrofica, Artrite reumatoide
Japanese 全身性関節リウマチ, イシュクセイカンセツエン, ゼンシンセイカンセツリウマチ, カンセツリウマチ, 関節リウマチ, 萎縮性関節炎, リウマチ様関節炎, 慢性関節リウマチ, 関節リウマチ-慢性, 関節炎-リウマチ様
Swedish Ledgångsreumatism
Czech polyartritida progresivní, Systémová revmatoidní artritida, Revmatoidní artritida, Atrofická artritida, artritida revmatoidní, revmatoidní artritida
Finnish Nivelreuma
Korean 상세불명의 류마티스 관절염
Polish Zapalenie stawów reumatoidalne, Gościec przewlekły postępujący, RZS, Reumatoidalne zapalenie stawów, Gościec pierwotnie przewlekły, Zapalenie gośćcowe
Hungarian RA (rheumatoid arthritis), Rheumatoid arthritis, Atrophiás arthritis, R arthritis, Rh arthritis, Systemás rheumatoid arthritis
Norwegian Artritt, revmatoid, Leddgikt, Revmatoid artritt
Derived from the NIH UMLS (Unified Medical Language System)

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