Updated: 12/31/2019

Rheumatoid Arthritis

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Snapshot
  • A 35-year-old woman presents with joint stiffness and pain of the hands and wrists for the last two months. Her symptoms are most severe in the morning and improve in the afternoon. She reports an unintentional loss of 15 pounds over the course of 3 months as well as fatigue. On physical exam, there is swelling and tenderness at the metacarpophalangeal and proximal interphalangeal joints.
Introduction
  • Clinical definition 
    • a chronic autoimmune disorder that primarily affects the joints and results in an inflammatory synovitis
  • Epidemiology
    • demographics
      • sex
        • more common in women
      • age
        • 30-50 years of age
    • risk factors
      • smoking
  • Etiology
    • environmental and genetic factors play a role
  • Pathogenesis
    • T- and B-cell response after a triggering event (e.g., infection in a genetically susceptible patient) eventually results in
      • pannus formation and subsequent damage to the adjacent cartilage and bone
        • Th1 cells release interferon-γ (IFN-γ) in order to activate macrophages and synovial cells
        • Th17 cells secrete interleukin-17 (IL-17) in order to recruit monocytes and neutrophils
        • synovial plasma cells produce antibodies against self-antigens such as citrullinated peptides 
  • Genetics
    • HLA-DR4
  • Associated conditions
    • Sjogren syndrome
    • Felty syndrome  
      • seropositive rheumatoid arthritis with neutropenia
        • many patients have splenomegaly
    • Caplan syndrome
      • seropositive rheumatoid arthritis with pneumoconiosis
  • Prognosis
    • certain patients with early rheumatoid arthritis may achieve remission
Presentation
  • Symptoms
    • fatigue and depression
    • morning stiffness that lasts > 1 hour
    • pain, stiffness, and/or swelling of the joint such as the
      • metacarpophalangeal (MCP) joints
      • proximal interphalangeal (PIP) joints
      • metatarsophalangeal (MTP) joints
  • Physical exam
    • anemia of chronic disease
    • weight loss
    • decreased grip strength
    • palmar erythema
    • subcutaneous (rheumatoid) nodules
    • splenomegaly in cases of Felty syndrome
    • ulnar deviation of the fingers
    • swan neck deformity
    • bouttoniere deformities
Imaging
  • Radiography
    • indications
      • can be obtained during the initial workup to have a baseline to compare to when following disease progression
      • can be performed of the neck to rule out odontoid ligament laxity
    • modality
      • hands, wrists, and feet
    • findings
      • diffuse osteopenia
      • joint space narrowing in the carpal, metacarpal, phalangeal, and interphalangeal joints
      • periarticular bony erosions
      • ulnar deviation of the fingers
Studies
  • Labs
    • rheumatoid factor (RF) antibody testing
      • RF is an IgM antibody that targets the Fc portion of IgG 
    • anti-CCP antibody testing 
      • more specific for rheumatoid arthritis 
    • erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels
      • typically elevated
  • Diagnostic criteria
    • diagnosis is based on clinical presentation and laboratory studies
Differential
  • Systemic lupus erythematous
  • Psoriatic arthritis
  • Scleroderma
  • Polymyalgia rheumatica
  • Gout
  • Osteoarthritis
  • Parvovirus B19 
    • mild symmetric arthralgias and a viral syndrome that is self-limited in adults 
    • slapped cheek fever in children
Treatment
  • Conservative
    • education, exercise, physical therapy, vaccinations, smoking cessation, and counseling
      • indication
        • a component of treatment for patients with rheumatoid arthritis
  • Medical
    • disease-modifying antirheumatic drugs (DMARDs)
      • indication
        • used to prevent, stop, or retard disease-associated damage
      • medications
        • methotrexate 
          • typically the initial DMARD used
          • side-effects include GI symptoms, oral ulcers, macrocytic anemia, and hepatotoxicity  
        • tumore necrosis factor (TNF) inhibitor such as
          • etanercept
          • adalimumab
        • leflunomide
        • sulfasalazine
        • hydroxychloroquine 
    • nonsteroidal antiinflammatory drugs (NSAIDs) and/or glucocorticoids
      • indication
        • initially given for symptomatic control while waiting for DMARD response
  • Operative
    • joint replacement surgery
      • indication
        • in patients with severe joint damage or failure to respond to conservative and medical therapy
Complications
  • Hand deformities
  • Atlantoaxial subluxation 
  • Popliteal cyst 
  • Greater risk of osteoporosis and osteopenia secondary to steroid use, inactivity, and disease process
    • bisphosphantes is an effective prophylactic therapy in these patients 
  • Nephrotic syndrome 
    • result of amyloid deposition 
 
 

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(M2.RH.15.95) A 50-year-old female presents to clinic complaining of joint pain. She reports stiffness is her knees, wrists, and hands, that is worst in the morning. Her symptoms have been present for many years. On physical exam, her vital signs are stable, and she has tenderness when her knees, hands, and wrists are articulated. You closely examine her hands (Figure A). Serum rheumatoid factor is positive. Which of the following is true regarding this patient's disease? Tested Concept

QID: 106064
FIGURES:
1

High titers of rheumatoid factor are usually associated with a better prognosis

11%

(3/28)

2

Exercise is discouraged as it may worsen range of motion

7%

(2/28)

3

The patient is at increased risk of developing osteopenia and osteoporosis

68%

(19/28)

4

Opioids are the drugs of choice for pain control in this disease

4%

(1/28)

5

Disease modifying drugs such as methotrexate should only be started one year after diagnosis

4%

(1/28)

M 6 E

Select Answer to see Preferred Response

(M2.RH.14.62) A 67-year-old male with no significant medical history comes to your office complaining of pain and stiffness in his hands upon wakening in the morning. You perform an x-ray (Figure A). What is the most likely diagnosis? Tested Concept

QID: 106427
FIGURES:
1

Gouty arthritis

0%

(0/25)

2

Osteoarthritis (OA)

52%

(13/25)

3

Rheumatoid arthritis (RA)

16%

(4/25)

4

Psoriatic arthritis

24%

(6/25)

5

Systemic lupus erythematosus (SLE)

0%

(0/25)

M 6 E

Select Answer to see Preferred Response

(M2.RH.14.62) A 45-year-old male with no significant medical history comes to your office complaining of pain and stiffness in his hands upon wakening in the morning for the past several months. The stiffness generally lasts one to two hours, per the patient. You perform an x-ray (Figure A). What is the most likely diagnosis? Tested Concept

QID: 106428
FIGURES:
1

Gouty arthritis

0%

(0/28)

2

Osteoarthritis (OA)

4%

(1/28)

3

Rheumatoid arthritis (RA)

86%

(24/28)

4

Psoriatic arthritis

0%

(0/28)

5

Systemic lupus erythematosus (SLE)

0%

(0/28)

M 6 D

Select Answer to see Preferred Response

(M2.RH.14.32) A 35-year-old woman presents to her family physician with a complaint of painful joints for the past 2 weeks. She reports symmetric bilateral joint pain in her hands, knees, and ankles. She has never had this before, and her past medical history is notable only for asthma. She states the pain is worse in the morning and improves throughout the day. Review of systems is notable for a recent low-grade fever with malaise. She works as a school teacher and is sexually active with men and women. Her temperature is 97.9°F (36.6°C), blood pressure is 120/84 mmHg, pulse is 70/min, respirations are 14/min, and oxygen saturation is 97% on room air. The patient is instructed to take ibuprofen and acetaminophen for her joint pain. She returns 1 month later stating that she has not needed to take the medications as her pain has been absent for the past 3 days. Which of the following is the most likely diagnosis? Tested Concept

QID: 104917
1

Osteoarthritis

2%

(1/41)

2

Parvovirus

2%

(1/41)

3

Reactive arthritis

56%

(23/41)

4

Rheumatoid arthritis

15%

(6/41)

5

Transient synovitis

22%

(9/41)

M 6 E

Select Answer to see Preferred Response

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Topic COMMENTS (8)
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