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High titers of rheumatoid factor are usually associated with a better prognosis
7%
3/43
Exercise is discouraged as it may worsen range of motion
The patient is at increased risk of developing osteopenia and osteoporosis
67%
29/43
Opioids are the drugs of choice for pain control in this disease
Disease modifying drugs such as methotrexate should only be started one year after diagnosis
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Rheumatoid arthritis puts patients at an increased risk of developing osteopenia and osteoporosis secondary to corticosteroid use, inactivity, and the disease process itself. Rheumatoid arthritis is a chronic inflammatory autoimmune disease that affects the synovium of the joints and results in cartilage and bone destruction. Key clinical features are a symmetrical inflammatory polyarthritis that may involve any joint except the DIP joints. Most commonly, the hands (PIP and MCP), wrists, knees, ankles, elbows, hips, and shoulders are affected. Treatment involves symptom management with NSAIDs and low dose corticosteroids as well as disease modifying drugs such as methotrexate. Studies have shown an increased risk of bone loss and fracture in individuals with rheumatoid arthritis and a greater risk of osteoporosis, partially iatrogenically caused by glucocorticoid use as well as joint inactivity due to pain. Bone loss is greatest in areas surrounding the affected joints. Rindfleisch and Muller discuss diagnosis and management of rheumatoid arthritis. Prevalence is estimated to be nearly 1% worldwide with women affected twice as often as men. Twenty to thirty percent of patients diagnosed will become work-disabled within two to three years of diagnosis. Diagnosis is mainly clinical with no single lab test confirmatory. Several new disease modifying drugs have become available including TNF inhibitors. Ono et al. discuss secondary osteoporosis and bone loss in rheumatoid arthritis. In rheumatoid arthritis, osteoclasts are activated by abnormal immune conditions accompanied by chronic inflammation resulting in osteoporosis. Decreased bone mineral density and bone quality may expose patients to an increased risk of fracture. The risk of fracture is best accomplished by controlling the underlying inflammation in the disease and by promoting weight-bearing activities. Image A depicts ulnar deviation of the MCP joints. Illustration A depicts the boutonniere deformity of the PIP joints. Illustration B depicts swan-neck deformity of the fingers. Illustration C depicts joint space narrowing and bony erosions / bone displacement in rheumatoid arthritis. Incorrect Answers: Answer 1: High titers of RF are associated with a worsened prognosis. Answer 2: Exercise is encouraged, especially to decrease the risk of osteoporosis. Answer 4: NSAIDs, not opioids, are the first line drug of choice for pain control. Answer 5: Disease modifying drugs should be started at diagnosis to prevent joint destruction.
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