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SOURCE

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Source: Wahl K, Schuna AA. Rheumatoid arthritis. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 10th ed. New York, NY: McGraw-Hill; 2017. http://accesspharmacy.mhmedical.com/content.aspx?bookid=1861&sectionid=133893255.

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DEFINITION

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  • Chronic and usually progressive inflammatory disorder characterized by polyarticular symmetric joint involvement and systemic manifestations.

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ETIOLOGY

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  • Genetic predisposition and exposure to unknown environmental antigens likely involved.

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PATHOPHYSIOLOGY

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  • Involves dysregulation of humoral and cell-mediated components of immune system.

  • Immunoglobulins activate complement system, which amplifies cell-mediated immunity.

  • Activated T cells produce cytotoxins and cytokines.

  • Tumor necrosis factor (TNF), interleukin-1 (IL-1), and IL-6 contribute to inflammation.

  • Polymorphonuclear leukocytes release cytotoxins that damage synovium and bone.

  • Histamine, kinins, and prostaglandins cause edema, warmth, erythema, and pain.

  • Pannus formation invades cartilage and bone surfaces, producing erosions and joint destruction.

  • Process results in:

    • Loss of joint space and motion.

    • Ankylosis.

    • Joint subluxation.

    • Tendon contractures.

    • Chronic deformity.

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EPIDEMIOLOGY

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  • Estimated prevalence: 1% with no racial predilection.

  • Can occur at any age, with increasing prevalence up to seventh decade.

  • Incidence in women ~3 times greater than in men.

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RISK FACTORS

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  • Family history.

  • Sex (more common in females)

  • Age (more common in ages 40–60 years)

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CLINICAL PRESENTATION

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SIGNS AND SYMPTOMS
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  • Nonspecific prodromal symptoms developing over weeks to months include:

    • Fatigue.

    • Weakness.

    • Low-grade fever.

    • Loss of appetite.

    • Joint pain.

  • Stiffness and myalgias may precede development of synovitis.

  • Joint involvement tends to be symmetric and affect:

    • Small joints of hands, wrists, and feet.

    • Elbows.

    • Shoulders.

    • Hips.

    • Knees.

    • Ankles may also be affected.

  • Joint stiffness worse in morning, lasts >30 min, and may persist all day.

  • Involved joint may be:

    • Swollen.

    • Soft.

    • Spongy.

    • Warm.

    • Erythematous.

  • Chronic joint deformities include:

    • Swan neck deformity.

    • Ulnar deviation.

  • Extra-articular involvement includes:

    • Rheumatoid nodules.

    • Vasculitis.

    • Pleural effusions.

    • Pulmonary fibrosis.

    • Ocular manifestations.

    • Pericarditis.

    • Cardiac conduction abnormalities.

    • Bone marrow suppression.

    • Lymphadenopathy.

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DIAGNOSIS

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MEANS OF CONFIRMATION AND DIAGNOSIS
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  • The American College of Rheumatology and European League Against rheumatism (ACR/EULAR) revised criteria for the diagnosis of RA. The criteria were developed to be used for patients early in their disease. With a score of more than 6 out of a possible total score of 10 as being diagnostic for RA.

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LABORATORY TESTS
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  • Normocytic, normochromic anemia.

  • Thrombocytosis or thrombocytopenia.

  • Leukopenia.

  • Elevated erythrocyte sedimentation rate and C-reactive protein.

  • Positive rheumatoid factor (60–70% of patients)

  • Positive anticyclic citrullinated peptide antibody (50–85% of patients)

  • Positive antinuclear antibodies (25% of patients)

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IMAGING
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  • Early radiologic findings may include soft-tissue swelling and periarticular osteoporosis.

    • Erosions occur later in disease.

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DIAGNOSTIC PROCEDURES
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  • Aspirated synovial fluid may be ...

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