Source: Schuna AA. Rheumatoid Arthritis.
In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM,
eds. Pharmacotherapy: A Pathophysiologic
Approach. 8th ed. http://accesspharmacy.com/content.aspx?aid=7997207.
Accessed June 26, 2012
- Chronic and usually progressive inflammatory disorder
characterized by polyarticular symmetric joint involvement and systemic
- Genetic predisposition and exposure to unknown environmental
antigens likely involved.
- Involves dysregulation of humoral and cell-mediated components
of immune system.
- Immunoglobulins activate complement system, which amplifies
- 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
- Joint subluxation
- Tendon contractures
- Chronic deformity
- Estimated prevalence: 1% with no racial predilection.
- Can occur at any age, with increasing prevalence up to seventh
- Incidence in women ~3 times greater than in men.
- Family history
- Sex (more common in females)
- Age (more common in ages 40–60 years)
- Nonspecific prodromal symptoms developing over weeks to
- 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
- Ankles may also be affected.
- Joint stiffness worse in morning, lasts >30 minutes, and may
persist all day.
- Involved joint may be:
- Chronic joint deformities include:
- Swan neck
- Boutonnière deformity
- Ulnar deviation
- Extra-articular involvement includes:
- Pleural effusions
- Pulmonary fibrosis
- Ocular manifestations
- Cardiac conduction abnormalities
- Bone marrow suppression
Means of Confirmation
- Normocytic, normochromic anemia
- Thrombocytosis or thrombocytopenia
- Elevated erythrocyte sedimentation rate and C-reactive protein
- Positive rheumatoid factor (60–70% of patients)
- Positive anticyclic citrullinated peptide antibody (50–85% of
- Positive antinuclear antibodies (25% of patients)
- Early radiologic findings may include soft-tissue swelling
and periarticular osteoporosis.
- Erosions occur later
- Aspirated synovial fluid may be turbid with leukocytosis,
reduced viscosity, and normal or low glucose relative to serum concentrations.
- Gout with tophi
- Systemic lupus erythematosus
- Polymyalgia rheumatica
- Lyme disease
- Rheumatic fever
- Rubella arthritis
- Systemic vasculitis
- Induce complete disease remission, if possible.
- Reduce joint swelling, stiffness, and pain.
- Preserve range of motion and joint function.
- Improve quality of life.
- Prevent systemic complications.
- Slow destructive joint changes.
- Start disease-modifying antirheumatic drug (DMARD) within
first 3 months of symptom onset (Figure 1).
- Nonsteroidal anti-inflammatory drugs ...