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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
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- Chronic and usually progressive inflammatory disorder
characterized by polyarticular symmetric joint involvement and systemic
manifestations.
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- Genetic predisposition and exposure to unknown environmental
antigens likely involved.
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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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- 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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- Family history
- Sex (more common in females)
- Age (more common in ages 40–60 years)
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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 minutes, and may
persist all day.
- Involved joint may be:
- Swollen
- Soft
- Spongy
- Warm
- Erythematous
- Chronic joint deformities include:
- Swan neck
deformity
- Boutonnière 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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Means of Confirmation
and Diagnosis
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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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- 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 turbid with leukocytosis,
reduced viscosity, and normal or low glucose relative to serum concentrations.
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Differential
Diagnosis
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- Gout with tophi
- Systemic lupus erythematosus
- Osteoarthritis
- Polymyalgia rheumatica
- Lyme disease
- Rheumatic fever
- Rubella arthritis
- Systemic vasculitis
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- 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.
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- Start disease-modifying antirheumatic drug (DMARD) within
first 3 months of symptom onset (...