Rheumatoid Arthritis

Common chronic systemic inflammatory disorder

Epidemiology and Risk Factors

Prevalence:

  • 1-2% of population
  • 3 times more common in women

Associations:

  • Anglo-saxon
  • HLA-DR4 subtype
    70% of cases.
  • Rheumatoid factor
    80% of cases.
  • Family history
  • Food allergies/intolerances
  • Psychological stressors
  • Heavy metal exposure
  • Smoking

Pathophysiology

Aetiology

Clinical Manifestations

Affected joints:

  • Wrists
  • Fingers
  • Neck
  • Shoulders
  • Elbows
  • Hips
  • Knees
  • Ankles
  • Feet

Joint pain:

  • Morning stiffness
  • Fatigue
  • Weight loss
  • General malaise
  • Depression
  • Disability

Examination:

  • Soft tissue swelling

Extra-articular manifestations:

  • Respiratory
    • Fibrosis
    • Rheumatoid nodules
    • Restrictive chest wall defect
    • Pleural effusions
  • Cardiac
    • Pericarditis
      With effusions and tamponade.
    • Myocarditis
    • Endocarditis
    • Peripheral vasculitis
    • Atherosclerosis and CAD
  • Renal
    • CKD
  • Hepatic
    • Hepatosplenomegaly
    • Hypoalbuminaemia

Diagnostic Approach and DDx

Investigations

Management

Medical

Surgical

Anaesthetic Considerations

  • A
    • Airway assessment
      • Range of neck movement
        Paraesthesia or loss of sensation in the hands is concerning and warrants pre-operative radiographic investigation.
      • TMJ dysfunction
      • Cricoarytenoid involvement
        May cause dyspnoea, stridor, hoarseness, or severe upper airway obstruction.
    • Atlanto-axial subluxation
      Potential risk of spinal cord injury.
    • Subaxial subluxation
      Uncommon, leads to early symptoms of nerve impingement.
  • B
    • Extra-articular respiratory disease
      • Fibrosis
      • Nodules
      • Pleural effusions
    • Extra-articular cardiac disease
      • Peri/myo/endocarditis
      • CAD
      • Peripheral vasculitis
  • E
    • Vascular access difficulties
    • Drug effects
      • Steroids
      • Methotrexate
        Pulmonary toxicity.
      • DMARDs
        Neutropaenia, thrombocytopaenia, aplastic anaemia, fibrosing alveolitis.
      • Methotrexate
        Pulmonary fibrosis, hepatic cirrhosis.
      • Gold
        Thrombocytopenia, haemolytic anaemia, nephrotic syndrome, myasthenia-like syndrome.
      • Biologics
        • Etanercept
          Flu-like symptoms, CNS demyelination.
        • Infliximab
          Extrapulmonary TB.
        • Adalimumab
          Flu-like symptoms, abdominal pain.
        • Anakinra
          Flu-like symptoms, diarrhoea, nausea, thrombocytopaenia.

Marginal and Ineffective Therapies

Complications

Prognosis

Key Studies

References