Rheumatoid arthritis

Rheumatoid arthritis - Chronic

 

Definition  

A chronic, inflammatory, systemic autoimmune disorder characterized by symmetric, erosive synovitis that frequently leads to joint destruction, deformity, and disability

 

Medical History  

* Smoking

* Family history of Rheumatoid arthritis

* Genetic predisposition

* Nulliparous

 

Findings  

* Joint stiffness

* Painful swelling of joint

* Joint deformity

* Limitation of joint movement

* Malaise and fatigue

* Subcutaneous rheumatoid nodule

* Muscle atrophy

* Increased body temperature

* Lymphadenopathy

 

Tests  

 

Initial evaluation of patients with suspected rheumatoid arthritis  

* Complete blood count with white cell differential, automated

* Hepatic function panel

* Creatinine measurement, serum

* Electrolytes measurement, serum

* Screening for occult blood in feces

 

Suspected or known rheumatoid arthritis  

* Rheumatoid factor measurement: Although rheumatoid factor is positive in most patients with rheumatoid arthritis, it is not specific for the disease; some patients will remain seronegative .

 

Suspected or known rheumatoid arthritis  

* Erythrocyte sedimentation rate measurement: The erythrocyte sedimentation rate (ESR) is often increased to more than 33 mm/hour ; however, in more than 40% of patients with active disease the ESR will be normal. It is a less precise measure of disease activity than C-reactive protein .

 

Suspected or known rheumatoid arthritis  

* Serum C reactive protein level: A C-reactive protein level greater than 1 mg/dL indicates an inflammatory process; however, results may be nonspecific and nonsensitive for rheumatoid arthritis .

 

Suspected or known rheumatoid arthritis  

* Joint X-ray: Changes seen on plain radiography that are characteristic of rheumatoid arthritis include erosions or loss of density adjacent to affected joints .

 

Suspected or known rheumatoid arthritis  

* Anti-cyclic citrullinated peptide antibody level: Elevated levels of anti-cyclic citrullinated peptide (anti-CCP) antibodies may assist in establishing a diagnosis of rheumatoid arthritis and may be useful for predicting patients that are likely to develop rheumatoid arthritis .

 

Suspected or known rheumatoid arthritis  

* Magnetic resonance imaging, Joint structure: MRI detects bone erosions in rheumatoid arthritis before they are apparent on plain radiography, allowing for an earlier diagnosis . MRI can detect the typical progression of rheumatoid arthritis, from synovitis to bone marrow edema to bony erosion .

 

Differential Diagnosis  

* Septic arthritis - Acute

* Arthritis due to viral infection

* Gout - Acute

* Polymyalgia rheumatica - Acute

* Ankylosing spondylitis - Chronic

* Osteoarthritis - Chronic

* Rheumatic fever - Acute

* Infective endocarditis - Acute

* Seronegative arthritis secondary to inflammatory bowel disease

* Systemic lupus erythematosus - Chronic

* Adult onset Still's disease

* Scleroderma - Chronic

* Fibromyalgia - Chronic

* Sarcoidosis - Chronic

* Psoriasis with arthropathy

* Gonococcal infection of joint

* Hemochromatosis - Chronic

 

Treatment  

 

Drug Therapy  

 

Reduction of joint pain and swelling in patients with rheumatoid arthritis  

 

ASPIRIN

Adults: Initial dose 3 g orally daily in divided doses; increase as needed for antiinflammatory efficacy with target plasma salicylate levels of 150 to 300 mcg/mL

 

IBUPROFEN

Adults: 300 mg orally 4 times daily OR 400 mg, 600 mg or 800 mg orally 3 or 4 times daily

 

 

Reduction of joint pain and swelling in patients with rheumatoid arthritis and increased risk of serious adverse gastrointestinal effects associated with NSAIDs  

 

CELECOXIB  

Adults: 100 to 200 mg orally twice a day

 

 

Symptomatic relief of active rheumatoid arthritis or as a bridge to effective disease-modifying antirheumatic drug therapy  

 

PREDNISONE  

Adults: 5 to 10 mg orally daily

 

 

Rheumatoid arthritis with disease duration less than 6 months, low disease activity, without features of poor prognosis  

 

HYDROXYCHLOROQUINE SULFATE  

Adults: 200 mg orally twice daily

 

LEFLUNOMIDE  

Adults: Initial loading dose of 100 mg orally once daily for 3 days, then 10 to 20 mg orally once daily

 

METHOTREXATE SODIUM  

Adults: Initial dose 10 to 15 mg orally once weekly; may increase by 5 mg weekly every 2 to 4 weeks up to 20 to 30 mg orally weekly; may be administered parenterally (subQ or IM) if inadequate clinical response or intolerance despite folic acid

 

MINOCYCLINE HYDROCHLORIDE  

Adults: 100 mg orally twice daily

 

SULFASALAZINE

Adults: 1000 mg orally 2 to 3 times daily

 

 

Rheumatoid arthritis with disease duration less than 6 months, low disease activity, with features of poor prognosis  

 

LEFLUNOMIDE  

Adults: Initial loading dose of 100 mg orally once daily for 3 days, then 10 to 20 mg orally once daily

 

METHOTREXATE SODIUM  

Adults: Initial dose 10 to 15 mg orally once weekly; may increase by 5 mg weekly every 2 to 4 weeks up to 20 to 30 mg orally weekly; may be administered parenterally (subQ or IM) if inadequate clinical response or intolerance despite folic acid

 

SULFASALAZINE

Adults: 1000 mg orally 2 to 3 times daily

 

 

Rheumatoid arthritis with disease duration less than 6 months, moderate or high disease activity, without features of poor prognosis  

 

LEFLUNOMIDE  

Adults: Initial loading dose of 100 mg orally once daily for 3 days, then 10 to 20 mg orally once daily

 

METHOTREXATE SODIUM  

Adults: Initial dose 10 to 15 mg orally once weekly; may increase by 5 mg weekly every 2 to 4 weeks up to 20 to 30 mg orally weekly; may be administered parenterally (subQ or IM) if inadequate clinical response or intolerance despite folic acid

 

SULFASALAZINE

Adults: 1000 mg orally 2 to 3 times daily

 

METHOTREXATE SODIUM - HYDROXYCHLOROQUINE SULFATE  

 

 

 

Rheumatoid arthritis with disease duration less than 6 months, moderate or high disease activity, with features of poor prognosis  

 

LEFLUNOMIDE  

Adults: Initial loading dose of 100 mg orally once daily for 3 days, then 10 to 20 mg orally once daily

 

METHOTREXATE SODIUM  

Adults: Initial dose 10 to 15 mg orally once weekly; may increase by 5 mg weekly every 2 to 4 weeks up to 20 to 30 mg orally weekly; may be administered parenterally (subQ or IM) if inadequate clinical response or intolerance despite folic acid

 

METHOTREXATE SODIUM - HYDROXYCHLOROQUINE SULFATE  

 

 

METHOTREXATE SODIUM - SULFASALAZINE

 

METHOTREXATE SODIUM - SULFASALAZINE

 

 

 

Rheumatoid arthritis with disease duration of 6 to 24 months, low disease activity, without features of poor prognosis  

 

HYDROXYCHLOROQUINE SULFATE  

Adults: 200 mg orally twice daily

 

LEFLUNOMIDE  

Adults: Initial loading dose of 100 mg orally once daily for 3 days, then 10 to 20 mg orally once daily

 

METHOTREXATE SODIUM  

Adults: Initial dose 10 to 15 mg orally once weekly; may increase by 5 mg weekly every 2 to 4 weeks up to 20 to 30 mg orally weekly; may be administered parenterally (subQ or IM) if inadequate clinical response or intolerance despite folic acid

 

SULFASALAZINE

Adults: 1000 mg orally 2 to 3 times daily

 

 

Rheumatoid arthritis with disease duration of 6 to 24 months, low disease activity, with features of poor prognosis  

 

LEFLUNOMIDE  

Adults: Initial loading dose of 100 mg orally once daily for 3 days, then 10 to 20 mg orally once daily

 

METHOTREXATE SODIUM  

Adults: Initial dose 10 to 15 mg orally once weekly; may increase by 5 mg weekly every 2 to 4 weeks up to 20 to 30 mg orally weekly; may be administered parenterally (subQ or IM) if inadequate clinical response or intolerance despite folic acid

 

SULFASALAZINE

Adults: 1000 mg orally 2 to 3 times daily

 

METHOTREXATE SODIUM - SULFASALAZINE

 

 

 

Rheumatoid arthritis with disease duration of 6 to 24 months, moderate or high disease activity, without features of poor prognosis  

 

LEFLUNOMIDE  

Adults: Initial loading dose of 100 mg orally once daily for 3 days, then 10 to 20 mg orally once daily

 

METHOTREXATE SODIUM  

Adults: Initial dose 10 to 15 mg orally once weekly; may increase by 5 mg weekly every 2 to 4 weeks up to 20 to 30 mg orally weekly; may be administered parenterally (subQ or IM) if inadequate clinical response or intolerance despite folic acid

 

SULFASALAZINE

Adults (high disease activity only): 1000 mg orally 2 to 3 times daily

 

METHOTREXATE SODIUM - HYDROXYCHLOROQUINE SULFATE  

 

 

METHOTREXATE SODIUM - SULFASALAZINE

 

 

METHOTREXATE SODIUM - LEFLUNOMIDE  

 

 

SULFASALAZINE

Adults (high disease activity only): Sulfasalazine 1000 mg orally 2 to 3 times daily AND hydroxychloroquine 200 mg orally twice daily .

 

METHOTREXATE SODIUM - SULFASALAZINE

 

 

 

Rheumatoid arthritis with disease duration of 6 to 24 months, moderate or high disease activity, with features of poor prognosis  

 

LEFLUNOMIDE  

Adults: Initial loading dose of 100 mg orally once daily for 3 days, then 10 to 20 mg orally once daily

 

METHOTREXATE SODIUM  

Adults: Initial dose 10 to 15 mg orally once weekly; may increase by 5 mg weekly every 2 to 4 weeks up to 20 to 30 mg orally weekly; may be administered parenterally (subQ or IM) if inadequate clinical response or intolerance despite folic acid

 

SULFASALAZINE

Adults (high disease activity only): 1000 mg orally 2 to 3 times daily

 

METHOTREXATE SODIUM - HYDROXYCHLOROQUINE SULFATE  

 

 

METHOTREXATE SODIUM - SULFASALAZINE

 

METHOTREXATE SODIUM - LEFLUNOMIDE  

 

 

METHOTREXATE SODIUM - SULFASALAZINE

 

 

 

Rheumatoid arthritis with disease duration greater than 24 months, low or moderate disease activity, without features of poor prognosis  

 

LEFLUNOMIDE  

Adults: Initial loading dose of 100 mg orally once daily for 3 days, then 10 to 20 mg orally once daily

 

METHOTREXATE SODIUM  

Adults: Initial dose 10 to 15 mg orally once weekly; may increase by 5 mg weekly every 2 to 4 weeks up to 20 to 30 mg orally weekly; may be administered parenterally (subQ or IM) if inadequate clinical response or intolerance despite folic acid

 

SULFASALAZINE

Adults: 1000 mg orally 2 to 3 times daily

 

METHOTREXATE SODIUM - HYDROXYCHLOROQUINE SULFATE  

 

Rheumatoid arthritis with disease duration greater than 24 months, low or moderate disease activity, with features of poor prognosis  

 

LEFLUNOMIDE  

Adults: Initial loading dose of 100 mg orally once daily for 3 days, then 10 to 20 mg orally once daily

 

METHOTREXATE SODIUM  

Adults: Initial dose 10 to 15 mg orally once weekly; may increase by 5 mg weekly every 2 to 4 weeks up to 20 to 30 mg orally weekly; may be administered parenterally (subQ or IM) if inadequate clinical response or intolerance despite folic acid

 

SULFASALAZINE

Adults: 1000 mg orally 2 to 3 times daily

 

METHOTREXATE SODIUM - HYDROXYCHLOROQUINE SULFATE  

 

 

METHOTREXATE SODIUM - LEFLUNOMIDE  

 

 

METHOTREXATE SODIUM - SULFASALAZINE

 

 

 

Rheumatoid arthritis with disease duration greater than 24 months, high disease activity, without features of poor prognosis  

 

LEFLUNOMIDE  

Adults: Initial loading dose of 100 mg orally once daily for 3 days, then 10 to 20 mg orally once daily

 

METHOTREXATE SODIUM  

Adults: Initial dose 10 to 15 mg orally once weekly; may increase by 5 mg weekly every 2 to 4 weeks up to 20 to 30 mg orally weekly; may be administered parenterally (subQ or IM) if inadequate clinical response or intolerance despite folic acid

 

SULFASALAZINE

Adults: 1000 mg orally 2 to 3 times daily

 

METHOTREXATE SODIUM - HYDROXYCHLOROQUINE SULFATE  

 

 

METHOTREXATE SODIUM - LEFLUNOMIDE  

 

 

METHOTREXATE SODIUM - SULFASALAZINE

 

METHOTREXATE SODIUM - SULFASALAZINE

 

Rheumatoid arthritis with disease duration greater than 24 months, high disease activity, with features of poor prognosis  

 

LEFLUNOMIDE  

Adults: Initial loading dose of 100 mg orally once daily for 3 days, then 10 to 20 mg orally once daily

 

METHOTREXATE SODIUM  

Adults: Initial dose 10 to 15 mg orally once weekly; may increase by 5 mg weekly every 2 to 4 weeks up to 20 to 30 mg orally weekly; may be administered parenterally (subQ or IM) if inadequate clinical response or intolerance despite folic acid

 

METHOTREXATE SODIUM - HYDROXYCHLOROQUINE SULFATE  

 

 

METHOTREXATE SODIUM - LEFLUNOMIDE  

 

 

METHOTREXATE SODIUM - SULFASALAZINE

 

METHOTREXATE SODIUM - SULFASALAZINE

 

 

 

Rheumatoid arthritis with disease duration less than 6 months in patients with either high disease activity for 3 to 6 months or high disease activity for less than 3 months with features of poor prognosis  

 

METHOTREXATE SODIUM - ADALIMUMAB  

 

 

METHOTREXATE SODIUM - ETANERCEPT  

 

 

METHOTREXATE SODIUM - INFLIXIMAB

 

 

 

Rheumatoid arthritis with disease duration greater than or equal to 6 months in patients who failed prior methotrexate therapy and have either moderate disease activity with features of poor prognosis or high disease activity  

 

ADALIMUMAB  

 

 

ETANERCEPT  

 

 

INFLIXIMAB

 

 

 

Rheumatoid arthritis with disease duration greater than or equal to 6 months in patients who failed prior methotrexate combination therapy or after sequential administration of other nonbiologic disease-modifying antirheumatic drugs who have moderate or high disease activity without features of poor prognosis  

 

ADALIMUMAB  

 

 

ETANERCEPT  

 

 

INFLIXIMAB

 

 

 

Rheumatoid arthritis with disease duration greater than or equal to 6 months in patients who failed prior methotrexate combination therapy or after sequential administration of other nonbiologic disease-modifying antirheumatic drugs (DMARDs) who have moderate or high disease activity with features of poor prognosis  

 

ABATACEPT  

Adults (<60 kg): 500 mg IV over 30 minutes, repeat dose at 2 and 4 weeks, then every 4 weeks thereafter; may be used as monotherapy or in conjunction with DMARDs other than tumor necrosis factor (TNF)-alpha antagonists

Adults (60 to 100 kg): 750 mg IV over 30 minutes, repeat dose at 2 and 4 weeks, then every 4 weeks thereafter; may be used as monotherapy or in conjunction with DMARDs other than TNF-alpha antagonists

Adults (>100 kg): 1000 mg IV over 30 minutes, repeat dose at 2 and 4 weeks, then every 4 weeks thereafter; may be used as monotherapy or in conjunction with DMARDs other than TNF-alpha antagonists

 

ADALIMUMAB  

Adults: 40 mg subQ every other week; other DMARDs may be continued during therapy; may increase to 40 mg subQ every week in patients not receiving concomitant methotrexate

 

ETANERCEPT  

Adults: 50 mg subQ weekly given as one 50 mg injection or two 25 mg injections in one day OR one 25 mg injection given twice weekly, 72 to 96 hours apart

 

INFLIXIMAB

Adults: When given in combination with methotrexate, 3 mg/kg IV over 2 hours given at weeks 0, 2, and 6, then every 8 weeks OR when given in patients who have an incomplete response, 10 mg/kg IV over 2 hours every 8 weeks or 3 mg/kg IV over 2 hours every 4 weeks

 

RITUXIMAB

Adults (in combination with methotrexate, in patients who had an inadequate response to one or more tumor-necrosis-factor antagonist therapies): 1000 mg IV followed by a second 1000 mg IV dose 2 wk later every 24 wk or based on clinical evaluation; no more often than every 16 wk; premedicate with acetaminophen; an antihistamine; and a glucocorticoid (such as methylprednisolone 100 mg IV or its equivalent) 30 min prior to each infusion

 

Procedural Therapy  

 

Rheumatoid arthritis .  

* Physical therapy procedure

* Occupational therapy

 

Rheumatoid arthritis .  

* Surgical procedure

 

Non-Procedural Therapy  

 

Rheumatoid arthritis  

* Alternative Therapies