Key Clinical Questions
Does this patient have rheumatoid arthritis or another inflammatory arthritis?
What are the extra-articular manifestations of rheumatoid disease?
Is a rheumatic condition responsible for this patient’s hospitalization?
Is this hospitalization due to medication toxicity?
How should the patient’s disease-modifying antirheumatic drugs be managed during the hospitalization, including perioperatively?
What tests and studies are useful to evaluate this patient’s presentation?
What treatments are indicated?
Rheumatoid arthritis (RA) affects 1% of the population worldwide, with women being more commonly affected. Within the past two decades, prior to routine early use of disease-modifying antirheumatic drugs (DMARDs), patients were frequently admitted to the hospital for active arthritis treatment. Today, most RA treatment occurs in the outpatient setting. However, RA is a systemic disease with numerous potential extra-articular manifestations, including cardiovascular disease. A hospitalist must be alert to these manifestations, as they may lead to hospitalization.
Early, aggressive DMARD use is a cornerstone of current RA management. The duration of rheumatoid arthritis prior to DMARD therapy is one of the most robust predictors of disease outcome. Longer delays in initiation of DMARDs are associated with greater long-term functional impairment. DMARDs may also attenuate the risk of cardiovascular disease, which is increased in RA.
Most other common inflammatory arthritides fall into the category of seronegative spondyloarthropathies, which affect up to 2% of individuals with an equal male-to-female ratio. The seronegative spondyloarthropathies include psoriatic arthritis (PsA) (population prevalence 0.3%-1.0%), ankylosing spondylitis (AS) (prevalence 0.1%-6.0%, depending on the population studied), inflammatory-bowel-disease-associated arthritis, reactive arthritis, and undifferentiated spondyloarthropathy. These illnesses are seronegative for rheumatoid factor (RF), and are associated with the presence of human leukocyte antigen (HLA)-B27. The presence of HLA-B27 varies by ancestry. In general, up to 15% of the population is HLA-B27 positive, although only about 10% of these individuals develop a spondyloarthropathy. However, among individuals with spondyloarthropathies, up to 90% are HLA-B27 positive. Spondyloarthritis is characterized by axial arthritis, with a predilection for the sacroiliac joints, oligoarthritis, especially of the lower extremities, and enthesitis, or inflammation of ligaments and tendons at their attachments to bone. Inflammatory arthritis may be just one manifestation of a systemic disease that may include psoriasis and psoriasiform skin lesions, oral and genital inflammation, inflammatory bowel disease, and inflammatory eye disease, such as uveitis or scleritis.
Rheumatoid arthritis is thought to result when an environmental factor triggers an aberrant immune response in a genetically susceptible host. Several genes are associated with susceptibility to the development of RA. Most significantly, RA is associated with HLA-DRB1. A short amino acid sequence within this gene, known as the shared epitope, is associated with increased risk of severe RA and development of anticitrullinated-peptide antibodies. Autoantibodies against citrullinated peptides appear to be almost 90% specific for rheumatoid arthritis, although less sensitive than the RF assay. Identification of these autoantibodies is now part of routine diagnostic testing for ...