Does this patient have rheumatoid arthritis or another inflammatory arthritis?
What are the extra-articular manifestations of rheumatoid disease?
Is one 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 available?
Rheumatoid arthritis (RA) affects 1% of the population worldwide, with women being more commonly affected. In the recent past, there were only a few disease-modifying antirheumatic drugs (DMARDs), which were not prescribed until after joint damage had occurred. Patients were frequently admitted to the hospital for arthritis treatment, including administration of ACTH, rest, and intra-articular corticosteroid injections. Today, early, aggressive DMARD therapy, including biologic DMARDs, has dramatically improved patient outcomes. Most patients with RA are treated exclusively as outpatients, and are never hospitalized due to the disease itself. 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.
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. They 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, 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. 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 attachments to bone. Inflammatory arthritis may be just one manifestation of a systemic disease that may include psoriasis and psoriasiform skin lesions, genital inflammation, inflammatory bowel disease, and inflammatory eye disease, such as uveitis or scleritis.
This chapter reviews articular and extra-articular manifestations of RA and the spondyloarthropathies. We will also review the indications, mechanisms, and most frequent complications of the DMARDs used to treat RA and other inflammatory arthritides, with recommendations for management of DMARD therapy in hospitalized patients with other illness, as well as during the perioperative period.