Rheumatoid arthritis is a chronic systemic disease characterised by inflammation of connective tissue in the diarthroidal (synovial) joints,typically with a period of remissio and exacerbation. (LEWIS)
Rheumatoid arthritis is a chronic disease that causes inflammation of the joints and surrounding tissues. It can also affect other organs. (BLACK)

Rheumatoid arthritis is a chronic disease, mainly characterized by inflammation of the lining, or synovium, of the joints. It can lead to long-term joint damage, resulting in chronic pain, loss of function and disability. (WWW.ASK.COM.Rhematoid)
Rheumatoid arthritis, an autoimmune disease that causes chronic joint inflammation, which has symptoms that include stiffness, fever, muscle and joint aches, loss of appetite, and fatigue.


AGE :---Onset is most frequent between the ages of 40 and 50, but people of any age can be affected. SEX:---womens are affected by RA 2-3 times more frequently than men.

The autoimmune theory suggest that changes associated with RA begin when a susceptible host experiences an initial response to an antigen.RA is characterised by the presence of autoantibodies against abnormal IgG .The autoantibodies are known as rheumatoid factor, and they combine with IgG to form immune complexes. It is initially deposited on synovial membranes or articular cartilages in the joints. This immunecomplex formation leads to activation of complements,and an inflammatory process results.neutrophils are attracted to the site of inflammation ,where they release proteolytic enzymes that can damage articular cartilage and cause synovial lining to thiken. Other inflammatory cells include T helper cells (CD4) that mediate cell mediated immune response.they stimulate monocytes,macrophages and

tender. subluxation and contracture. is common. problems involving other organs of the body are known to occur. Joint pain.IL-6 and TNF. Pannus (vascular granulation tissue)form with in the joint.These are primary factors that drive the inflammatory response in RA. but larger joints like the shoulder and knee can also be involved.synovial fibroblast to secrete the proinflammatory cytokines interleukin-1. painful and stiff. feet and cervical spine. parvovirus B19 and rubella. ultimately causing joint laxicity. Gentle movements may relieve symptoms in early stages of the disease. warm. with the affected joints being swollen. Familial influence is mainly due to HLA antigen known as HLA-DR4 in white RA patients. and stiff when not used for as little as an hour. . Some infectious organisms suspected of triggering rheumatoid arthritis include Mycoplasma. Synovitis can lead to tethering of tissue with loss of movement and erosion of the joint surface causing deformity and loss of function. Extra-articular ("outside the joints") manifestations other than anemia (which is very common) are clinically evident in about 15–25% of individuals with rheumatoid arthritis. With time RA nearly always affects multiple joints (it is a polyarthritis).the pannus scars and shortens supporting structures such as tendons and ligaments. Epidemiological studies have confirmed a potential association between RA and two herpesvirus infections: Epstein-Barr virus (EBV) and Human Herpes Virus 6 (HHV-6) CLINICAL FEATURES Signs and symptoms While rheumatoid arthritis primarily affects joints.it covers the entire surface of the articular cartilage. tender and warm.Rheumatoid arthritis typically manifests with signs of inflammation. and stiffness limits their movement. Joints become swollen. Increased stiffness early in the morning is often a prominent feature of the disease and typically lasts for more than an hour. Genetic factors Higher occurance of disease has been noted in identical rather than fraternal twins. Joints can even become warm. Erysipelothrix.  Morning stiffness. particularly early in the morning on waking or following prolonged inactivity. most commonly small joints of the hands.the production of inflammatory cytokines at the pannus-cartilage junction furthure contribute to the cartilage distruction. Joints SYNOVITIIS :---The arthritis of joints known as synovitis is inflammation of the synovial membrane that lines joints and tendon sheaths. which lasts more than 1 hour.

a necrotizing. jaw. . these can occur in internal organs or at diverse sites on the body.  Joint pain is often felt on both sides of the body. The fingers (but not the fingertips). which is often subcutaneous. skin associated symptoms include:         pyoderma gangrenosum.Skin  The rheumatoid nodule. It is estimated that about one quarter of Americans with RA develop Rheumatoid Lung Disease. shoulders. and skin fragility (often worsened by corticosteroid use). noninfectious neutrophilic dermatosis. Kidneys Renal amyloidosis can occur as a consequence of chronic inflammation. ankles. Other rare. toes. hips. knees. Lungs  Fibrosis of the lungs is a recognized response to rheumatoid disease. Nodules are associated with a positive RF (rheumatoid factor) titer and severe erosive arthritis.  Pleural effusions are also associated with rheumatoid arthritis. elbows. joints lose their range of motion and may become deformed. Rarely. A benign form occurs as microinfarcts around the nailfolds. a neutrophilic dermatosis usually associated with myeloproliferative disorders drug reactions erythema nodosum lobular panniculitis atrophy of digital skin palmar erythema diffuse thinning (rice paper skin).  livedo reticularis. It is also a rare but well recognized consequence of therapy (for example with methotrexate and leflunomide  Caplan's syndrome describes lung nodules in individuals with rheumatoid arthritis and additional exposure to coal dust. .  Over time. which is a network (reticulum) of erythematous to purplish discoloration of the skin caused by the presence of an obliterative cutaneous capillaropathy. and neck may be affected. Rheumatoid arthritis may affect the kidney glomerulus directly through a vasculopathy or a mesangial infiltrate but this is less well documented.  Rheumatoid Lung Disease. wrists. ulcerative.  The joints are often swollen and feel warm and boggy (or spongy) to the touch. is the cutaneous feature most characteristic of rheumatoid arthritis. Sweet's syndrome. Treatment with Penicillamine and gold salts are recognized causes of membranous nephropathy.  Several forms of vasculitis occur in rheumatoid arthritis.

which may be palpably enlarged . loss of appetite and loss of weight are common systemic manifestations seen in patients with active rheumatoid arthritis. To reduce cardiovascular risk. left ventricular failure. such as C-reactive protein. valvulitis and fibrosis. Hepatic Cytokine production in joints and/or hepatic Kupffer cells leads to increased activity of hepatocytes with increased production of acute-phase proteins. Rather more common is the indirect effect of keratoconjunctivitis sicca. Hematological Anemia is by far the most common abnormality of the blood cells. Preventive treatment of severe dryness with measures such as nasolacrimal duct occlusion is important.  pericarditis. Such an erosion (>3mm) can give rise to vertebrae slipping over one another and compressing the spinal cord. it is crucial to maintain optimal control of the inflammation caused by rheumatoid arthritis (which may be involved in causing the cardiovascular risk). and increased release of enzymes such as alkaline phosphatase into the blood. It is postulated to be partially caused by inflammatory cytokines. An increased platelet count (thrombocytosis) occurs when inflammation is uncontrolled. Neurological Peripheral neuropathy and mononeuritis multiplex may occur. but without due care this can progress to quadriplegia. More general osteoporosis is probably contributed . A low white blood cell count (neutropenia) usually only occurs in patients with Felty's syndrome with an enlarged liver and spleen. which is a dryness of eyes and mouth caused by lymphocyte infiltration of lacrimal and salivary glands. Constitutional symptoms Constitutional symptoms including fatigue. Clumsiness is initially experienced. and to use exercise and medications appropriately to reduce other cardiovascular risk factors such as blood lipids and blood pressure. owing to erosion of the odontoid process and or/transverse ligaments in the cervical spine's connection to the skull. Others Ocular The eye is directly affected in the form of episcleritis which when severe can very rarely progress to perforating scleromalacia. The red cells are of normal size and colour (normocytic and normochromic). and risk of myocardial infarction (heart attack) and stroke is markedly increased. malaise. Rheumatoid arthritis may cause a warm autoimmune hemolytic anemia. Osteoporosis Local osteoporosis occurs in RA around inflamed joints. as does the anemia. When severe. Kuppfer cell activation is so marked that the resulting increase in hepatocyte activity is associated with nodular hyperplasia of the liver. morning stiffness.Heart and blood vessels  People with rheumatoid arthritis are more prone to atherosclerosis. endocarditis. In Felty's syndrome.Hepatic involvement in RA is essentially asymptomatic. Atlanto-axial subluxation can occur. low grade fever. The mechanism of neutropenia is complex. dryness of the cornea can lead to keratitis and loss of vision. The most common problem is carpal tunnel syndrome caused by compression of the median nerve by swelling around the wrist.

abnormalities of soft tissue around joint possible Stage IV :--.abnormalities of soft tissue around joint possible CLASSIFICATION OF FUNCTIONAL STATUS OF PEOPLE WITH RHEUMATOID ARTHRITIS  Class I: completely able to perform usual activities of daily living  Class II: able to perform usual self-care and work activities but limited in activities outside of work (such as playing sports. Lymphoma The incidence of lymphoma is increased in RA. work.on X-ray.on X-ray. and other activities STUDIES . although there may be signs of bone thinning Stage II :. evidence of bone thinning around a joint with or without slight bone damage .joint deformity without permanent stiffening or fixation of the joint.slight cartilage damage possible joint mobility may be limited. systemic cytokine effects.joint deformity with permanent fixation of the joint (referred to as ankylosis) .to by immobility.extensive muscle atrophy . although it is still uncommon STAGES OF RHEUMATOID ARTHRITIS The American College of Rheumatology has developed a system for classifying rheumatoid arthritis that is primarily based upon the X-ray appearance of the joints. evidence of cartilage and bone damage and bone thinning around the joint . local cytokine release in bone marrow and corticosteroid therapy. no joint deformities observed . Stage I -.atrophy of adjacent muscle abnormalities of soft tissue around joint possible Stage III :--. household chores)  Class III: able to perform usual self-care activities but limited in work and other activities  Class IV: limited in ability to perform usual self-care. extensive muscle atrophy . evidence of cartilage and bone damage and osteoporosis around joint . DIAGNOSTIC  History and physical examination .no damage seen on X-rays.on X-ray.

 Bone scanning. particularly because of the chronic inflammation .. The presence of anti-CCP antibodies can be used to predict which patients will get more severe rheumatoid arthritis. . Rheumatoid factors are a variety of antibodies that are present in 70% to 90% of people with rheumatoid arthritis (RA).a procedure using a small amount of a radioactive substance. since anemia is common in rheumatoid arthritis. Rheumatoid factor can be found in people without RA or with other autoimmune disorders   Point-of-care test (POCT) for the early detection of RA has been developed.   Agglutination reactions: Positive in more than 50% of typical cases.  Synovial membrane biopsy: Reveals inflammatory changes and development of pannus (inflamed synovial granulation tissue). X-rays of other joints may be taken if symptoms of pain or swelling occur in those joints. there may be bony erosions and subluxation. levels of antibodies that bind citrulline modified proteins (anti-CCP) is more specific and tends to be only elevated in patients with rheumatoid arthritis or in patients about to develop rheumatoid arthritis. The sed rate is usually faster during disease flares and slower during remissions.  Rheumatoid factor test (positive in about 75% of people with symptoms).. :-. As the disease progresses.  Radionuclide scans: Identify inflamed synovium. or the x-ray may demonstrate juxta-articular osteopenia. Joint X-rays may be normal or only show swelling of soft tissues early in the disease.Blood testing may also reveal anemia. X-rays can show bony erosions typical of rheumatoid arthritis in the joints. Thrombocytopaenia (due to splenomegaly in Felty's syndrome).  Blood tests    Complete blood count :-. can also be used to demonstrate the inflamed joints  Ultrasonography :-. soft tissue swelling and loss of joint space. X RAY :--. Immune disorder/exhaustion results in depressed total complement levels. Immunoglobulin (Ig) (IgM and IgG): Elevation strongly suggests autoimmune process as cause for RA. C-reactive protein Serum complement: C3 and C4 increased in acute onset (inflammatory response). As the disease advances.Ultrasonography (left side of image) in the (a) longitudinal and (b) the transverse planes shows both signs of destruction and inflammation  MRI :-. May return to normal as symptoms improve.The sed rate is used as a crude measure of the  inflammation of the joints.. MRI scanning can also be used to demonstrate joint damage. This assay combines the detection of rheumatoid factor and anti-MCV for diagnosis of rheumatoid arthritis and shows a sensitivity of 72% and specificity of 99.7%. ): Usually greatly increased (80–100 mm/hr). Erythrocyte sedimentation rate :-.  Direct arthroscopy: Visualization of area reveals bone irregularities/degeneration of joint. there may be no changes in the early stages of the disease.

g. if initially negative. increases sensitivity when used in combination with rheumatoid factor. decreased viscosity and complement (C3 and C4). or bacterial infections). wrist and ankle films are useful as baselines for comparison with future studies. Laboratory and Imaging Findings Associated with Rheumatoid Arthritis Laboratory test Creactive protein* Associated findings Typically increased to >0. more specific than rheumatoid factor (90 versus 80 percent). in . bleeding. White blood count* Anticyclic citrullinated peptide antibody May be increased Tends to correlate well with disease progression.000 white blood cells per mm (5 to 25 × 10 per 3 9 L) with 85 percent polymorphonuclear leukocytes a common finding. hemoglobin averages around 10 g per dL (100 g per L). can repeat six to 12 months after disease onset. sarcoidosis. yellow appearance (inflammatory response..7 picograms per mL. lupus. not readily available in many laboratories. Sjögren’s syndrome. Systemic inflammation may cause microscopic hematuria (blood in the urine) and proteinuria (excess albumin in the urine) in a 24-hour urine specimen. fluid may clot at room temperature.May reveal volume greater than normal. elevated levels of WBCs and leukocytes. parasitic. scleroderma. 5. cloudy. Erythrocyte sedimentation Often increased to >30 mm per hour. Normal or slightly elevated alkaline phosphatase Usually increased May be normal or show osteopenia or erosions near joint spaces in early disease. Synovial fluid analysis :-. Slightly decreased.000 to 25. straw-colored fluid with fibrin flecks often seen. Negative in 30 percent of patients early in illness. also may be normocytic or microcytic. opaque. may be used to monitor disease course. neoplastic disease. Consider if an affected joint can be tapped and diagnosis is uncertain. may be used to monitor disease rate* Hemoglobin/hematocrit* Liver function* Platelets* Radiographic findings of involved joints* Rheumatoid factor* course. normochromic anemia. not an accurate measure of disease progression. various viral.  Urine studies. degenerative waste products). Antinuclear antibody Complement levels Immunoglobulins Joint fluid evaluation Limited value as a screening study for rheumatoid arthritis Normal or elevated Elevated alpha-1 and alpha-2 globulins possible. can be positive in numerous other processes (e.

ESR. hip joints and knees as large joints:      Involvement of 1 large joint gives 0 points Involvement of 2-10 large joints gives 1 point Involvement of 1-3 small joints (with or without involvement of large joints) gives 2 points Involvement of4-10 small joints (with or without involvement of large joints) gives 3 points Involvement of more than 10 joints (with involvement of at least 1 small joint) gives 5 points  serological parameters – including the rheumatoid factor as well as ACPA – "ACPA" stands for "anti-citrullinated protein antibody":    Negative RF and negative ACPA gives 0 points Low-positive RF or low-positive ACPA gives 2 points High-positive RF or high-positive ACPA gives 3 points  acute phase reactants: 1 point for elevated erythrocyte sedimentation rate. or elevated CRP value (c-reactive protein)  duration of arthritis: 1 point for symptoms lasting six weeks or longer In clinical practice. jointly published by the American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR) establish a point value between 0 and 10. and fluid glucose level typically is low. Urinalysis Criteria The "new" classification criteria. there are no crystals. the following criteria apply  two or more swollen joints . the interphalangeal joint of the thumb. designating the metacarpophalangeal joints.Laboratory test Associated findings rheumatoid arthritis. cultures are negative. proximal interphalangeal joints. Microscopic hematuria or proteinuria may be present in many connective tissue diseases. second through third metatarsophalangeal joint and wrist as small joints. Four areas are covered in the diagnosis "MORNING Always Helps to See Nature Fresh and RADIANT"  joint involvement. provided he has synovitis in at least one joint and given that there is no other diagnosis better explaining the synovitis. and elbows. Every patient with a point total of 6 or higher is unequivocally classified as an RA patient.

education.Gold has an anti-inflammatory action & may decrease phagocytosis and lysosomal activity. Gold therapy often causes side effects like skin rashes. Chemically synthesised DMARDs:          azathioprine ciclosporin (cyclosporine A) D-penicillamine gold salts hydroxychloroquine leflunomide methotrexate (MTX) minocycline sulfasalazine (SSZ)  Anti-inflammatory medications: . in addition to rest. including medications. Usually given as weekly injection for 5 month.mouth sores.  Methotrexate (Rheumatrex) is the most commonly used DMARD for rheumatoid arthritis.penicillamine may be used if the patient does not respond to either methotrexate or gold therapy.  Azathioprine(imuran) or D. MANAGEMENT Treatment RA usually requires lifelong treatment. aggressive treatment for RA can delay joint destruction. morning stiffness lasting more than one hour for at least six weeks  the detection of rheumatoid factors or autoantibodies against ACPA such as autoantibodies to mutated citrullinated vimentin can confirm the suspicion of rheumatoid arthritis. MEDICATIONS  Disease modifying antirheumatic drugs (DMARDs): These drugs are the current standard of care for RA.These drugs may have serious side effects. so you will need frequent blood tests when taking them.  Goldtherapy may be considered for patients who do not respond to methotrexate. Leflunomide (Arava) may be substituted for methotrexate. then biweeklyor monthly to sustain clinical effect. strengthening exercises. Early. and possibly surgery. physical therapy. A negative autoantibody result does not exclude a diagnosis of RA. and anti-inflammatory drugs.and GI problems like diarrhoea. exercise.

anakinra (kineret) . monoclonal antibodies against B cells – rituximab (Rituxan) T cell costimulation blocker – abatacept (Orencia) Biologic agents can be very helpful in treating rheumatoid arthritis. etanercept (Enbrel).  Antimalarial medications: This group of medicines includes hydroxychloroquine (Plaquenil) and sulfasalazine (Azulfidine). long-term use can cause stomach problems.Although NSAIDs work well. infliximab (Remicade). Talk to your doctor about whether COX-2 inhibitors are right for you. such as ulcers and bleeding. and is usually used along with methotrexate.  Corticosteroids: These medications work very well to reduce joint swelling and inflammation. such as ibuprofen. It may be weeks or months before you see any benefit from these medications.  Celecoxib (Celebrex) is another anti-inflammatory drug. and fungi Leukemia Possibly psoriasis .Sideeffect include redness and swelling at the subcutaneous injection site. They may be given when other medicines for rheumatoid arthritis have not worked. and possible heart problems. corticosteroids should be taken only for a short time and in low doses when possible.it reduses pain and swelling associated with RA . Because of long-term side effects. golimumab (Simponi). and certolizumab (Cimzia) Interleukin-6 (IL-6) inhibitors: tocilizumab (Actemra) IL-1 Receptor antagonist:.These include aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs). Most of them are given either under the skin (subcutaneously) or into a vein (intravenously). but it is labeled with strong warnings about heart disease and stroke. However. viruses. There are different types of biologic agents:       White blood cell modulators include: abatacept (Orencia) and rituximab (Rituxan) Tumor necrosis factor (TNF) inhibitors include: adalimumab (Humira). people taking these drugs must be watched very closely because of serious risk factors:    Infections from bacteria.  Analgesics include: o paracetamol (acetaminophen in US and Canada) o opiates o diproqualone o lidocaine topical  BIOLOGIC AGENTS: Biologic drugs are designed to affect parts of the immune system that play a role in the disease process of rheumatoid arthritis.

(using a small lighted instrument to remove debris or inflamed tissue from the synovial sac). They also show people how to better cope with day-to-day tasks at work and at home. Historic treatments for RA have also included: Rest. It consists of the removal of the inflammed synovia and prevents a quick destruction of the affected joints. Analysis of the joint fluid in the laboratory can help to exclude other causes of arthritis. :-. a sterile needle and syringe are used to drain joint fluid out of the joint for study in the laboratory. an arthroscopic or open synovectomy may be performed. and splints or orthotic devices to support and align joints may be very helpful. SURGICAL MANAGEMENT Occasionally.PHYSICAL THERAPY      Range-of-motion exercises and exercise programs prescribed by a physical therapist can delay the loss of joint function. The surgery is mostly done on knee. ankle or tarsal joints.which is the removal of the joint lining (synovium). as well as 8 to 10 hours of sleep per night. and others may be done.In extreme cases. Postoperatively. :-. Sometimes therapists will use special machines to apply deep heat or electrical stimulation to reduce pain and improve joint mobility. These surgeries can mean the difference between being totally dependent on others and having an independent life at home. heat and cold treatments. Joint protection techniques. shoulder replacement. It has to be performed before the destruction of the cartilage. :----In this procedure. Arthrocentesis can also be helpful in relieving joint swelling and pain. cortisone medications are injected into the joint during the arthrocentesis in order to rapidly relieve joint inflammation and further reduce symptoms. hip replacement. Occupational therapists can create splints for the hand and wrist. elbow. Total joint replacement is needed. Frequent rest periods between activities. It is successful in approximately half of patients. shoulder. such as infection and gout. the yttrium synovectomy may be performed. total knee. despite limitations caused by RA. . surgery is needed to correct severely affected joints. are recommended. Arthrocentesis. Ice. Occasionally. Arthroplasty (replacing all or part of a hip or knee joint). ankle replacement. and arthroscopy :-. and teach how to best protect and use joints when they are affected by arthritis. In older patients. Surgeries can relieve joint pain and deformities. physiotherapy is always necessary. Synovectomy. Compression and Elevation.

Alleviate pain.inability to perform ADLS 3. 4. . Promote positive self-concept. Self care deficit related to disease progression.pain and fatigue as manifested by slf doubt about ability to manage disease . 2. 7 Plan in place to meet needs after discharge.NURSING MANAGEMENT NURSING DIAGNOSIS 1.altered self concept.flat affect. Provide information about disease process/prognosis and treatment needs 6 Patient is managing ADLs by self/with assistance as appropriate. Support independence. Ineffective therapeutic regimen management related to complexity of chronic health problem . NURSING INTERVENTIONS To prevent trauma to joints. Disturbed body image related to chronic disease activity . weakness and contractures as manifested by inability to perform ADL’s NURSING GOALS 1.guarding behaviour and limited joint function hot swollen painful joints. Impaired physical mobility related to joint pain. 4. 5.ability to perform activities for only short periods.longterm treatment. 5.overuse of joints and ineffective pain and or comfort measures as manifested by verbalisation of pain. Increase mobility.deformities. Chronic pain related to joint inflammation.: * avoiding activities that cause pain or discomfort * avoiding gripping things tightly * avoiding positions that push the joints toward deformity * using stronger and more stable joints for any activity.stiffnessand inability to perform ADL’s as manifested by social withdrawal . strength .stiffness and deformityas manifested by limitation of joint motion. 2. 3.

including: • Scheduling NSAIDs at equal intervals throughout the day • Taking morning NSAID dose with milk and crackers approximately 30 minutes before rising • Performing ROM exercises in shower or bathtub • Applying local heat with paraffin dip or compress. watch for adverse effects. nurses usually do the following:         We assess joints and look for deformities contracture. Emotional Support o Encourage the patient to talk about feelings and promote a sense of independence by allowing her to perform as many tasks as possible. • Provide Arthritis Foundation literature and information. • Explore ways to incorporate 30-minute rest breaks into work schedule. which can affect people of all ages.Regular aerobic exercise programs can help the patient improve joint mobility. inability to perform daily activities. • Discuss ways to delegate household tasks to other family members. Then we administer analgesics. and level of pain. Monitor for signs of depression and low self-esteem In patients with arthritis. sensory disturbances. immobility. We monitor duration of morning stiffness. arthritis such as rheumatoid is an inflammatory disease. We apply splints carefully and observe for pressure sores if patients are in traction or wearing splints. We make sure patient and family understand that RA is a chronic disease that requires major changes in life-style. If muscle weakness is present. We urge patient to perform activities of daily living and control weight (obesity adds stress to joints). We even give meticulous skin care. It usually starts in the fingers and can affect several simultaneously. We monitor vital signs and take note of weight changes. the patient may be unsteady and require assistance walking. aerobic fitness and function. Some people may suffer from only one attack of this disease in their lives. muscle strength. We explain the diagnostic tests and procedures. We tell the patient that multiple blood samples allow firm diagnosis and accurate monitoring of therapy. • Provide information about the disease process and its manifestations. and that there are no miracle cures. which reflects disease's severity more accurately. performing range of motion exercises and other daily activities. Unlike osteoarthritis. In others. and psychological well-being without increasing fatigue or joint symptoms. Teach techniques for relieving pain and morning stiffness. using cold packs as needed • Teach techniques to minimize joint stress while performing ADLs. and the importance of balancing rest and activity Daily Living Activities o The patient may need help dressing. bathing. as ordered. the disease may be long-term and progressive . prescribed medications with desired and adverse effects.

C4-C5 and C5-C6 subluxations are possible. Cardiac complications Cervical spine disease Pericarditis—one third of patients may have asymptomatic pericardial effusion at diagnosis. bleeding stomach ulcers. Vasculitis may also affect the brain. three fourths of patients have anemia of chronic disease. lymphomas and leukemias two to three times more common in patients with rheumatoid arthritis. and heart. Caution must be used during endotracheal intubation. may or may not be symptomatic. It can involve almost all organs.  Sjogren syndrome  Severe deformity of the joints(s).  Pleural effusion (fluid accumulating between the layers of the membrane lining the lungs and the chest cavity).COMPLICATIONS Rheumatoid arthritis is not only a disease of joint destruction.  Dryness of the eyes and mouth. perhaps because of nonsteroidal anti-inflammatory drugs. may see loss of lordosis of the neck and decreased range of motion. nerves. which can lead to skin ulcers and infections.  Enlarge spleen. Tenosynovitis of transverse ligament can lead to instability of atlas on axis. increased risk for various solid tumors. Affects 1 in 10 people with progressive disease. genitourinary cancer risk is reduced in rheumatoid arthritis. and nerve problems that cause pain. which can cause stroke. or tingling.    Anemia Damage to the lung tissue (rheumatoid lung) Injury to the spinal cord when the cervical spine (neck bones) becomes unstable as a result of RA  Rheumatoid vasculitis (inflammation of the blood vessels). heart attack. due to failure of the bone marrow to produce enough new red blood cells Cancer May be secondary to treatments. or heart failure. Both of these conditions can lead to congestive heart failure. numbness.  Swelling and inflammation of the outer lining of the heart (pericarditis) and of the heart muscle (myocarditis). myocarditis—diffuse inflammation can occur. atrioventricular block—rare. Complications of Untreated Rheumatoid Arthritis Complication Anemia Comments  Correlates with erythrocyte sedimentation rate and disease activity. one fourth of patients respond to iron therapy. may .

boutonniere deformity—flexed PIP and hyperextended DIP. pleuritis—present in 20 percent at onset of disease. found in 20 to 35 percent of patients with rheumatoid arthritis. swan neck deformity—the reverse of boutonniere. dressing. peripheral neuropathy. Vasculitis Forms include distal arteritis. and eating. vocal cords. and unable to do simple daily living tasks such as washing. may form nearly anywhere. Lung nodules can coexist with cancers and form cavitary lesions. avoid flexion films until odontoid fracture ruled out if injury is suspected. not usually associated with pleuritic pain. usually found on extensor surfaces of the limbs or other pressure points. Rheumatoid nodules Often have necrotic tissue in their centers.Other people develop a more severe form of the disease. However. increased risk of developing if male sex. including on the sclera. high rheumatoid factor titers. PROGNOSIS The course of rheumatoid arthritis differs from person to person. and coronary arteritis. the disease becomes less aggressive over time and symptoms may improve. increased risk of tendon rupture Other joint deformities Respiratory complications Frozen shoulder may develop. connecting bursa to the skin. pericarditis. Eye problems Fistula formation Increased infections Hand joint deformities Episcleritis rarely occurs. after many years.Treatment for rheumatoid arthritis has improved. or vertebral bodies. about 10% of those with RA are severely disabled. Ulnar deviation at metacarpophalangeal joints. Many people with RA work full-time. arteritis of viscera. with flexed DIP and hyperextended PIP. Around 20%-30% will have . popliteal cysts can arise. cricoarytenoid joint inflammation can arise. associated with increased risk of myocardial infarction. with gradual onset of upper extremity weakness and paresthesias. interstitial fibrosis—rales may be noted on lung examination. myelopathy can occur. cutaneous lesions. PREVENTION Rheumatoid arthritis has no known prevention. carpal and tarsal tunnel syndromes common. Cutaneous sinuses form near affected joints.Complication Comments see joint space narrowing on lateral cervical spine films. thumb hyperextension. sacrum. However. it is often possible to prevent further damage to the joints with proper early treatment. with hoarseness and laryngeal pain. treatment with steroids. number of disease-modifying antirheumatic drugs prescribed. For some patients. More likely to be an effect of rheumatoid arthritis treatment.

L.N. antibodies against native D.).N. Healthcare professionals treating those with the disease should therefore be aware of this elevated risk and advise their patients to follow a healthy diet and lifestyle and be alert to the early signs and symptoms of CVD in addition to managing their RA. ARTHRITIS DOUBLES THE RISK OF RA Dr. this is associated with a poor prognosis EVIDENCE BASED RESEARCH STUDIES 1. .subcutaneous nodules (known as rheumatoid nodules). a figure that was double that reported in the general population (4. antibodies has provided a sensitive diagnostic and therapeutic aid to the management of this disease. Study revealed that Of the wide variety of circulating anti-bodies described in systemic lupus erythematosus (S." 2.A.E. The introduction of an immunoassay for the detection of anti-D. the studies suggest that RA should be considered an important cardiovascular disease risk factor.6% of the RA population studied. are obscure.E. At least one CV-event was reported in 8.N. SIGNIFICANCE OF ANTI-D./anti-D.A. have been found highly specific for this disease.L.A.H Hughes conducted a study regarding this.3%). complexes in the production of the nephritis of S.N.A. The factors leading to the production of these antibodies and the reasons for their peculiar specificity for S.N. Increasing evidence suggests a central role for D. the Netherlands conduct a study regarding this.E. Amsterdam.A. Mike Peters of the VU University Medical Center and Jan van Breemen Institute.L. ANTIBODIES IN SYSTEMIC LUPUS ERYTHEMATOSUS G.The risk of cardiovascular disease (CVD) for people with rheumatoid arthritis (RA) has been found to be comparable to the risk of CVD in people with type 2 diabetes.

&#$% &#$ $$   .

.°n½f° f ©°°€f¯¯f°  ¾ €©°¾f° ° €€ n ½f°f°  n¯€¯ f¾ ¾f¾¯f°€ ¾    f¾f°€½f° –f °– ff°  ¯ ©°€°n°¾ °½f°€©°¾    ¯½f ½¾nf¯  f ©°½f° ¾€€° ¾¾f°  €¯f¾¯f°€ ¾  ¯f°€©°¯° ¾ °– °f ½ €¯   ¾   ¯f–  f n°n ¾ f¾ fn °– ¯  f¯ ° €¯ ¾ ¾€€° ¾¾f° °f ½ €¯#¾f¾¯f°€ ¾  ¾nf  ff €ff€€ n f  ¾ €n°n ½    ° €€ n  f½ n –¯ °¯f°f– ¯ ° f n¯½ €n°n f ½  ¯ ½f°f° €f– f¾¯f°€ ¾  ¾€  f f ¯f°f–  ¾ f¾  f ½ €¯fn ¾€°¾½  ¾     €nf  €n f  ¾ f¾ ½– ¾¾°  f° ¾¾f° n°fn ¾f¾ ¯f°€ ¾  °f ½ €¯#¾  -D-  33.76:.5   509.:3.   #9646.:46/3.7.

4/354894389../6.4/3755393899 .5175150   #9615694.  #3.:..5..03997.9.5573.   &7769.779679..06507.95:890439894..65.944398  .:7960::79656::.4/3..9.91: #.9  .51:.347/8.1:.:::.9089.9   !%&!!'%!'"!& %4570.7//014729 :838974307.421479 ..9..3/247089.51.9...:805..3.

98 .3/ 4801 089002  35.55742.08:705.9 .078..889449071.88.-4:910038.:7.304124943007.4397..041-..3  24943.943  W8...0780 0110.3489.9039949.3907.904:804/9..0415...0/:3$8.9039.99070.802./4901443 O O 0.074-.9..-0:3890.94/8.:88.043924-9 2:8.3.0- .0905..308 803847/89:7-.980..:708  0:705.3/58.4307945071472.08  .0 -0394:93.28.#0:.805747.3..00..95045041.90./.703427.9:0474398259428  %0..3/44147/01472908.90898.4172/.93 507147237.808..9.110.3/.9438 5708.4/5...8974:4:990/.803907 ./0797984:3/.99:- W5534.08.:4:883.9 706:7082.8889.9.3.894/00.9.880884398.9039945071472.908 12:8.07.110..85488-0 4394714783841/05708843.0.809..4397409 4-089 .7385398  02.4257088:83..3/9.7.90398.90841/.35.3.8394478.947/80.-043 9072.743.304:8 $420504502.03.3/ 4907/.08 349078 90/80.:7.2:3/0789.847/070/.3/1.31089..088.3/574.3/5742490.7010.9:70.0 .9.70  005.7.0 897039 .0.0/:708 090905.906:.943.3..9.2202-078  W5470..8:1107174243430..36:089423204398970880507147238  W!74.5585398.//8897088944398  O O O O O O &3048904.98  00.3/9025479.8300/0/ W%0.3/2473389113088 23:908 -01470783 W!0714723# 007../238907.838.70.$:55479 4 3.-994 5071472/.-4:990/80.4198/80.3/9.08 9:8:.:/3  W$. 82:9.308885708039 905.9:70 224-9 3.3/.79798 .90  0.034904109.0209.3/0..4:7.80380413/0503/03.5  0243947/:7.83 1.8 .3.0./..701:.79798 3:7808:8:.8083840747-.007.3/5747088.8943.3.98/80.324733$/48092.90392574.3/..0792470 .193088.3/982.995.074-.7-0/ 20/.943907.90392..2508.797988:.3 .9.305905..94389/0870/.943412473389113088 .7.90 23:907089-70.908  0243947.113/547.300/05/70883 -.9#8.703 97..07800110.90399.331.80 .943470.390/.39.37089 .79839013078./.0/:0  W! -44/8.3/.3/.22...3/4-807.80 880.3/.90243947341907.80574.3 %030.3.908 4 %05.3/1:3./031472.943 .014757088:708470815.147./80.90392.89... W%..870:2..3/9.3/ 706:70.308310 890 .82.36:08147700.47547.3488.

 O .943841&3970.43/9438.089..990-7.943 302.011:843 1:/.0. !% $ #0:2.22..07..00.08 .0 24..94/.8041439/0897:. 5045095747088..3/ 41900..0 574-0289.-0.8530 30.4208 :389..30.38  O 302..0 /80.2489.94/:3  O 3:79490853. 4220398 O .:2:.79 507.:70  O $03.43089./94 ..:70  O $470383/7420 O $0.3/0.22.:8089740 0. 47.792:8....99..:98 31.9  O 3.-4308 -0.  470.3..070/01472941904398 8 110.3 307..8.078 .7/98 49419080..79798834943.7/98 ...791.7085003  O 730884190008.30.33.:.08808 .0784190202-7.79 ...93-0900390.708:941# O #0:2./ 9483:.94/.943 9.:805.3033 90:38.3/310.09490:3988:0 70:2.94341904:9073341900./80.9438 -00/38942..9434190-44/.3/31.3/24:9   425.8.3 3:2-3088 47933 '..2.84 .4..80  O !0:7.3/90.3/307.90/#0:2.47/0390.791.:982.94/79798  425.8.110.

825942.507.22..07 ..80 !07.9..3/0:02.7...9438 07.70.843. 7.9..-941.0778870/:.74:884/ 9:24780394:73. f ¾ n ¾ ¯ °f°f f°  ¾ f¾ fn   €¾€½f °¾f f° ¯f€n°n ¾ f¾ ° € €½f °¾ ¾½° ° f½ /:0941.:704190-430 2.7/98 /11:8031.304124943 .9203982542..8949497009208 2470.425.3488..30.4224335.9.08  ..90398970:2.0034:3070/-44/..58 -0.43/.39:-.947/7:8  .794970.22.0397.8.0.:943 2:89-0:80//:7303/497.7-4.7/98 43097/415.0.7/.-080. .77494574/:.3/ 8:-:.011:843..7024.8004884147/488419030.943.472.9438../94389.80/78147.79798 507.3//0.8 .0780.:.38.  %034834.705488-02.0/370:2.34.3.:804134389074/.984197.2039..9432.70.8530 /80...349-0825942. 2.94/.797983..94/.39 31.903982.7/.80/7.974.3..:7  . .9 /.

90/950:79.3/.943    !#'%  #0:2./014729 9070.3.774343.79798/11078174250784394507843 4784205..7/98 507507.3088.:98 47283.9.9203914770:2..19072.70.4:7804170:2.943 4220398 80043985.94/.23.79034/ 43931.3/5070903/0/!!9:2-50709038433.0841902-8474907 57088:70543982..045312.4398-4:9433070/014729 100/!! .884.07014724190/80.:/0/89.80 %70.92039989074/8 3:2-0741/80.147230.7803088.3/ .2574..:78  :9.79798:8:.30.3..-0/ .1-7488 7.07.94/1.039.304:883:808147230.80349:8:. 31.30.94/ 34/:08 1903.9438 740384:/072.749.943.70.22.3/5070903/0/!8.3/:3..83 /70883 ..5.0391:7907/.94/..92039  &3.30110.90/93.../7:85708. 4380941:55070970290.4/1043128:39 4/4394/17.4208088.8.80/7841903/43 7:59:70 907439 /01472908 #0857..03943 40.14:3/4309038478:71.0 .93-:78.078.94/.70.0 907 50450/0..40899.7...07...7:2 47..780 94.7.9 .78.947 .704.80-0..949083  470094-0.-4:9 4194809#.93 74:3/   .903989 70:2.7/0.07987..94/..:7 97.3/..834343570.2.7/.8.47/8  8.79798.30:745./:.80/7841/0.3/5.04.94799078 970..79798970..7-0/.708908.94/.80/ 310.90398  90/80.790798 507.-03490/43:30....330.425. ..04554590.09490439895745070.045.4743.884.943.3/0.7545. 1472..4330.:9.3 3907899.07920.7080.. .70..3504509#471: 920 40.3970:2.304:808438  .8.3/82594282.8530128.730.79079841..080  70:2..39.92039  9- %0. .3/439 /01472908 58.039415.:/343908.888:.78  .4.780.9438 .3.425. 98419035488-094 570.7088..07 .0790-7.79798 ..03907814:3/3 94507.030.3/1472./0.9.708438.070/8.898.9209.247080.94380941/80.082.-094/48250/..07.907.943 3.90/2045.80/784124.7.350:798 5708039 3 507..42243  :334/:08.80 24/13 ..03.9.9:707:0/4:913:788:850.943  #0:2.-4/08  '.90/4398 .7907983.94170:2.8  0574-028 89:.82574.5.988:03907.7970.3070 9 100/!..9:330 83/74208.

8:-.:9..90/9.5447 5743488 I-.884.304:834/:08 343.870:2.94/34/:08 988.


8 970..039 ./03..7 850.1.43/:..07890/.7/80.7/398 90.843814790750.948:8 $   .0/9.740147   .8-00314:3/94-0.9147$   .7 838.947 0..-0908 9089:/088:0899.@D   @@D @ 7 0!090784190'&&3.93.809075.:.3/./39490 574/:..3/ .89:/70..:5:8 07902.9..14798/80.7.3/-0.0.90/78.3.80 '  14750450970:2.325479.8084:/90701470-0.70.3/9070. .80781.3/825942841'3.39 -4/08/08.3/10890.89:/70.943   %07841.80 %01.8..07994900.8/4:- 1 90/0.87054790/3 4190#545:..3893.08:0898.704-8.9039894144..9/09.94/..3907#     $ %    % $$$%&!&$ #%% $&$   :08.37002033899:90  28907/.90/.9#84:/-0 .:.1.79798 # .1:709.39-4/08.9 7054790/3900307.9.39-4/08.3/8.94780.7/398 $9:/70.9.438/070/.-0949078 41'3504509950/.:.70574108843.7.939480990/80.03907.:70 3.943419080.39.7/4..94389:/0/ .7-0/388902.3.2 900907..:.9.//943942.7/80.425.7/4./.89430' 0.43/:.0   ..0397.70941.0-003 14:3/850.830.545:.

020394198/80.425008390574/:.50:9.80389.322:34. .3/907.39    .39-4/08.3./0/.8574.14790 /090.80    .9434190 30579841$   %03974/:.3489./94902.0/.94341.88.94341.39    ...