Rheumatoid Arthritis


Article Author:
Krati Chauhan


Article Editor:
Mohammed Al-Dhahir


Editors In Chief:
Stephen Leslie
Karim Hamawy


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Kyle Blair
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Daniyal Ameen
Altif Muneeb
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
8/30/2019 1:19:09 PM

Introduction

Rheumatoid arthritis (RA) is a systemic autoimmune disease characterized by inflammatory arthritis and extra-articular involvement. RA with symptom duration of fewer than six months is defined as early, and when the symptoms have been present for more than months, it is defined as established.[1][2][3]

There is no labortaory test that is pathognomonic for rheumatoid arthritis. The treatment of patients with rheumatoid arthritis requries both pharmacological and non-pharmacological agents. Today, the standard of care is early treatment with disease modifying anti-rheumatic drugs.

Etiology

The etiology of RA remains unknown. It is thought to result from the interaction between patients genotype and environment. Twin studies have shown a concordance rate of 15% to 30% among monozygotic twins and 5% among dizygotic twins. The heritability of rheumatoid arthritis is approximately 40% to 65% for seropositive rheumatoid arthritis and 20% for seronegative rheumatoid arthritis. The risk of developing rheumatoid arthritis has been associated with HLA-DRB1 alleles: HLA-DRB1*04, HLA-DRB1*01, and HLA-DRB1*10. These HLA-DRB1 alleles contain a stretch of conserved five amino acid sequence, the shared epitope (SE), in the third hypervariable region of their DRB1 chain, which has been associated with the risk of developing RA.[4][5][6]

It has been suggested that polymorphism in signaling transducers and activators of transcription (STAT)-4 and interleukin (IL) -10 genes also confer susceptibility to RA. Single nucleotide polymorphism (SNP) in PSORS1C1, PTPN2 and MIR 146 A genes are associated with severe disease.

The term epigenetics refers to heritable changes without altering the DNA sequence; these changes may be present in chromatin or the DNA. These include DNA methylation, histone modification, noncoding RNA-mediated regulation. RA-FLS (fibroblast-like synoviocytes) overexpress tyrosine phosphatase SHP-2, coded by gene PTPN11 as compared to synoviocytes from osteoarthritis (OA) patients and this promotes invasive nature of RA-FLS. Enhancer region of the PTPN11 intron contained two hypermethylated sites, resulting in abnormal epigenetic regulation of the gene and alteration of function of RA-FLS.

Cigarette smoking is the strongest environmental risk factor associated with rheumatoid arthritis. Studies have shown in ACPA (anti-citrullinated protein antibody) positive individuals; there is an interaction between genes and smoking that increases the risk of RA.

Changes in the composition and function of intestinal microbiome have been related to rheumatoid arthritis. The composition of gut microbiome is altered in patients with rheumatoid arthritis (dysbiosis), rheumatoid arthritis patients have decreased gut microbiome diversity when compared with healthy individuals. There is an increase in these genera: Actinobacteria, Collinsella, Eggerthalla, Faecalibacterium. Collinsella alters gut mucosal permeability and has been related with increased rheumatoid arthritis disease severity.

Epidemiology

Incidence rates of RA are higher in northern Europe and North America compared with southern Europe. Incidence is 29 cases/100,000 in northern Europe, 38/100,000 in North America, and 16.5/100,000 in southern Europe. In North America and northern Europe, RA affects 0.4% to 1% of the population, in southern Europe, it affects 0.3% to 0.7% of the population. Female to male ratio is 2-3:1 and the prevalence of RA increase with age.[7][8]

Pathophysiology

Rheumatoid arthritis patients contain antibodies to citrullinated proteins. Citrulline is an amino acid generated by post-translational modification of arginyl residues by peptidyl arginine deaminases. These antibodies are called anti-citrullinated protein antibodies (ACPA). ACPA can be IgG, IgM, or IgA isotypes. ACPA can bind citrullinated residues on self-proteins like vimentin, fibronectin, fibrinogen, histones and type 2 collagen. Binding of antibodies to proteins leads to complement activation. The presence of antibodies in rheumatoid arthritis is associated with severe disease, joint damage and an increase in mortality. ACPA can be present in the serum up to 10 years before the onset of clinical symptom, with time concentration of ACPA and serum cytokine level increases.

The synovium in rheumatoid arthritis is infiltrated by immune cells which include innate immune cells (monocytes, dendritic cells, mast cells) and adaptive immune cells (Th1 (T helper 1), Th17 (T helper 17), B cells and plasma cells. Cytokines and chemokines like tumor necrosis factor (TNF), interleukin-6 (IL-6), granulocyte-monocyte colony stimulating factors activate endothelial cells and attract immune cells within the synovial compartment. The fibroblast in the rheumatoid synovium changes to an invasive phenotype. Fibroblast and inflammatory cells lead to osteoclast generation resulting in bone erosion the hallmark feature of rheumatoid arthritis.[9]

Histopathology

During the early phase of the disease, influx of inflammatory cells into the synovial membrane is obvious. As the disease progresses, there is a proliferation of monocytes and thickening of the synovial membrane with small villous projections into the joint space. Rheumatoid nodules initially have small vessel vasculitis phenomenon followed by a chronic inflammatory granulomatous phase.

History and Physical

Most common clinical presentation of RA is polyarthritis of small joints of hands: proximal interphalangeal (PIP), metacarpophalangeal (MCP) joints and wrist. Some patients may present with monoarticular joint involvement. Most commonly joint involvement occurs insidiously over a period of months, however, in some cases, joint involvement may occur over weeks or overnight. Other commonly affected joints include wrist, elbows, shoulders, hips, knees, ankles and metatarsophalangeal (MTP) joints. Stiffness in the joints in the morning may last up to several hours, usually greater than an hour. The patient may have a "trigger finger" due to flexor tenosynovitis.

On examination, there may be swelling, stiffness, deformity, and tenderness of the PIP, MCP wrist, knee joints, referred to as synovitis, and there may be a decreased range of motion.

Rheumatoid nodules may be present in 20% of patients with rheumatoid arthritis; these occur over extensor surfaces at elbows, heals, and toes.

Late in the course of the disease patient may present with "boutonniere (flexion at PIP and extension at DIP), swan neck (flexion at DIP and extension at PIP) deformities, subluxation of MCP joints and ulnar deviation.

Other features may include the presence of carpal tunnel syndrome, tenosynovitis and finger deformities.

Rheumatoid arthritis can affect almost every organ in the body.

Evaluation

Lab evaluation of patients with rheumatoid arthritis consists of obtaining rheumatoid factor (antibody against the Fc portion of IgG). About 45% to 75% of patients with rheumatoid arthritis test positive for rheumatoid factor. However, the presence of rheumatoid factor is not diagnostic of rheumatoid arthritis. It may be present in connective tissue disease, chronic infections, and healthy individuals, mostly in low titers. Anti-citrullinated protein antibodies (ACPA) are found in about 50% of patients with early arthritis, which subsequently are diagnosed with rheumatoid arthritis. Acute-phase reactants, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) may be elevated in the active phase of arthritis.

X-ray of both hands and feet are usually obtained for the presence of erosions, the pathognomonic feature of rheumatoid arthritis, however, plain radiograph does not show early changes of the disease. Magnetic resonance imaging (MRI) and ultrasound (USG) of joints detect erosions earlier than an x-ray. MRI and USG are more sensitive than clinical examination in identifying synovitis and joint effusion.[10][11][12]

Treatment / Management

A strategic approach is followed when managing rheumatoid arthritis, disease activity is assessed at regular intervals and treatment is changed as per the disease activity. Disease-modifying, anti-rheumatic drugs (DMARDs) are initiated as soon as the diagnosis of rheumatoid arthritis is made. Traditional or conventional DMARD include methotrexate, leflunomide, sulfasalazine, hydroxychloroquine. Biologic DMARDs include TNF (tumor necrosis factor): Adalimumab, Etanercept, Infliximab, Golilumab, Certolizumab. And non-TNF inhibitors: Tocilizumab (Interleukin-6 inhibitor), Abatacept (inhibits T-cell costimulation), Rituximab (anti-B cell).[13][14][15]

Disease activity is defined as low, moderate, or high. This is based on validated scales which are obtained from the tender joint count, swollen joint count, global patient assessment, physician global assessment, and/or maker of inflammation. These are:

  • Simplified disease activity (SDAI) index: tender joint count, swollen joint count, patient global assessment, physician global assessment and c reactive protein in mg/dl
  • Clinical disease activity index (CDAI): tender joint count, swollen joint count, patient global assessment, physician global assessment
  • DAS28-ESR (disease activity score): tender joint count, swollen joint count, patient global assessment, and erythrocyte sedimentation rate in mm
  • DAS-Crp (disease activity score): tender joint count, swollen joint count, patient global assessment, and c reactive protein in mg/dl.

According to the American College of Rheumatology, 2015 recommendations for the treatment of early (symptoms duration less than 6 months) RA include initiation of DMARD monotherapy (methotrexate is the preferred DMARD). It is recommended to use monotherapy over double or triple therapy. Along with methotrexate, glucocorticoids may be used as bridge therapy, usually for a period of three months when the DMARD becomes effective. If the disease activity remains moderate or high, despite the use of DMARD monotherapy, then to use a combination of DMARD which can be either traditional DMARD, TNF inhibitors or non-TNF inhibitors. For disease flares to use short-term glucocorticoids at the lowest dose for the shortest duration.

For the management of established rheumatoid arthritis (symptoms present for greater than six months), for a patient who has never taken a DMARD to use DMARD monotherapy (methotrexate is the preferred DMARD), to use monotherapy over double or triple therapy. If the disease activity remains moderate or high, despite the use of DMARD monotherapy, then to use a combination of DMARD: traditional DMARD, TNF inhibitors, or non-TNF inhibitors.

If the patient has used TNF inhibitor and the disease activity remains moderate or high despite the use of single TNF inhibitor then to use the non-TNF inhibitor biologic, this can be with or without methotrexate.  Similarly, if a patient has failed two or multiple TNF inhibitors, use the non-TNF inhibitor biologic, with or without methotrexate. If using a non-TNF inhibitor is not feasible then to use tofacitinib with or without methotrexate.

For patients with congestive heart failure, avoid TNF inhibitor and use non-TNF inhibitor biologic, as TNF inhibitors may worsen the symptoms of congestive heart failure.

For patients with active hepatitis B infection who are receiving concomitant antiviral therapy, immunosuppressive medications may be used safely. For hepatitis B patients with immunity from prior exposure (hepatitis core antibody positive, normal liver function tests, hepatitis B surface antibody positive and hepatitis B surface antigen negative), can be treated similarly to unexposed patients, on a condition that viral load is regularly monitored.

For patients with hepatitis C infection who are receiving antiviral therapy to be treated like RA patients without hepatitis C.

For a patient with melanomatous and non-melanomatous skin cancer, to use DMARD over biologics. For patients with previously treated lymphoproliferative disorder to use rituximab over TNF inhibitors or to use DMARD in combination with abatacept or tocilizumab over TNF inhibitors. For previously treated solid organ malignancy to treat these patients as those without these conditions. For previous serious infections to use a combination DMARD over TNF inhibitors or to use abatacept over TNF inhibitors.[16]

Differential Diagnosis

  • Lupus
  • Chronic Lyme disease
  • Osteoarthritis
  • Septic arthritis
  • Psoriatic arthritis
  • Sjogren syndrome
  • Sarcoidosis

Staging

Disease progression:

Stage 1: No destructive changes on x-rays

Stage 2: Presence of x-ray evidence of periarticular osteoporosis, subchondral bone destruction but no joint deformity

Stage 3: X-ray evidence of cartilage and bone destruction in addition to joint deformity and periarticular osteoporosis.

Stage 4: Presence of bony or fibrous ankylosis along with stage 3 features.

Prognosis

Rheumatoid arthritis has no cure and is a progressive disease. All individuals have multiple exacerbations and remissions. Close to 50% of patients with the disease become disabled within 10 years. Besides the joint disease, the individuals can suffer from many extra joint related problems which significantly alters the quality of life. However, the progression of disease does vary from individual to individual. In general, the following factors determine worse prognosis:

  • Elevated serum titer of autoantibodies
  • Presence of HLA-DRB1*04 genotype
  • Involvement of many joints
  • Extra-articular features
  • Female gender
  • Age of less than 30
  • Insidious onset
  • Presence of systemic symptoms

Rheumatoid arthritis is also associated with cardiovascular risk factors, infection, respiratory disease and development of malignancies. Patients with rheumatoid arthritis have 2-3 times higher risk of death compared to the general population.

Complications

  • Infections
  • Chronic anemia
  • Gastrointestinal cancers
  • Pleural effusions
  • Osteoporosis
  • Heart disease
  • Sicca syndrome
  • Felty syndrome
  • Lymphoma

Consultations

  • Rheumatologist
  • Orthopedic surgeon
  • Physical and occupational therapist
  • Cardiologist
  • Dentist
  • Dermatologist
  • Ophthalmologist

Enhancing Healthcare Team Outcomes

Rheumatoid arthritis is a chronic disorder that has no cure. All the currently available treatments are geared towards improving the symptoms and offering a better quality of life. Revealing the diagnosis of such a disabling disorder requires a team approach. In addition, one has to discuss the prognosis and types of treatment available. Patients need to be educated about the many misconceptions of the disease and be realistic.

Because the disorder affects many other organs, it is best managed with an interprofessional team. The key is patient education by nurses, pharmacists, and primary care providers. The nurse should inform the patient about the signs and symptoms of different organ systems and when to seek medical care. The patient should enroll in an exercise program to recover joint function. An occupational therapy consult can help the patient manage daily living activities. The pharmacist should educate the patient on types of drugs used to treat rheumatoid arthritis and their potential side effects.

At each clinic visit, clinicians and nurse should provide patient education and encourage the individual to stop smoking, maintain a healthy body weight, get the recommended vaccinations and eat a healthy diet.

The social worker should be involved in ensuring that the patient's home is liveable and the patient has ample support systems. The patient should be encouraged to join support groups.

Because the condition can lead to disability, chronic pain and a poor quality of life, many patients develop depression; hence a mental health nurse should see the patient regularly. Finally, the patient should not be offered false hopes but in fact, a supportive environment where the quality of life can be improved.[17][18][19] (Level V)

Outcomes

The outcome of most patients with Rheumatoid arthritis is guarded. The disorder has frequent relapses and remissions, and at least 40% of patients will become disabled within ten years. While some patients do have mild disease, others may have a fulminant disease that severely affects the quality of life. Worse outcomes are usually seen in patients with a high titer of autoantibodies, HLA-DRB1 genotypes, age younger than 30, multiple joint involvement, female gender, and extra-articular involvement. In addition, the drugs used to treat rheumatoid arthritis also have potent side effects which often are not well tolerated. As the disease progresses, many patients will develop adverse cardiac events leading to death. The overall mortality in patients with rheumatoid arthritis is three times higher than in the general population. Despite advances in care, mortality from infection, cancer, and ongoing vasculitis remains unchanged.[20][21] (Level V)


  • Image 5919 Not availableImage 5919 Not available
    Contributed by StatPearls
Attributed To: Contributed by StatPearls

Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Rheumatoid Arthritis - Questions

Take a quiz of the questions on this article.

Take Quiz
Which statement about rheumatoid arthritis is true?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
When does radiographically visible damage due to rheumatoid arthritis occur?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
In a patient diagnosed with rheumatoid arthritis, which of the following could be the first drug of choice in treatment that alters the course of the disease?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A female is found to have a deformed finger. The proximal interphalangeal (PIP) joint appears to be bent towards the palm whereas the distal interphalangeal (DIP) joint is bent away and appears hyperextended. Which condition is most likely?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A female reports symmetrical small joint polyarthritis for 2 weeks. Labs show rheumatoid factor levels at 1:320 (positive is 1:40) and anti-CCP at 58 units (40 to 59 units are considered strongly positive). An antinuclear antibody test is negative. Labs also reveal positive cytomegalovirus and parvovirus IgG, and negative parvovirus IgM. The erythrocyte sedimentation rate is 62 mm/hour. What is the appropriate next step in the management of this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 40-year-old female patient is diagnosed with rheumatoid arthritis with a large number of joints involved. She has rheumatoid nodules, pericardial rub, elevated erythrocyte sedimentation rate and C-reactive protein, positive rheumatoid factor, and anti-CCP antibody. The patient has minimal relief with naproxen 500 mg twice a day. What is the appropriate next step in her treatment?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 40-year-old patient is diagnosed with rheumatoid arthritis and started on prednisone 20 mg a day, hydroxychloroquine 200 mg twice a day, methotrexate 10 mg per week, calcium, vitamin D, and physical therapy. The patient follows up 1 month later. A complete blood count and chemistry panel are normal. Which of the following would be most appropriate for the management of this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient diagnosed with rheumatoid arthritis 3 months ago is being treated with methotrexate 15 mg per week, hydroxychloroquine 200 mg twice a day, and prednisone, which has been tapered from 20 mg a day to 5 mg a day. Despite some improvement, the patient still has morning stiffness, swelling, and tenderness of several metatarsophalangeal joints. She still cannot open a jar. Which of the following would be most appropriate for this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following statements about rheumatoid arthritis is true?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following statements about rheumatoid arthritis is true?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Ulnar deviation of the metacarpophalangeal (MCP) joint is MOST likely to be seen in patients with which condition?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is true regarding rheumatoid arthritis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 70-year-old female with a history of osteoarthritis, diabetes, congestive heart failure, and a significant smoking history presents with a deep, productive cough and fever. Auscultation reveals decreased breath sounds in the left chest. Thoracentesis reveals a fluid with a lactate dehydrogenase of 500 units/L, pH 7.45, and low glucose. She may have which of the following conditions?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient presents with morning stiffness lasting greater than 45 minutes and associated boggy, tender metacarpal joints in both hands. What is the likely diagnosis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
In a synovial fluid analysis, which of the following differentiates rheumatoid arthritis from osteoarthritis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is the initial step in the management of a patient with rheumatoid arthritis (RA)?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Patients with rheumatoid arthritis require a balance of activity and which of the following?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is the most important for preoperative evaluation for general anesthesia in a 70-year-old with rheumatoid arthritis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is most consistent with synovial fluid analysis in a patient with rheumatoid arthritis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is most consistent with the diagnosis of rheumatoid arthritis (RA) in a 44-year-old woman?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 28-year-old female presents with the pain of the hand joints for about four months. She has also noticed her joints are stiff in the morning and somedays the stiffness may last for a couple of hours. For the past two months has started to notice swelling of the hand joints. She denies pain and swelling of the elbows, ankles, or the knee joints — no shoulder pain and stiffness. On physical examination, she has tenderness of the 2, 4 metacarpophalangeal (MCP) joints of the right hand. The physician plans to do a lab test and get an X-ray of the hands, with rheumatoid arthritis (RA) being the top differential diagnosis. What is the classic finding for the RA on plain radiographs?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following should be the initial drug of choice for rheumatoid arthritis (RA) in the elderly?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
In a patient with rheumatoid arthritis, what is the most common organism that causes an infected joint?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Select the best intervention for a patient just diagnosed with rheumatoid arthritis that is having an acute flair.



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient with rheumatoid arthritis reports doing their home exercises despite increased pain. When demonstrating the exercises for the OT, the patient does ROM quickly. What should be done?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient with rheumatoid arthritis was treated with moist heat and active range of motion. She reports that for the following 30 minutes there was joint pain. What therapy should be done on the following day?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which part of the body is primarily affected in individuals with rheumatoid arthritis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Select the best treatment for a patient with an acute flare of rheumatoid arthritis (RA) to maintain joint mobility.



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient with rheumatoid arthritis (RA) has been on corticosteroids long-term and complains of progressive fatigue and pain, especially when climbing steps or combing her hair. What is the most likely etiology?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is true regarding rheumatoid arthritis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A female patient with rheumatoid arthritis (RA) complains that sexual relations with her boyfriend have become painful due to joint pain. Which of the following would be the best advice?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 47-year-old female has swelling of both knees, morning stiffness lasting more than an hour, and pain with walking. Further history reveals bilateral hand and wrist pain. What kind of arthritis is most likely?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient with an acute flare-up of rheumatoid arthritis (RA) is referred to physical therapy for knee pain and stiffness. Which intervention would be contraindicated?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Select the correct statement about differentiating rheumatoid arthritis (RA) and osteoarthritis (OA).



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Select the true statement about rheumatoid arthritis.



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is the most likely presentation of new-onset rheumatoid arthritis (RA)?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following may be affected by rheumatoid arthritis (RA) potentially causing serious morbidity?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the best indicator of disease activity in rheumatoid arthritis (RA)?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following statements is true concerning nonsteroidal anti-inflammatory drug (NSAID) treatment for rheumatoid arthritis (RA)?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 58-year-old female with no prior history presents with a complaint of bilateral hand pain for several weeks that is worse in the morning and improves with activity. She has warmth and mild tenderness of both hand proximal interphalangeal joints. The remainder of her exam is normal. What is the most likely diagnosis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following joints is most commonly affected in rheumatoid arthritis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the next treatment for patients with rheumatoid arthritis (RA) who have been started on nonsteroidal anti-inflammatory drugs (NSAIDs) treatment?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
The American College of Rheumatology has recommended the use of which auto-antibody to make a diagnosis of rheumatoid arthritis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient has new-onset rheumatoid arthritis. For follow up, how often should plain x-rays of the extremities be obtained?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
You have a patient with rheumatoid arthritis whom you have been following for the past 2 years. You note that she has steadily been gaining weight and her latest BMI is 29kg/m2. How much does this elevated BMI increase her risk of cardiovascular mortality?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A female has just been diagnosed with early rheumatoid arthritis which is not acutely active. According to the American College of Rheumatology, which is true of treatments of patients with low disease activity?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient you had referred to a rheumatologist returns back for a follow-up visit. The rheumatologist wrote that she has "early rheumatoid arthritis." What does this mean according to the American College of Rheumatology?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A middle-aged female was diagnosed with rheumatoid arthritis 2 years ago. She has been closely followed up and found to have low-level disease activity. At present, she has been managed on NSAIDs and has never been received disease-modifying antirheumatic drugs (DMARDs). In such patients with established disease, the American College of Rheumatology recommends what type of treatment?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient has severe rheumatoid arthritis. Which of the following should be included in the treatment plan? Select all that apply.

(Move Mouse on Image to Enlarge)
  • Image 5919 Not availableImage 5919 Not available
    Contributed by StatPearls
Attributed To: Contributed by StatPearls



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
You are responsible for the care of a patient with rheumatoid arthritis. Which of the following would you expect? Select all that apply.



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A female client has just been admitted to the medical-surgical unit with a diagnosis of rheumatoid arthritis. Which of the following is true about this disorder? Select all that apply.



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A female patient with no significant past medical history is diagnosed with rheumatoid arthritis, and the physician decides to start her on drug therapy. Which of the following medications would be used initially? Select all that apply.



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is true of rheumatoid arthritis? Select all that apply.



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is a predisposing factor for the development of rheumatoid arthritis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which part of the body is primarily affected in individuals with rheumatoid arthritis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Rheumatoid Arthritis - References

References

Carbone F,Bonaventura A,Liberale L,Paolino S,Torre F,Dallegri F,Montecucco F,Cutolo M, Atherosclerosis in Rheumatoid Arthritis: Promoters and Opponents. Clinical reviews in allergy     [PubMed]
Cai Q,Xin Z,Zuo L,Li F,Liu B, Alzheimer's Disease and Rheumatoid Arthritis: A Mendelian Randomization Study. Frontiers in neuroscience. 2018     [PubMed]
Voigt A,Seipelt E,Bastian H,Juche A,Krause A, [Improved early diagnostics of rheumatic diseases : Monocentric experiences with an open rheumatological specialist consultation]. Zeitschrift fur Rheumatologie. 2018 Sep 25     [PubMed]
Kłodziński Ł,Wisłowska M, Comorbidities in rheumatic arthritis. Reumatologia. 2018     [PubMed]
du Teil Espina M,Gabarrini G,Harmsen HJM,Westra J,van Winkelhoff AJ,van Dijl JM, Talk to your gut: the oral-gut microbiome axis and its immunomodulatory role in the etiology of rheumatoid arthritis. FEMS microbiology reviews. 2018 Sep 14     [PubMed]
Wu H,Liao W,Li Q,Long H,Yin H,Zhao M,Chan V,Lau CS,Lu Q, Pathogenic role of tissue-resident memory T cells in autoimmune diseases. Autoimmunity reviews. 2018 Sep     [PubMed]
Bao YK,Weide LG,Ganesan VC,Jakhar I,McGill JB,Sahil S,Cheng AL,Gaddis M,Drees BM, High Prevalence of Comorbid Autoimmune Diseases in Adults with Type 1 Diabetes from the HealthFacts Database. Journal of diabetes. 2018 Sep 18     [PubMed]
Tuncer T,Gilgil E,Kaçar C,Kurtaiş Y,Kutlay Ş,Bütün B,Yalçin P,Akarirmak Ü,Altan L,Ardiç F,Ardiçoğlu Ö,Altay Z,Cantürk F,Cerrahoğlu L,Çevik R,Demir H,Durmaz B,Dursun N,Duruöz T,Erdoğan C,Evcik D,Gürsoy S,Hizmetli S,Kaptanoğlu E,Kayhan Ö,Kirnap M,Kokino S,Kozanoğlu E,Kuran B,Nas K,Öncel S,Sindel D,Orkun S,Sarpel T,Savaş S,Şendur ÖF,Şenel K,Uğurlu H,Uzunca K,Tekeoğlu İ,Guillemin F, Prevalence of Rheumatoid Arthritis and Spondyloarthritis in Turkey: A Nationwide Study. Archives of rheumatology. 2018 Jun     [PubMed]
López-Mejías R,David Carmona F,Genre F,Remuzgo-Martínez S,González-Juanatey C,Corrales A,Vicente EF,Pulito-Cueto V,Miranda-Filloy JA,Ramírez Huaranga MA,Blanco R,Robustillo-Villarino M,Rodríguez-Carrio J,Alperi-López M,Alegre-Sancho JJ,Mijares V,Lera-Gómez L,Pérez-Pampín E,González A,Ortega-Castro R,López-Pedrera C,García Vivar ML,Gómez-Arango C,Raya E,Narvaez J,Balsa A,López-Longo FJ,Carreira P,González-Álvaro I,Rodríguez-Rodríguez L,Fernández-Gutiérrez B,Ferraz-Amaro I,Gualillo O,Castañeda S,Martín J,Llorca J,González-Gay MA, A genome-wide association study identifies a 3'UTR genetic variant of RARB associated with carotid intima-media thickness in rheumatoid arthritis. Arthritis     [PubMed]
Baffour FI,McKenzie GA,Bekele DI,Glazebrook KN, Sonography of active rheumatoid arthritis during pregnancy: a case report and literature review. Radiology case reports. 2018 Dec     [PubMed]
Mochizuki T,Ikari K,Yano K,Okazaki K, Evaluation of factors associated with locomotive syndrome in Japanese elderly and younger patients with rheumatoid arthritis. Modern rheumatology. 2018 Sep 2     [PubMed]
Bremander A,Forslind K,Eberhardt K,Andersson MLE, The importance of measuring hand and foot function over the disease course in rheumatoid arthritis: An eight-year follow-up study. Arthritis care     [PubMed]
Holroyd CR,Seth R,Bukhari M,Malaviya A,Holmes C,Curtis E,Chan C,Yusuf MA,Litwic A,Smolen S,Topliffe J,Bennett S,Humphreys J,Green M,Ledingham J, The British Society for Rheumatology biologic DMARD safety guidelines in inflammatory arthritis. Rheumatology (Oxford, England). 2018 Sep 18     [PubMed]
Zerbini CAF,Abud-Mendoza C,Mendez-Patarroyo P,De Angelo Andrade M,Pedersen R,Vlahos B,Borlenghi CE, Maintenance of low disease activity and remission with etanercept-disease-modifying antirheumatic drug (DMARD) combination therapy compared with treatment with DMARDs alone in Latin American patients with active rheumatoid arthritis: Subset analysis of a randomized trial. Medicine. 2018 Sep     [PubMed]
Holroyd CR,Seth R,Bukhari M,Malaviya A,Holmes C,Curtis E,Chan C,Yusuf MA,Litwic A,Smolen S,Topliffe J,Bennett S,Humphreys J,Green M,Ledingham J, The British Society for Rheumatology biologic DMARD safety guidelines in inflammatory arthritis-Executive summary. Rheumatology (Oxford, England). 2018 Aug 21     [PubMed]
Fiehn C,Holle J,Iking-Konert C,Leipe J,Weseloh C,Frerix M,Alten R,Behrens F,Baerwald C,Braun J,Burkhardt H,Burmester G,Detert J,Gaubitz M,Gause A,Gromnica-Ihle E,Kellner H,Krause A,Kuipers J,Lorenz HM,Müller-Ladner U,Nothacker M,Nüsslein H,Rubbert-Roth A,Schneider M,Schulze-Koops H,Seitz S,Sitter H,Specker C,Tony HP,Wassenberg S,Wollenhaupt J,Krüger K, [S2e guideline: treatment of rheumatoid arthritis with disease-modifying drugs]. Zeitschrift fur Rheumatologie. 2018 Aug     [PubMed]
McCulley C,Katz P,Trupin L,Yelin EH,Barton JL, Association of Medication Beliefs, Self-efficacy, and Adherence in a Diverse Cohort of Adults with Rheumatoid Arthritis. The Journal of rheumatology. 2018 Sep 15     [PubMed]
Betancourt BY,Biehl A,Katz JD,Subedi A, Pharmacotherapy Pearls in Rheumatology for the Care of Older Adult Patients: Focus on Oral Disease-Modifying Antirheumatic Drugs and the Newest Small Molecule Inhibitors. Rheumatic diseases clinics of North America. 2018 Aug     [PubMed]
Geenen R,Overman CL,Christensen R,Åsenlöf P,Capela S,Huisinga KL,Husebø MEP,Köke AJA,Paskins Z,Pitsillidou IA,Savel C,Austin J,Hassett AL,Severijns G,Stoffer-Marx M,Vlaeyen JWS,Fernández-de-Las-Peñas C,Ryan SJ,Bergman S, EULAR recommendations for the health professional's approach to pain management in inflammatory arthritis and osteoarthritis. Annals of the rheumatic diseases. 2018 Jun     [PubMed]
Muñoz-Fernández S,Otón-Sánchez T,Carmona L,Calvo-Alén J,Escudero A,Narváez J,Rodríguez Heredia JM,Romero Yuste S,Vela P,Luján Valdés S,Royo García A,Baquero JL, Use of prognostic factors of rheumatoid arthritis in clinical practice and perception of their predictive capacity before and after exposure to evidence. Rheumatology international. 2018 Sep 24     [PubMed]
Solomon DH,Yu Z,Katz JN,Bitton A,Corrigan C,Fraenkel L,Harrold LR,Smolen JS,Losina E,Lu B, Adverse Events and Resource Use Before and After Treat to Target in Rheumatoid Arthritis:A Post-Hoc Analysis of a Randomized Controlled Trial. Arthritis care     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Surgery-Urologic. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Surgery-Urologic, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Surgery-Urologic, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Surgery-Urologic. When it is time for the Surgery-Urologic board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Surgery-Urologic.