Rheumatoid Arthritis

Question 1

Etiology of RA

Answer 1

onset 25-55 years old
women > men
exact cause is unknown (shocker…) but triggered by environmental factors with a genetic predisposition

Question 2

What are synovial joints?

Answer 2

occur where bones articulate and are physically the most moveable joints within the human body

Question 3

What are the 6 types of synovial joints?

Answer 3

gliding, saddle, pivot, hinge, ball and socket, and condyloid joints

Question 4

The greater the movement allowed by the joint, the greater the ____

Answer 4

risk for developing an injury

Question 5

Signs and symptoms of RA include

Answer 5

tender, warm, swollen joints
morning stiffness that can last hours
firm bumps of tissue under the skin on arms
fatigue, fever, weight loss

Question 6

Differences between osteoarthritis (OA) and rheumatoid arthritis (RA)

Answer 6

OA - degenerative, morning stiffness <30 mins, cartilage loss, asymmetrical
RA - autoimmune disease, morning stiffness >30mins, inflamed synovium, symmetrical

Question 7

Early RA vs Progressed RA

Answer 7

early - affect smaller joints first (fingers and toes)

progressed - spread to wrists, knees, ankles, elbows, hips, and shoulders

Question 8

What is responsible for most of the symptoms and chronic disability associated with RA?

Answer 8

inflammation and destruction of synovial tissues

Question 9

What is ‘overproduced’ in RA? (3 things)

Answer 9

proinflammatory cytokines, tumor necrosis factor (TNF), interactions between T and B lymphocytes

Question 10

C1-C2 instability results from

Answer 10

erosion and collapse of bones from destruction of supporting cervical ligaments

Question 11

Atlanto-odontoid articulation separation may allow

Answer 11

the odontoid process of the axis to impinge on the spinal cord = neurologic damage

Question 12

C1 is referred to as the ___ while C2 is referred to as the ___

Answer 12

atlas; axis

Question 13

What is a diarthordial joint? Include an example

Answer 13

Surrounded by fibrous joint capsule and has synovial fluid lubricating the surfaces of the bones
example: cricoarytenoid joint

Question 14

How does RA affect the cricoarytenoid joint?

Answer 14

causes inflammation of the synovial lining which spreads to the surface of the bones = fibrosis = rigidity and adhesion (ankylosis) = reduced mobility and function

Question 15

Consequence(s) of cricoarytenoid joint involvement in RA

Answer 15

1. less able to move the vocal cords
2. less able to assist in breathing
3. fixed in a position that obstructs airflow

Question 16

Possible signs and symptoms indicative of cricoarytenoid joint involvement in RA

Answer 16

hoarseness, pain with swallowing, stridor, dyspnea

Question 17

Pulmonary effects with RA (3 P’s)

Answer 17

pleural effusion
pneumonitis
pulmonary nodules

Question 18

Cardiac effects with RA

Answer 18

pericarditis
pericardial effusion
mitral/aortic regurgitation
conduction defects

Question 19

Eye effects with RA

Answer 19

destruction of lacrimal and salivary duct (dry eyes)

Question 20

Muscle effects with RA

Answer 20

rheumatoid myositis (seen as muscle weakness and eventual muscle necrosis)

Question 21

Mild to moderate RA treatment

Answer 21

rest, joint immobilization, NSAIDs, possibly glucocorticoids

Question 22

Disease Modifying AntiRheumatic Drugs (DMARDs)

Answer 22

work to reduce the body’s overactive immune and inflammatory processes (joint pain and swelling)

Question 23

Which drug is the ‘cornerstone’ of RA therapy?

Answer 23

Methotrexate

Question 24

How does Methotrexate work?

Answer 24

interferes with cancer cells’ ability to absorb and use folate (vitamin B) which is necessary for cell survival

Question 25

Common side effects of Methotrexate

Answer 25

GI upset (can be combated with folic acid supplements), hepatotoxicity and pneumonitis (monitor liver enzymes and blood counts q3months)

Question 26

What are biologic DMARDs?

Answer 26

proteins manufactured using recombinant DNA technology
immunosuppressants that target and block the action of cells or chemicals that enable the immune system to cause inflammation and other symptoms

Question 27

Examples of biologic DMARDs

Answer 27

TNF inhibitors - Etanercept (Enbrel), Adalimumab (Humira), Infliximab (Remicade)
IL-1 receptor agonists - Leflunomide (Arava)
Anti-CD20 monoclonal antibody - Rituximab (Rituxan)

Question 28

Examples of non-biologic DMARDs

Answer 28

Anti-metabolite - Methotrexate (Rheumatrex), Sulfasalazine, Azathioprine

Question 29

What labs/tests would you maybe want to look at prior to surgery for someone with RA?

Answer 29

renal and liver function, blood counts, cervical x-ray potentially

Question 30

What supplementation would you consider giving for RA patients perioperatively?

Answer 30

corticosteroids d/t potential HPA suppression

supplementation will depend on daily dose and surgery type

Question 31

What about the airway would you want to assess preoperatively?

Answer 31

TMJ involvement (can limit mouth opening), 
Neck pain or limited cervical range of motion (hold c-spine with intubation), 
Presence of hoarseness (indicates cricoarytenoid involvement)

Question 32

What equipment would be a good idea to use for intubating a RA patient?

Answer 32

McGrath or video laryngoscope (avoid neck manipulation)
Smaller ETT (if concerned for narrowed glottic opening)

Question 33

What considerations do you need to know concerning spinal anesthesia for RA patients?

Answer 33

the spread of sensory spinal anesthesia is higher in RA patients d/t the potential for narrowing of the subarachnoid space and decrease in CSF… so may want to decrease the dose but keep in mind you may have an incomplete/insufficient block