Rheumatoid Arthritis

Question 1

What is the underlying pathology in the joints of

patients with rheumatoid arthritis?

Answer 1

Cellular hyperplasia occurs in the synovium with progressive
infiltration by lymphocytes, plasma cells, and fibroblasts. The
articular cartilage is eventually completely destroyed.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 633.

Question 2

What symptoms characterize rheumatoid arthritis?

Answer 2

Rheumatoid arthritis is characterized by symmetric
polyarthropathy that affects weight-bearing joints and proximal
interphalangeal and metacarpophalangeal joints. It is typically
worse in the morning. In the most severe forms, every joint can
be affected except for the lumbar and thoracic spine.
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 454.

Question 3

What are the treatment options for rheumatoid

arthritis?

Answer 3

Medical therapy is directed toward palliative treatment.
Corticosteroids suppress many of the inflammatory symptoms
of RA. Anticytokine agents such as etanercept, adlimumab,
and infliximab interfere with the cytokine known as tumor
necrosis factor and help slow the progression of the disease.
Methotrexate is effective in reducing symptoms, as are
immunosuppressive drugs such as cyclophosphamide and
cyclosporine.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 836.

Question 4

What are the major anesthetic considerations for the

patient with rheumatoid arthritis?

Answer 4

Because of the arthritic changes involving the laryngeal,
temporomandibular, and cervical joints, a careful airway
evaluation is crucial. The chronic use of NSAIDs may inhibit
platelet function and lead to liver and/or kidney dysfunction
which may alter the pharmacologic plan. The use of
cyclophosphamide can inhibit plasma cholinesterase and
prolong the duration of action of succinylcholine. The use of
long-term corticosteroid therapy will warrant extra steroid
coverage.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 836-837.

Question 5

What is the most common hematologic abnormality

accompanying rheumatoid arthritis?

Answer 5

Anemia
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 455.

Question 6

What is the most common pulmonary complication of

rheumatoid arthritis?

Answer 6

Pleural effusion
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 455.

Question 7

What cardiac complications may be present in the

patient with rheumatoid arthritis?

Answer 7

Approximately 1/3 of patients with rheumatoid arthritis exhibit
pericardial thickening with effusion. Pericarditis, myocarditis,
and coronary artery arteritis may be present. Aortitis may
produce dilation of the aortic root and subsequent aortic
regurgitation. The cardiac conduction system can be disrupted
by the presence of rheumatoid nodules.
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 454-455.

Question 8

What are the airway management concerns in the

patient with rheumatoid arthritis?

Answer 8

The disease often affects the temporomandibular joint and
restricts mouth opening. It can also affect the joints of the
larynx and cause generalized edema and laryngeal swelling.
Cervical spine instability may be present and atlantoaxial
subluxation can push the odontoid process into the foramen
magnum during laryngoscopy.
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s
Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill;
2013: 795.