Evaluation and medical management of end-stage rheumatoid arthritis
- Simon M Helfgott, MD
Simon M Helfgott, MD
- Associate Professor of Medicine
- Harvard Medical School
- Section Editor
- Ravinder N Maini, BA, MB BChir, FRCP, FMedSci, FRS
Ravinder N Maini, BA, MB BChir, FRCP, FMedSci, FRS
- Section Editor — Rheumatoid Arthritis
- Emeritus Professor of Rheumatology, Imperial College London
- Visiting Professor, Oxford University
End-stage rheumatoid arthritis (RA) is an advanced stage of disease in which there is severe joint damage and destruction in the absence of ongoing inflammation. Despite the availability of methotrexate and other nonbiologic disease-modifying antirheumatic drugs (DMARDs), as well as biologic DMARDs and kinase inhibitors, some patients with RA do not adequately respond to therapy [1,2]. The joints of such patients may eventually be destroyed by a variety of mechanisms, resulting in end-stage RA and often requiring joint arthroplasty to improve or restore function.
The evaluation and management of patients with apparent end-stage disease requires:
●Assessment of whether residual disease activity is present that may respond to adjustment of the drug therapies
●Identification of factors other than articular inflammation that may be contributing to the clinical state and may require interventions distinct from antirheumatic drug therapy
●Recognition and referral of patients who may benefit from rehabilitative or orthopaedic interventions
- Minichiello E, Semerano L, Boissier MC. Time trends in the incidence, prevalence, and severity of rheumatoid arthritis: A systematic literature review. Joint Bone Spine 2016; 83:625.
- O'Dell JR, Mikuls TR, Taylor TH, et al. Therapies for active rheumatoid arthritis after methotrexate failure. N Engl J Med 2013; 369:307.
- Kay J, Morgacheva O, Messing SP, et al. Clinical disease activity and acute phase reactant levels are discordant among patients with active rheumatoid arthritis: acute phase reactant levels contribute separately to predicting outcome at one year. Arthritis Res Ther 2014; 16:R40.
- THOMPSON M, BYWATERS EG. Unilateral rheumatoid arthritis following hemiplegia. Ann Rheum Dis 1962; 21:370.
- Nakano KK, Schoene WC, Baker RA, Dawson DM. The cervical myelopathy associated with rheumatoid arthritis: analysis of patients, with 2 postmortem cases. Ann Neurol 1978; 3:144.
- ETIOLOGIC FACTORS
- CLINICAL MANIFESTATIONS
- Physical findings
- Laboratory findings
- Imaging abnormalities
- EVALUATION OF PATIENTS WITH END-STAGE DISEASE
- History and physical examination
- Laboratory, imaging, and other studies
- Disease activity present or suspected
- - Patients currently receiving anti-rheumatic drug therapy
- - Patients NOT currently receiving anti-rheumatic drug therapy
- Disease activity absent
- - Chronic pain management
- - Surgical management
- Rehabilitation therapies
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS