Rheumatoid arthritis is an inflammatory autoimmune disease, which may result in severe disabilities and deformities if not diagnosed early and managed with adequate dose of DMARDs. The early diagnosis is often impaired by initial atypical presentations and its close mimic to other autoimmune rheumatic diseases. From the point of diagnosis to treatment of the disease, the practicing rheumatologist confronts various challenges. With an intention to address such challenges and to develop a quick reference guide for all clinicians, author started publishing the question and answer series on rheumatoid arthritis since 2012. The answers provided are substantiated by well-accepted guidelines, literature evidence and clinical experience. These answers can assist decision making in diverse clinical circumstances. Author has made a sincere attempt to make the complied volume more scenario-oriented.

Volume -5 focuses on two drugs ‘Sulfasalazine’ and ‘Hydroxychloroquine’. They have been in clinical use for over 50 years and they were the recommended first choice for managing rheumatoid arthritis prior to the introduction of methotrexate aggressive therapy and pyramidal approach in DMARD prescription. The lack of further studies and probable bias in the clinical trials toward biologics have made these drugs less preferred in routine clinical practice. The present volume provides the most up-to-date information regarding the current status, safety and efficacy, adverse events, and the precautionary measures to be adopted while prescribing these drugs

Treating an individual patient in majority of circumstances can be guided by protocols, criteria and available evidence-based information. Whenever adequate or suitable literatures are not available, some of the questions are answered based on experience, as well as after discussion with experts. In some circumstances, the answer may not be completely relevant to the clinical scenario of that region and the practice. The current volume is first of the series and has dealt with investigation and evaluation of patients suspected to have RA.

First Prize, Orthopaedics and Rheumatology, BMA Awards 2009 This state-of-the-art reference provides current insights into the etiology, diagnosis and management of rheumatoid arthritis. Leading international authorities in RA examine all of the latest scientific and clinical developments in understanding and managing this challenging disease, including new concepts in pathogenesis, epidemiology, risk factors, imaging, clinical outcomes and treatment. It’s the guidance you need to offer optimal care to your patients with rheumatoid arthritis. Presents the work of leading international experts in rheumatoid arthritis for guidance you can trust. Provides the very latest understanding of the pathogenesis of rheumatoid arthritis, including molecular pathways/mechanisms, and genetic and environmental factors that instigate and drive the disease. Includes comprehensive coverage of clinical features of rheumatoid arthritis including articular, peri-articular and extra-articular manifestations, comorbidities, and outcome measures—disease activity, joint assessment, imaging, and more—for expert diagnosis and monitoring of disease progression. Examines evidence-based treatment options—including traditional and biologic DMARDs and combination therapies—as well as promising therapies on the horizon, placing up-to-date guidance on disease modifying or disease controlling agents at your fingertips.

The seventh volume of the book series focuses on the use of tofacitinib for managing rheumatoid arthritis (RA). The book may serve as a clinical guide to assist healthcare professionals for using the drug safely and effectively, thereby to improve the prescription practice. In the past one decade, tofacitinib has emerged as a potent target synthetic (ts) DMARD for managing RA. The availability of the generic form in global markets has improved its accessibility and clinical use. The drug though very effective in the management of RA, has narrow therapeutic to toxicity ratio. The drug needs to be prescribed with caution. There are set guidelines and pre-introduction evaluation of the drug for safety and probable adverse events. The guidelines and recommendations provided in this book may help to clarify the uncertainties related to tofacitinib prescription. To improve the patient’s compliance, it is critical that the physician provides all the necessary information to the patient. Additionally, the clinician should have thorough knowledge on managing special circumstances, including drug-related complications. The content includes a brief introduction of the drug, followed by questions and answers explaining different clinical scenarios. The author has attempted to address almost all plausible clinical scenarios involved in the RA management using tofacitinib.

The third volume of the book series has focused on the use of methotrexate (MTX) for managing rheumatoid arthritis (RA). The book is written with an intention to develop a clinical guide to assist healthcare professionals for using the drug safely and effectively, thereby to improve the prescription practice. In the past two decades, MTX has emerged as the gold standard DAMRD treatment for managing RA. The prescription of MTX has also changed significantly based on the accumulated experience from clinical practice. However, the assessment of the prescription patterns indicates the lack of evidence-based guidelines for prescribing the drug. The guidelines and recommendations provided in this book may help to clarify the uncertainties related to MTX prescription. To improve the patients’ compliance, it is critical that the physician should provide necessary information about the drug to the patient. Additionally, the clinician should have thorough knowledge on managing special circumstances, including the development of drug-related complications. The content includes a brief introduction of the drug, followed by questions and answers explaining different clinical scenarios. The author has attempted to address almost all plausible clinical scenarios involved in the RA management using MTX.

Millions of people are suffering from rheumatoid arthritis (RA) and are looking for pain relief and treatments. Rheumatoid arthritis is a painful and distressing condition that blights the lives of sufferers. The aim of this book is to explain the many different treatments and remedies that are available to sufferers. Arthritis in general and Rheumatoid Arthritis (RA) in particular have stopped making headlines in the newspapers or medical journals for almost two decades now. This doesn't mean that the disease has stopped confronting people or there is somewhat less number of people being affected from it. The truth is people have accepted it as a harsh reality of life and now they are trying to deal with it. This book is aimed for people who want to make necessary adjustments in their life that can enable them to live a full life despite having RA. By learning more about rheumatoid arthritis, it's causes and the steps that can be taken to better manage the condition, the reader can learn about the various methods that are available to treat and manage rheumatoid arthritis more effectively. This is another very informative book by Robert Rymore. He continues with his interest in writing medical educational guides. This guide is intended to be a tool, one that will give you a lot of helpful information and hopefully some pain relief.

This book is for postgraduate fellows, internists, and students interested in rheu- tology. It contains real cases and is designed to stimulate thought and further reading in this rapidly evolving specialty. I have included a series of common and uncommon cases that I have seen over the past decade in a busy consultative practice and have inserted up-to-date ref- ences and questions you may be asked on ward rounds or in clinic. My hope is that it will be a useful adjunct for physicians preparing for examinations or entering the field and will stimulate further interest. I would like to acknowledge my mentors Pierre Bouloux, MD, Tom Cooney, MD and thank Atul Deodhar, MD for his careful review of the manuscript. This book is dedicated to my parents and wife Batool who have made many sacrifices for which I remain eternally grateful. Brooklyn, NY Yousaf Ali v Contents Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Self Assessment Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 vii Question 1 A 56-year-old female presents with arthralgias and fatigue. Lab work is unrema- able apart from normocytic anemia and Howell Jolly bodies on peripheral smear. Her examination reveals a blistering rash on the elbows.

This book covers all fields in rheumatology and aims to help readers comprehend, familiarize and evaluate their knowledge of the subject area. It contains short questions and concise answers on definitions, pathogenetic aspects, clinical and laboratory manifestations, differential diagnosis and the management of all rheumatic diseases. The book also provides questions and answers on major aspects of basic immunology, valuable for understanding underlying immunological mechanisms of autoimmune rheumatic diseases. Illustrations and images help present information in a clear and schematic way.