6. The Synovial Membrane Normal synovial membrane, photomicrograph Used with permission from the American College of Rheumatology.
7. Pathophysiology of Rheumatoid Arthritis Synovitis, villous, gross (left) and photomicrograph (right) Used with permission from the American College of Rheumatology.
8. Pathophysiology of Rheumatoid Arthritis: Late Destruction Finger joint, bony ankylosis, photomicrograph Used with permission from the American College of Rheumatology.
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12. Parameter Timing Rheumatoid factor Baseline to establish diagnosis Repeat 6-12 months following disease onset if negative Complete blood count (CBC) Baseline to assess organ dysfunction due to co-morbidities Serum chemistries Baseline Liver function tests Baseline Urinalysis Baseline Synovial fluid analysis Baseline to rule out other diseases During disease flares to rule out septic arthritis Diagnosis of Rheumatoid Arthritis: Laboratory Evaluations
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24. The New Treatment Paradigm Orthopedic surgery Higher dose steroids for flares or extraarticular disease Occupational therapy Physical therapy Patient education Intraarticular steroids Simple analgesic Weaver AL, 1998.
25. Treatment of Rheumatoid Arthritis: DMARDs *Physicians’ Desk Reference, 1998. Recommended doses are not necessarily those utilized in clinical practice. Agent Azathioprine Cyclosporin Gold, oral Gold, parenteral Hydroxychloroquine Leflunomide Methotrexate D -Penicillamine Sulfasalazine Recommended Dose * 1.0-2.5 mg/kg/d 2.5-4.0 mg/kg/d 6-9 mg/d 25-50 mg every 2-4 weeks following initial weekly titration doses 200-400 mg/d 100 mg x 3 days loading; 20 mg/q.d. 7.5-20 mg/wk 125-750 mg/d 0.5-3.0 g/d
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27. Selection of an Initial DMARD Toxicities to monitor Myelosuppression, hepatotoxicity, lymphoproliferative Renal, hyperuricemia Myelosuppression, rash, proteinuria, gastrointestinal Myelosuppression, rash proteinuria Macular damage Hepatotoxicity, gastrointestinal Hepatotoxicity, pulmonary, myelosuppression Myelosuppression, proteinuria Myelosuppression, gastrointestinal Potential toxicity Moderate High Low Moderate Low Low Moderate High Low Time to benefit 2-3 months 4-8 weeks 4-6 months 3-6 months 2-4 months 4-8 weeks 1-3 months 3-6 months 1-3 months Agent Azathioprine Cyclosporin Gold, oral Gold, parenteral Hydroxychloroquine Leflunomide Methotrexate D -Penicillamine Sulfasalazine
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33. Leflunomide/A77 1726 O N NH C H 3 C F 3 C O Leflunomide O CH 3 N NH C F 3 C C C OH A77 1726 Active Metabolite