Rheumatoid arthritis - NYSORA | NYSORA

Rheumatoid arthritis

Learning objectives

  • Describe rheumatoid arthritis
  • Recognize the symptoms and signs of rheumatoid arthritis
  • Anesthetic management of a patient with rheumatoid arthritis

Definition and mechanisms

  • Rheumatoid arthritis (RA) is a chronic autoimmune inflammatory disorder that mainly affects the synovial joints → symmetrical erosive polyarthropathy
  • Early RA affects the smaller joints first (hands and feet)
  • As RA progresses, symptoms spread to the wrists, knees, ankles, elbows, hips, and shoulders
  • Periods of increased disease activity (flares) alternate with periods of relative remission
  • RA also affects other organs in more than 15-25% of the cases → systemic

Signs and symptoms

  • Tender, warm, swollen joints
  • Joint stiffness that is usually worse in the mornings and after inactivity
  • Fatigue, fever, loss of appetite
  • The painful swelling can eventually result in bone erosion and joint deformity

Risk factors

  • Female gender
  • Family history
  • Increasing age
  • Smoking
  • Overweight


  • Osteoporosis
  • Rheumatoid nodules
  • Dry eyes and mouth (Sjogren’s syndrome)
  • Infections
  • Abnormal body composition
  • Carpal tunnel syndrome
  • Cardiovascular disease
  • Lung disease
  • Lymphoma

Extra-articular manifestations

  • Neurological: Central neuropathy, peripheral neuropathy (carpal tunnel syndrome), autonomic neuropathy
  • Ocular: Kerato-conjuctivitis
  • Cardiovascular: Pericarditis, pericardial effusion, cardiac tamponade, valvular heart disease (usually regurgitation), conduction abnormalities, granulomatous disease, endocarditis or myocarditis, coronary artery disease
  • Respiratory: Reduced chest wall compliance (costochondral disease), pleural effusion, restrictive lung disease, pulmonary nodule
  • Hematological: Anemia [chronic disease, iron deficiency (bleeding) and bone marrow suppression from medication], thrombocytopenia, Felty’s syndrome, lymphoma
  • Hepatic: Hepatic fibrosis, hepatomegaly with splenomegaly, hypoalbuminemia
  • Renal: Glomerulonephritis, tubulointerstitial nephritis, amyloidosis
  • Skin: Fragile skin, pyoderma gangrenosum, Sicca syndrome, scleritis, scleromalacia perforans
  • Musculoskeletal: Osteoporosis


  • Medications: Relieve pain, reduce inflammation, slow down the progression of RA
    • Non-steroidal anti-inflammatory drugs (NSAIDs): Ibuprofen and naproxen
    • Corticosteroids: Prednisone
    • Conventional disease-modifying anti-rheumatic drugs (DMARDs): Methotrexate, leflunomide, hydroxychloroquine, and sulfasalazine
    • Biological DMARDs: Abatacept, adalimumab, anakinra, certolizumab, etanercept, golimumab, infliximab, rituximab, sarilumab, and tocilizumab
    • Targeted synthetic DMARDs: Baricitinib, tofacitinib, and upadacitinib
  • Physical therapy: To reduce pain and stiffness
  • Surgery: Repair damaged joints to restore function and reduce pain
    • Synovectomy
    • Tendon repair
    • Joint fusion
    • Total joint replacement


rheumatoid arthritis, preoperative, intraoperative, postoperative, management, obstetric anesthesia, systemic disease, thromboprophylaxis, difficult airway, atlantoaxial instability, cricoarytenoid arthritis, antibiotics, breathing exercises, infection, pain

Recommendations on how to deal with RA medications during elective surgical procedures

MedicationAdministration during surgical procedure
CorticosteroidsSee next table
Conventional DMARDsContinue
Biologic DMARDsWithhold before surgery and schedule surgery at the end of the dosing cycle
Targeted synthetic DMARDsWithhold at least 7 days prior to surgery

Recommended steroid doses during surgery

Type of surgeryEndogenous cortisol secretion rateExamplesRecommended steroid dosing
Superficial8-10 mg/day (baseline)Dental surgery, biopsyUsual daily dose
Minor50 mg/dayInguinal hernia, colonoscopy, uterine curettage, hand surgeryUsual daily dose
hydrocortisone 50 mg i.v. before incision + hydrocortisone 25 mg i.v. every 8 hrs for 1 day + usual daily dose
Moderate75-150 mg/dayLow extremity revascularization, total joint replacement, cholecystectomy, colon cancer, abdominal hysterectomyUsual daily dose
hydrocortisone 50 mg i.v. before incision + hydrocortisone 25 mg i.v. every 8 hrs for 1 day + usual daily dose
Major75-150 mg/dayEsophagectomy, total proctocolectomy, major cardiac/vascular surgery, hepaticojejenostomy, delivery, traumaUsual daily dose
hydrocortisone 100 mg i.v. before incision + continuous i.v. infusion of hydrocortisone 200 mg for >1 day
hydrocortisone 50 mg i.v. every 8 hours/day + taper dose by half/day until usual daily dose reached and continuous i.v. fluids with 5% dextrose and 0.2-0.45% sodium chloride, based on degree of hypoglycemia

Keep in mind

  • Carefully perform a preoperative evaluation to prevent complications and minimize injury
  • Anesthetic management strategies should consider RA-related systemic problems
  • Individualize postoperative management

Suggested reading

  • Kim HR, Kim SH. Perioperative and anesthetic management of patients with rheumatoid arthritis. Korean J Intern Med. 2022;37(4):732-739.
  • Samanta R, Shoukrey K, Griffiths R. Rheumatoid arthritis and anaesthesia. Anaesthesia. 2011;66(12):1146-1159.

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