In the orthopedic setting, the anesthesiologist often encounters the rheumatoid patient after the disease has run a resistant course. Despite optimal medical therapy, the patient at this point has intolerable levels of pain or limitation of function because of structural joint damage. Given the duration of the disease and severity of symptoms, a number of pharmacologic modalities already have been tried for which the patient has suffered some side effects. Now that the disease has spanned a significant period, the patient has become older with one or more coexisting illnesses. These comorbidities may occur independently or as part of the extra-articular manifestations of the underlying rheumatic disorder. Because of these reasons, rheumatoid patients today present major anesthetic challenges.