Rheumatoid Arthritis: Common Questions About Diagnosis and Management

 

Rheumatoid arthritis is the most commonly diagnosed systemic inflammatory arthritis, with a lifetime prevalence of up to 1% worldwide. Women, smokers, and those with a family history of the disease are most often affected. Rheumatoid arthritis should be considered if there is at least one joint with definite swelling that is not better explained by another disease. In a patient with inflammatory arthritis, the presence of a rheumatoid factor and/or anti-citrullinated protein antibody, elevated C-reactive protein level, or elevated erythrocyte sedimentation rate is consistent with a diagnosis of rheumatoid arthritis. Rheumatoid arthritis may impact organs other than the joints, including lungs, skin, and eyes. Rapid diagnosis of rheumatoid arthritis allows for earlier treatment with disease-modifying antirheumatic drugs, which is associated with better outcomes. The goal of therapy is to initiate early medical treatment to achieve disease remission or the lowest disease activity possible. Methotrexate is typically the first-line agent for rheumatoid arthritis. Additional disease-modifying antirheumatic drugs or biologic agents should be added if disease activity persists. Comorbid conditions, including hepatitis B or C or tuberculosis infections, must be considered when choosing medical treatments. Although rheumatoid arthritis is often a chronic disease, some patients can taper and discontinue medications and remain in long-term remission.

Rheumatoid arthritis (RA) is the most common autoimmune inflammatory arthritis, with a lifetime prevalence of up to 1% worldwide.1 It has a significant impact on occupational and daily activities, as well as mortality.24 This article reviews common questions on the diagnosis and management of RA, and presents evidence-based answers.

WHAT IS NEW ON THIS TOPIC

The 2015 American College of Rheumatology guidelines continue to recommend methotrexate as the first-line treatment for rheumatoid arthritis, unless contraindications (e.g., frequent alcohol use, preexisting liver disease) are present.

In a randomized trial of patients who were on stable disease-modifying antirheumatic drug (DMARD) regimens and in clinical remission for at least six months, 84% of patients who continued full DMARD treatment remained in remission after 12 months, compared with 61% who tapered DMARDs by 50%, and with 48% of those who stopped all DMARDs.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Methotrexate should be the first-line disease-modifying antirheumatic drug in patients with rheumatoid arthritis unless there are contraindications.

A

1618

Patients with rheumatoid arthritis should be treated as early as possible to have the best chance of remission.

A

1925

Patients should be screened for chronic infections, including latent tuberculosis, hepatitis B virus, and hepatitis C virus, before starting rheumatoid arthritis treatment.

C

16, 27, 28

Patients who are in remission from rheumatoid arthritis for more than six months and on stable medication regimens are candidates for tapering or discontinuing disease-modifying antirheumatic drug or biologic treatment.

B

35, 36


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Methotrexate should be the first-line disease-modifying antirheumatic drug in patients with rheumatoid arthritis unless there are contraindications.

A

1618

Patients with rheumatoid arthritis should be treated as early as possible to have the best chance of remission.

A

1925

Patients should be screened for chronic infections, including latent tuberculosis, hepatitis B virus, and hepatitis C virus, before starting rheumatoid arthritis treatment.

C

16, 27, 28

Patients who are in remission from rheumatoid arthritis for more than six months and on stable medication regimens are candidates for tapering or discontinuing disease-modifying antirheumatic drug or biologic treatment.

B

35, 36


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

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BEST PRACTICES IN RHEUMATOLOGY

Recommendations from the Choosing Wisely Campaign

RecommendationSponsoring organization

Do not prescribe biologics for rheumatoid arthritis before a trial of methotrexate (or other conventional nonbiologic disease-modifying

The Author

AMY WASSERMAN, MD, is an assistant professor in the Rheumatology Department at Westchester Medical Center, New York Medical College, Valhalla, NY.

Address correspondence to Amy Wasserman, MD, Westchester Medical Center, 100 Woods Rd., Taylor Care Pavilion, 3rd Fl., Valhalla, NY 10595 (e-mail: amy.wasserman@wmchealth.org). Reprints are not available from the author.

Author disclosure: No relevant financial affiliations.

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