Key principles of rheumatoid arthritis (RA) management include early patient evaluation by a rheumatologist and early initiation of pharmacologic therapy in patients at risk for chronic disease. Early diagnosis and appropriate management are essential to prevent joint damage. Patients with RA usually report pain and swelling in multiple joints and prolonged stiffness in the morning that improves with activity. Joint involvement typically is bilateral and symmetric. RA affects large and small joints, particularly the metacarpophalangeal and proximal interphalangeal joints of the hands. Patients with RA may be started on nonsteroidal anti-inflammatory drugs, glucocorticoids, or conventional synthetic disease-modifying antirheumatic drugs (DMARDs) before evaluation by a rheumatologist. Patients who have a poor response to conventional synthetic DMARDs or aggressive arthritis at initial evaluation may be prescribed biologic or targeted synthetic DMARDs. Anti–tumor necrosis factor alpha agents also may be used. Patients typically are managed with a treat-to-target strategy to achieve and maintain low disease activity or remission. Regular monitoring visits using formal assessment of disease activity have been shown to improve outcomes. RA and the medications used in its treatment are associated with increased risks of infections and malignancy. Integrative medicine therapies with limited evidence include acupuncture, mind-body therapies (eg, yoga, tai chi), and dietary supplements.
Case 4. FA is a 54-year-old patient with well-controlled diabetes, hypertension, and gastroesophageal reflux disease. She presents to your office for evaluation of joint pain that has persisted for 3 months. FA says she initially noticed mild aching and stiffness in her hands. The symptoms progressed to include pain and swelling in the knuckles, wrists, knees, and right shoulder. FA reports no recent trauma, injury, fevers, infections, or travel. She says she tried acetaminophen for pain with initial relief, but it has not been effective for the last 3 weeks. Ibuprofen provided some relief but caused stomach upset.
FA’s main concerns are difficulty gripping and twisting objects and increased pain with typing. She reports fatigue but no weight loss, eye redness or pain, oral ulcers, cough or dyspnea, chest pain, diarrhea, or numbness. FA reports heartburn with consumption of spicy foods and says she uses over-the-counter antacids as needed. There is no personal or family history of autoimmune disease.
On physical examination, FA has synovitis and tenderness over the metacarpophalangeal joints, proximal interphalangeal joints, wrists, and knees and pain with range of motion. You suspect rheumatoid arthritis (RA).
Overview and Diagnosis
Key principles of RA management include early patient evaluation by a rheumatologist (within 3 months if possible) and early initiation of pharmacotherapy in patients at risk for chronic disease. This approach has been shown to improve clinical outcomes, but may be difficult due to limited access to rheumatology specialists.1 Early diagnosis and appropriate management are essential to prevent joint damage. History and physical examination findings can lead to a high initial suspicion for RA, which can be confirmed with serology and inflammatory marker testing. Table 12 lists initial laboratory tests that can establish the diagnosis and prepare for treatment.
Table 1 Initial Laboratory Tests to Establish the Diagnosis of Rheumatoid Arthritis and Prepare for Treatment
| Laboratory Tests | Purpose | Comments |
|---|---|---|
| RF, CCP | Due to high false-positivity rate of RF and high specificity of CCP, obtaining both tests is valuable | It is helpful if patient can complete these tests and have results available for review before rheumatologist visit |
| ESR and/or CRP | Can confirm suspicion of systemic inflammation | These tests are nonspecific and may indicate the presence of other systemic conditions |
| Pretreatment CBC, CMP | DMARDs may cause cytopenia or liver enzyme abnormalities | Repeat these tests within 4 months of therapy initiation |
| Serologies for HIV and hepatitis B and C | Patients initiating immunosuppression with synthetic and biologic DMARDs are at risk for infection | TB testing determines the need to treat latent TB infection |
| TB testing (preference for interferon gamma release assay) | History of hepatitis B infection may require long-term suppressive therapy |
CBC = complete blood cell count; CCP = cyclic citrullinated peptide; CMP = comprehensive metabolic panel; CRP = C-reactive protein; DMARD = disease-modifying antirheumatic drug; ESR = erythrocyte sedimentation rate; RF = rheumatoid factor; TB = tuberculosis.
Information from reference 2.
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