RA is the most commonly diagnosed systemic inflammatory arthritis.
Diagnosis
H&P
Risk factors.
Ddx and Etiology:
2010 Classification Criteria for RA reviewed.
Joint involvement: ____________
Duration of symptoms: ≥ 6 weeks
Diagnostic studies
-RF and anti-CCP antibodies;
-CRP and ESR
-CBC (with diff) and CMP
-ANA and Uric acid.
-Test for Hep B, hep C, and TB since biologics will be used.
-X-rays of joints.
Treatment
Counseling provided.
Address CV risk factors since CVD is the main cause of death in patients with RA.
DMARDs: Methotrexate (1st line). Biologic agents (such as TNF inhibitors) are 2nd-line agents or can be added for dual therapy.
Joint replacement when indicated.
Refer to Rheumatology.
F/u after lab work for final classification.
Refer to PT / OT.
Exercise recommended.
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Key Points
- The wrists, metacarpophalangeal (MCP) joints, and proximal interphalangeal (PIP) joints, are the most commonly involved joints in RA.
- Anti-CCP = Anti-cyclic citrullinated peptide (anti-CCP). Anti-CCP is also called ACPA = anti-citrullinated protein antibody.
- Diagnostic Testing: RF and anti-CCP antibodies are serologies will help with classification; CRP and ESR are acute phase reactants will help with classification; CMP to check renal function and hepatic function; X-rays of joints to look for juxta-articular erosions and symmetric joint space narrowing (which is contrasted with asymmetry in OA). However, the diagnosis of RA is clinical; ANA (to r/o SLE) and Uric acid (to assess for gout).
Typical Clinical Clinical Presentation:
RA is typically symmetric and polyarticular at presentation and particularly affects the wrists and other extremity joints that have a high ratio of synovium to articular cartilage. RF is often negative early in the disease process, although it may be positive later.
“Patients with RA typically present with pain and stiffness in multiple joints. The wrists, metacarpophalangeal (MCP) joints, and proximal interphalangeal (PIP) joints, are most commonly involved. Morning stiffness lasting more than one hour suggests an inflammatory etiology. Boggy swelling due to synovitis may be visible, or subtle synovial thickening may be palpable on joint examination. Patients may also present with more indolent arthralgias before the onset of clinically apparent joint swelling. Systemic symptoms of fatigue, weight loss, and low-grade fever may occur with active disease.” The AAFP
Sample RA presentation: “A 50-year-old female reports a 1-month history of pain in her wrists. She does not recall any injury. On examination both wrists are warm but not red, feel boggy on palpation, and lack 30° of both flexion and extension. No other joints are affected. She feels fatigued and unwell, but attributes this to her busy schedule. Radiographs of the wrists are normal. Laboratory findings are unremarkable except for a mildly elevated erythrocyte sedimentation rate and a negative rheumatoid factor.” ABFM
“As is true for the general population in the United States, coronary artery disease is the leading cause of death in patients with rheumatoid arthritis (RA). RA patients have accelerated atherosclerosis related to a chronic inflammatory state. It is thus particularly important to address modifiable risk factors for coronary disease in these patients, including tobacco use, hypertension, and dyslipidemia. Patients with RA also have an increased risk of lymphoma, lung cancer, and thromboembolic disease, but these are not as common as coronary disease. Infections are a concern for patients on disease-modifying agents but are not the leading cause of death.” ABFM
References:
Am Fam Physician 2011;84(11):1245-1252. http://www.aafp.org/afp/2011/1201/p1245.html