Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease of unknown cause. An external trigger (eg, cigarette smoking, infection, or trauma) that triggers an autoimmune reaction, leading to synovial hypertrophy and chronic joint inflammation along with the potential for extra-articular manifestations, is theorized to occur in genetically susceptible individuals. See the image below. Rheumatoid changes in the hand. Signs and symptoms In most patients with RA, onset is insidious, often beginning with fever, malaise, arthralgias, and weakness before progressing to joint inflammation and swelling. Signs and symptoms of RA may include the following: · Persistent symmetric polyarthritis (synovitis) of hands and feet (hallmark feature) · Progressive articular deterioration · Extra-articular involvement · Difficulty performing activities of daily living (ADLs) · Constitutional symptoms The physical examination should address the following: · Upper extremities (metacarpophalangeal joints, wrists, elbows, shoulders) · Lower extremities (ankles, feet, knees, hips) · Cervical spine During the physical examination, it is important to assess the following: · Stiffness · Tenderness · Pain on motion · Swelling · Deformity · Limitation of motion · Extra-articular manifestations · Rheumatoid nodules Guidelines for evaluation · 2010 American College of Rheumatology (ACR)/EULAR classification criteria · 2012 ACR disease activity measures · 2011 ACR/EULAR definitions of remission 2010 ACR/EULAR Diagnostic Criteria Historically, the diagnosis of RA was based on the 1987 American College of Rheumatology (ACR) criteria. These criteria were based on the persistence of arthritic symptoms over time; however, this classification system failed to identify patients with early inflammatory arthritis. It is now recognized that early therapeutic intervention significantly improves clinical outcomes and reduces irreversible joint damage and disability. With this focus, the ACR and the European League Against Rheumatism (EULAR) devised new classification criteria for early arthritis, which assess joint involvement, autoantibody status, acute-phase response, and symptom duration, as well as revised criteria for classifying RA in newly presenting patients, those with erosive disease typical of RA, and those with inactive disease with or without treatment. [2010 ACR/EULAR classification criteria for RA are designed to identify patients with unexplained inflammatory arthritis in at least 1 peripheral joint and a short duration of symptoms who would benefit from early therapeutic intervention. They represents a paradigm shift from the 1987 ACR criteria, which lacked the sensitivity to detect early RA. [1] According to the ACR/EULAR criteria, patients who should be tested are those (1) who have at least 1 joint with definite clinical synovitis and (2) whose synovitis is not better explained by another disease (eg, lupus, psoriatic arthritis, or gout). The ACR/EULAR classification system is a score-based algorithm for RA that incorporates the following 4 factors: Joint involvement Serology test results Acute-phase reactant test results Patient self-reporting of the duration of signs and symptoms The maximum number of points possible is 10. A classification of definitive RA requires a score of 6/10 or higher. Patients with a score lower than 6/10 should be reassessed over time. If patients already have erosive changes characteristic of RA, they meet the definition of RA, and application of this diagnostic algorithm is unnecessary. Joint involvement consists of swelling or tenderness upon examination. The presence of synovitis may be confirmed on imaging studies. Points are allocated as follows: 1 large joint (ie, shoulders, elbows, hips, knees, ankles) = 0 points 2-10 large joints = 1 point 1-3 small joints (with or without involvement of large joints), such as MCP, PIP, second to fifth MTP, thumb interphalangeal (IP), and wrist joints = 2 points 4-10 small joints (with or without involvement of large joints) = 3 points More than 10 joints (at least 1 small joint, plus any combination of large and additional small joints or joints such as the temporomandibular, acromioclavicular, or sternoclavicular) = 5 points At least 1 serology test result is needed for RA classification. Points are allocated as follows: Negative rheumatoid factor (RF) and negative anti−citrullinated protein antibody (ACPA; in the ACR/EULAR criteria set, tested as anti−cyclic citrullinated peptide [anti-CCP]) = 0 points Low-positive RF or low-positive ACPA = 2 points High-positive RF or high-positive ACPA = 3 points Negative serology test results are defined as international unit (IU) values that do not exceed the upper limit of normal (ULN) for the reporting laboratory or assay. Low-positive results are defined as IU values that exceed the ULN but are no more than 3 times the ULN for the reporting laboratory or assay. High-positive results are IU values that are more than 3 times higher than the ULN for the reporting laboratory or assay. When RF is available only as a positive or negative finding, a positive result should be scored as low-positive RF. At least 1 test acute-phase reactant test result is needed for classification. Local laboratory standards determine which results are normal and which are abnormal. Points are allocated as follows: Normal C-reactive protein (CRP) and normal erythrocyte sedimentation rate (ESR) = 0 points Abnormal CRP or abnormal ESR = 1 point Points for the patient’s self-reporting of the duration of signs or symptoms of synovitis in clinically involved joints are allocated as follows: Shorter than 6 weeks = 0 points 6 weeks or longer = 1 point Diagnosis No test results are pathognomonic; instead, the diagnosis is made by using a combination of clinical, laboratory, and imaging features. Potentially useful laboratory studies in suspected RA include the following: · Erythrocyte sedimentation rate · C-reactive protein level · Complete blood count · Rheumatoid factor assay · Antinuclear antibody assay · Anti−cyclic citrullinated peptide and anti−mutated citrullinated vimentin assays Potentially useful imaging modalities include the following: · Radiography (first choice): Hands, wrists, knees, feet, elbows, shoulders, hips, cervical spine, and other joints as indicated · Magnetic resonance imaging: Primarily cervical spine · Ultrasonography of joints: Joints, as well as tendon sheaths, changes and degree of vascularization of the synovial membrane, and even erosions Joint aspiration and analysis of synovial fluid may be considered, including the following: · Gram stain · Cell count · Culture · Assessment of overall appearance Management Nonpharmacologic, nonsurgical therapies include the following: · Heat and cold therapies · Orthotics and splints · Therapeutic exercise · Occupational therapy · Adaptive equipment · Joint-protection education · Energy-conservation education Guidelines for pharmacologic therapy · 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis · 2013 EULAR management guidelines · 2012 Agency for Healthcare Research and Quality (AHRQ) recommendations Nonbiologic disease-modifying antirheumatic drugs (DMARDS) include the following: · Hydroxychloroquine · Azathioprine · Sulfasalazine · Methotrexate · Leflunomide · Cyclosporine · Gold salts · D-penicillamine · Minocycline Biologic tumor necrosis factor (TNF)–inhibiting DMARDs include the following: · Etanercept · Infliximab · Adalimumab · Certolizumab · Golimumab Biologic non-TNF DMARDs include the following: · Rituximab · Anakinra · Abatacept · Tocilizumab · Sarlilumab · Tofacitinib Other drugs used therapeutically include the following: · Corticosteroids · Nonsteroidal anti-inflammatory drugs (NSAIDs) · Analgesics Surgical treatments include the following: · Synovectomy · Tenosynovectomy · Tendon realignment · Reconstructive surgery or arthroplasty · Arthrodesis Source
