Rheumatoid Arthritis

General Overview

  • Definition
    • Inflammatory arthritis involving 3+ joints
    • Duration >6w
    • Positive RF and/or anti-CCP
    • Elevated CRP/ESR
    • No evidence of other diseases (eg. psoriatic arthritis, viral polyarthritis, gout/pseudogout, SLE)

Risk

  • Age
  • Female
  • Family history
  • Smoking (both current and prior)
  • Early menarche (<10yo)
  • Very irregular menstrual periods
  • Nulliparous

History

  • Duration morning stiffness >30mins
  • Joint pain location, swelling, tender
  • Function, ADLs
  • Extrarticular
    • Anemia
    • Subcutaneous (rheumatoid) nodules
    • Pleuropericarditis
    • Neuropathy
    • Episcleritis/scleritis
    • Splenomegaly
    • Sjögren's syndrome
    • Vasculitis
    • Renal disease
  • Rule out other causes
    • Spondyloarthropathy - Psoriasis, IBD, prominent back involvement
    • SLE - Malar/discoid rash, oral ulcers, anti-dsDNA, anti-Sm
    • Viral - Less than 6 weeks of symptoms
    • Crystal arthropathy - Recurrent self-limited episodes
    • Fibromyalgia (can coexist with RA)

Physical exam

  • Joint exam
    • Limited joint ROM
    • Synovial hypertrophy/thickening, effusion, inflammation, tenderness
      • Classically involving MCP, PIP, thumb IP, wrists, MTP
  • Extraarticular disease manifestations (as above)
    • Skin (rheumatoid nodules)
    • Lung
    • Cardiac
    • Eye

Investigations

  • Labs
    • ESR, CRP
    • RF
    • Anti-citrullinated protein or peptide antibodies (Anti-CCP)
    • Antinuclear antibodies (ANA)
    • Consider CBC (anemia) , liver, kidney, uric acid, UA
  • Imaging (joint erosions)
    • Bilateral radiographs of hands, wrists, feet
    • May consider MRI/ultrasound
  • May consider arthrocentesis to rule out other causes
  • May consider viral testing if short history and seronegative for anti-CCP and RF
    • eg. Human parovirus B19, HBV, HCV, Lyme

Treatment

  • Patient education
    • Smoking cessation
    • Psychosocial interventions
    • Guided exercise program
    • PT/OT
    • Assess CV risk factors (highest cause of mortality)
  • Rapid referral to rheumatology
    • NSAIDs, glucocorticoids for bridging to DMARDs, flares
    • DMARDs as soon as diagnosis of RA made (eg. within 3mo)
      • Methotrexate is first-line (other DMARDs include sulfasalazine, leflunomide, hydroxychloroquine, biologics)
      • Screening for latent TB, HepB/C as needed
      • Eye exam prior to hydroxychloroquine
    • Frequent follow-up to assess disease activity q1-3 months (treat-to-target: sustained remission or low disease activity)
  • Monitor for complication of RA and treatment
    • Depression
    • Infection
    • Malignancy (lymphoma, lung, skin)