From the Guidelines
The workup for inflammatory arthritis should begin with a thorough history and physical examination, focusing on joint symptoms, duration, pattern, and associated systemic features, and patients presenting with arthritis should be referred to, and seen by, a rheumatologist within 6 weeks after the onset of symptoms. The clinical examination is the method of choice for detecting arthritis, which may be confirmed by ultrasonography 1. Laboratory testing should include complete blood count, comprehensive metabolic panel, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), rheumatoid factor (RF), and anti-cyclic citrullinated peptide (anti-CCP) antibodies.
Key Laboratory Tests
- Complete blood count
- Comprehensive metabolic panel
- ESR
- CRP
- RF
- Anti-CCP antibodies Additional tests may include HLA-B27 for suspected spondyloarthropathies, uric acid levels for gout, and synovial fluid analysis from affected joints to assess for crystals, infection, or inflammatory cells.
Imaging Studies
- Plain radiographs of affected joints to evaluate for erosions, joint space narrowing, or other structural changes
- Ultrasound to detect early synovitis and erosions
- MRI to provide detailed assessment of soft tissues and bone marrow edema In some cases, a synovial biopsy may be necessary for definitive diagnosis. The workup should be tailored to the clinical presentation, as inflammatory arthritis encompasses various conditions including rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and systemic lupus erythematosus, each with distinct clinical and laboratory features.
Treatment Approach
- Early diagnosis is crucial as prompt treatment with disease-modifying antirheumatic drugs (DMARDs) can prevent joint damage and disability
- Methotrexate is considered the anchor drug and should be part of the first treatment strategy in patients at risk of persistent disease 1
- Non-pharmacological interventions, such as dynamic exercises and occupational therapy, should be considered as adjuncts to drug treatment in patients with early arthritis 1
- Patient information concerning the disease, its outcome, and its treatment is important, and education programs aimed at coping with pain, disability, and maintenance of work ability may be employed as adjunct interventions 1
From the Research
Workup for Inflammatory Arthritis
The workup for inflammatory arthritis, such as rheumatoid arthritis, involves several key steps and considerations:
- Initial Treatment: Effective treatment includes oral conventional synthetic disease-modifying antirheumatic drugs (DMARDs; eg, methotrexate), injectable biologic DMARDs, and targeted synthetic DMARDs (oral) 2.
- Treatment Escalation: Rapid escalation of treatment with various DMARDs is recommended if methotrexate alone is not effective in controlling rheumatoid arthritis 2.
- Combination Therapy: Combination therapy with methotrexate, sulfasalazine, and hydroxychloroquine is more effective than either methotrexate alone or a combination of sulfasalazine and hydroxychloroquine 3, 4.
- Treatment Goals: The goal of treatment is to achieve low disease activity or remission by frequently monitoring disease activity and escalating treatment 2.
- Importance of Early Diagnosis: Early diagnosis and treatment of rheumatoid arthritis are crucial to improve disease control, slow radiological progression, and improve functional outcomes 5, 6.
Key Recommendations
- Start effective treatment immediately with DMARDs to reduce disability 2.
- Use effective doses of methotrexate (oral or subcutaneous) with folic acid as the initial treatment 2.
- Consider combination therapy with methotrexate, sulfasalazine, and hydroxychloroquine for patients who do not respond to methotrexate alone 3, 4.
- Monitor disease activity regularly and escalate treatment as needed to achieve low disease activity or remission 2.