What is the workup and treatment for rheumatoid arthritis (RA)?

From the Guidelines

The workup for rheumatoid arthritis (RA) should begin with a thorough clinical evaluation, laboratory tests, and imaging studies, and treatment should follow a treat-to-target approach, starting with methotrexate as first-line therapy, as recommended by the most recent guidelines 1. The clinical evaluation should include a complete rheumatologic history and examination of all peripheral joints for tenderness, swelling, and range of motion, as well as examination of the spine. Laboratory tests should include rheumatoid factor (RF), anti-cyclic citrullinated peptide (anti-CCP) antibodies, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) 2. Imaging studies, such as X-rays, ultrasound, or MRI, may be used to assess joint damage and detect early inflammatory changes. Treatment should be aimed at reaching a target of sustained remission or low disease activity (LDA) in every patient, with therapy adjusted as needed to achieve this goal 3. Methotrexate, typically 15-25 mg weekly with folic acid supplementation, is recommended as first-line therapy, with combination therapy with other conventional synthetic DMARDs or biologic agents added as needed for patients with moderate to severe disease or inadequate response to conventional DMARDs 1. Regular monitoring of disease activity, medication side effects, and periodic laboratory tests are essential for optimal management, with treatment adjusted as needed to minimize disease activity and prevent joint damage and disability. Key points to consider in the workup and treatment of RA include:

• Early aggressive treatment to prevent joint damage and disability
• Use of methotrexate as first-line therapy, with combination therapy added as needed
• Regular monitoring of disease activity and medication side effects
• Adjustment of treatment as needed to achieve a target of sustained remission or LDA
• Consideration of biologic agents, such as TNF inhibitors, IL-6 inhibitors, or JAK inhibitors, for patients with moderate to severe disease or inadequate response to conventional DMARDs 4.

From the FDA Drug Label

1.3 Rheumatoid Arthritis (RA) RITUXAN, in combination with methotrexate, is indicated for the treatment of adult patients with moderately- to severely-active rheumatoid arthritis who have had an inadequate response to one or more TNF antagonist therapies.

The workup and treatment for rheumatoid arthritis (RA) involves the use of rituximab in combination with methotrexate for adult patients with moderately to severely active RA who have had an inadequate response to one or more TNF antagonist therapies.

• Key points:
  • Rituximab is used in combination with methotrexate.
  • It is indicated for adult patients with moderately to severely active RA.
  • Patients should have had an inadequate response to one or more TNF antagonist therapies. 5

From the Research

Workup for Rheumatoid Arthritis

• The workup for rheumatoid arthritis (RA) involves considering the disease if there is at least one joint with definite swelling that is not better explained by another disease 6.
• The presence of a rheumatoid factor and/or anti-citrullinated protein antibody, elevated C-reactive protein level, or elevated erythrocyte sedimentation rate is consistent with a diagnosis of RA 6, 7.
• Physical examination and laboratory tests, such as rheumatoid factor, anti-cyclic citrullinated peptide antibody, C-reactive protein, and erythrocyte sedimentation rate, are used in the diagnosis of RA 7, 8.
• The combination of these tests can help confirm a diagnosis of RA, with anti-CCP being more specific than the other parameters 7.

Treatment for Rheumatoid Arthritis

• The goal of therapy is to initiate early medical treatment to achieve disease remission or the lowest disease activity possible 6.
• Methotrexate is typically the first-line agent for RA, and additional disease-modifying antirheumatic drugs or biologic agents should be added if disease activity persists 6.
• Comorbid conditions, such as hepatitis B or C or tuberculosis infections, must be considered when choosing medical treatments 6.
• Early diagnosis and treatment of RA can lead to better outcomes, and primary care physicians play a crucial role in early diagnosis and initiating disease-modifying therapy 9.

Diagnostic Markers

• Rheumatoid factor, anti-citrullinated protein antibodies, and anti-carbamylated protein antibodies are autoantibodies that can be used in the diagnosis and prognosis prediction of RA 10.
• These autoantibodies can precede the development of RA by years and can function synergistically to promote disease progression 10.
• The presence of these autoantibodies can help predict the development of RA and an erosive phenotype, and can also be used to monitor response to therapy 10.