What is the workup and treatment for a 21-year-old male with symptoms of arthritis?

Workup and Treatment for Arthritis in a 21-Year-Old Male

A 21-year-old male with symptoms of arthritis should be promptly referred to a rheumatologist, ideally within 6 weeks of symptom onset, for proper diagnosis and early initiation of disease-modifying treatment to prevent joint damage and disability. 1

Initial Diagnostic Workup

Clinical Examination

• Clinical examination is the primary method for detecting arthritis 1
• Key findings to assess:
  • Number and pattern of swollen and tender joints
  • Morning stiffness duration (>60 minutes suggests inflammatory arthritis) 2
  • Ability to make a fist (difficulty suggests inflammatory arthritis) 2
  • Patient-reported joint swelling 2

Laboratory Testing

At minimum, the following tests should be ordered:

• Complete blood cell count
• Erythrocyte sedimentation rate (ESR)
• C-reactive protein (CRP)
• Rheumatoid factor (RF)
• Anti-citrullinated protein antibodies (ACPA)
• Liver function tests (transaminases)
• Renal function tests
• Urinalysis
• Antinuclear antibodies (ANA) 1, 3

Imaging

• Plain radiographs of hands and feet (even if not clinically affected) to assess for erosions or joint space narrowing 3
• Ultrasound or MRI if clinical examination is inconclusive for detecting synovitis 1

Risk Stratification

After initial assessment, determine risk for persistent and/or erosive disease based on:

1. Number of swollen and tender joints
2. Elevated ESR or CRP
3. Positive RF or ACPA
4. Presence of radiographic erosions 1

Treatment Approach

For Patients at Risk of Persistent Disease

1. Disease-Modifying Antirheumatic Drugs (DMARDs)

   • Start DMARDs as early as possible, ideally within 3 months, even if classification criteria for inflammatory rheumatologic disease are not yet fulfilled 1
   • Methotrexate is the anchor drug and should be part of the first treatment strategy 1
   • Consider subcutaneous over oral methotrexate for better bioavailability 1

2. Symptomatic Treatment

   • NSAIDs for symptom relief at minimum effective dose for shortest time possible after evaluating gastrointestinal, renal, and cardiovascular risks 1
   • Systemic glucocorticoids at lowest effective dose as temporary (<6 months) adjunctive treatment 1
   • Intra-articular glucocorticoid injections for local symptom relief 1

3. Treatment Monitoring

   • Assess disease activity every 1-3 months until treatment target (remission) is reached 1
   • Monitor tender and swollen joint counts, patient and physician global assessments, ESR and CRP 1
   • Radiographic assessment every 6-12 months during first few years 1

Non-Pharmacological Interventions

• Dynamic exercises and occupational therapy as adjuncts to drug treatment 1
• Patient education about the disease, outcomes, and treatment 1
• Smoking cessation, dental care, weight control, and vaccination status assessment 1

Disease Activity Assessment

Monitor disease activity using composite measures:

• Low disease activity: ≤4 active joints, normal ESR/CRP, physician global assessment <4/10, patient global assessment <2/10 1
• Moderate/high disease activity: >4 active joints, elevated ESR/CRP, physician global assessment ≥7/10, patient global assessment ≥5/10 1

Treatment Escalation

If inadequate response to initial DMARD therapy:

• Consider adding biologic DMARDs such as TNF inhibitors (adalimumab, etanercept) 3, 4, 5
• Prior to starting biologics, screen for hepatitis B, hepatitis C, and tuberculosis 4, 5, 6

Treatment Goal

The main goal of treatment is to achieve clinical remission, defined as:

• Tender joints, swollen joints, CRP, and patient global assessment all ≤1 3
• Prevention of radiographic damage and visible deformity 6
• Maintenance of work and personal activities 6

Common Pitfalls to Avoid

1. Delaying referral to a rheumatologist (should be within 6 weeks of symptom onset) 1
2. Overlooking inflammatory arthritis when only one or few joints are affected initially 3
3. Failing to start DMARDs early in patients at risk for persistent disease 1
4. Inadequate monitoring of disease activity and treatment response 1
5. Not screening for tuberculosis and hepatitis before starting biologic therapy 4, 5

Early diagnosis and aggressive treatment are essential to prevent joint damage and disability in young patients with arthritis.