What are the clinical features and management of Rheumatoid Arthritis (RA)?

Clinical Features and Management of Rheumatoid Arthritis

Rheumatoid arthritis (RA) is characterized by symmetric polyarthritis primarily affecting small joints of hands and feet, with morning stiffness lasting at least 1 hour, and should be promptly referred to a rheumatologist within 6 weeks of symptom onset to prevent joint damage and disability. 1, 2

Clinical Features

Joint Manifestations

• Pattern of joint involvement:

  • Symmetric polyarthritis predominantly affecting metacarpophalangeal, proximal interphalangeal, wrist, and metatarsophalangeal joints 1, 3
  • Larger joints (knees, ankles, elbows, shoulders) may also be involved
  • Distal interphalangeal, sacroiliac, and lumbar spine joints are rarely affected 3

• Key clinical signs:

  • Joint swelling, tenderness, and warmth
  • Morning stiffness lasting ≥1 hour (correlates with disease activity) 1, 3
  • Progressive loss of range of motion
  • Tendon and bursal involvement (often clinically dominant in early disease) 3

Extra-articular Manifestations

• Subcutaneous rheumatoid nodules
• Interstitial lung disease
• Vasculitis
• Inflammatory eye disease
• Hematologic abnormalities (anemia, thrombocytosis)
• Felty's syndrome (RA, splenomegaly, neutropenia)
• Constitutional symptoms: fatigue, low-grade fever, weight loss, malaise 1, 3

Patterns of Presentation

• Insidious onset (most common) - gradual development of symmetric small joint pain and swelling
• Acute/subacute onset (25% of patients)
• Palindromic onset - recurrent episodes of oligoarthritis without residual damage
• Monoarticular presentation
• Extra-articular synovitis (tenosynovitis, bursitis)
• Polymyalgic-like onset (especially in elderly)
• Constitutional symptoms predominance 3

Diagnosis

Clinical Assessment

• Evaluate for symmetric joint swelling, tenderness, and limited range of motion
• Assess duration of morning stiffness
• Complete examination of all peripheral joints 2

Laboratory Testing

• First-line tests:

  • Complete blood count
  • Inflammatory markers: ESR and CRP
  • Rheumatoid factor (RF)
  • Anti-cyclic citrullinated peptide antibodies (anti-CCP/ACPA) 2, 4
  • Liver and kidney function tests

• Additional tests when indicated:

  • Antinuclear antibodies (ANA)
  • HLA-B27 (if spondyloarthropathy suspected)
  • Synovial fluid analysis (if infection or crystal arthropathy suspected) 2

Imaging

• Plain radiographs: Initial assessment for baseline joint damage and exclusion of other pathologies
• Ultrasonography: More sensitive than clinical examination for detecting synovitis
• MRI: Most sensitive for early detection of synovitis and bone edema 2

Diagnostic Criteria

• ACR/EULAR 2010 Classification Criteria uses a scoring system (≥6/10 points needed):
  • Joint involvement (0-5 points)
  • Serology (0-3 points)
  • Acute phase reactants (0-1 point)
  • Duration of symptoms (0-1 point) 2

Management

General Principles

• Early referral to rheumatologist (within 6 weeks of symptom onset) 1, 2
• Treat-to-target strategy aiming for remission or low disease activity
• Regular monitoring of disease activity using composite measures (SDAI, CDAI)
• Multidisciplinary approach involving rheumatologists, nurses, physical/occupational therapists 1, 2

Pharmacological Management

First-Line Treatment

• Methotrexate is the anchor DMARD and first-line therapy
  • Starting dose 7.5-15 mg weekly, escalating to 20-25 mg weekly
  • Folic acid supplementation to reduce side effects 1, 2, 5

Additional DMARDs

• Leflunomide: Alternative to methotrexate (loading dose 100 mg daily for 3 days, then 20 mg daily) 6
• Hydroxychloroquine: Often used in mild disease or combination therapy
• Sulfasalazine: Alternative DMARD, especially when methotrexate is contraindicated 5

Glucocorticoids

• Short-term bridging therapy (prednisone 10-20 mg daily with tapering over 4-8 weeks)
• Not recommended for long-term use (>1-2 years) due to adverse effects 2

Biological DMARDs (for inadequate response to conventional DMARDs)

• TNF inhibitors: Adalimumab, etanercept, infliximab, golimumab, certolizumab
• T-cell costimulation blocker: Abatacept
• IL-6 receptor antagonist: Tocilizumab
• B-cell depleting therapy: Rituximab 2, 5

Targeted Synthetic DMARDs

• JAK inhibitors: Tofacitinib, baricitinib, upadacitinib

Management of Difficult-to-Treat RA

For patients with difficult-to-treat RA (D2T RA) who have failed ≥2 biological/targeted synthetic DMARDs with different mechanisms of action:

• Confirm the diagnosis and rule out mimicking conditions
• Assess for true inflammatory activity (ultrasound may help)
• Consider comorbidities and non-inflammatory factors contributing to symptoms 1

Non-Pharmacological Management

• Patient education about disease and self-management
• Occupational therapy for joint protection techniques and assistive devices
• Physical therapy with dynamic exercises (aerobic and resistance training)
• Cognitive behavioral therapy for fatigue management
• Adequate rest during disease flares 1, 2

Monitoring

• Assess disease activity every 1-3 months until target is reached
• Monitor for medication toxicity (complete blood count, liver and kidney function)
• Radiographic assessment every 6-12 months in early disease 2

Common Pitfalls

• Delayed referral to rheumatologist
• Failure to start DMARDs early in patients at risk for persistent disease
• Inadequate monitoring of disease activity
• Overlooking RA in patients with only one or few affected joints initially
• Assuming hand stiffness in older adults is always due to osteoarthritis 2

Prognosis

• Life expectancy is shortened by 3-5 years, especially in patients with extra-articular manifestations
• Work disability affects more than one-third of patients
• Early aggressive treatment significantly improves outcomes and may prevent joint destruction 1