What are the typical clinical presentations and treatment options for Rheumatoid Arthritis (RA)?

Rheumatoid Arthritis: Clinical Presentation and Treatment

Rheumatoid arthritis (RA) typically presents as symmetric polyarthritis with prolonged morning stiffness, primarily affecting small joints of the hands and feet, and requires early aggressive treatment with methotrexate as first-line therapy to prevent joint destruction and improve mortality and quality of life. 1, 2

Clinical Presentation

Key Diagnostic Features

• Symmetric joint involvement: Particularly metacarpophalangeal (MCP), proximal interphalangeal (PIP), wrists, and metatarsophalangeal (MTP) joints 1, 3
• Morning stiffness: Lasting 1 hour or longer 1
• Persistent synovitis: Joint swelling, tenderness, and warmth 1, 3
• Duration: Symptoms present for at least 6 weeks 4

Extra-articular Manifestations

• Subcutaneous rheumatoid nodules
• Interstitial lung disease
• Vasculitis
• Inflammatory eye disease
• These manifestations often indicate more severe disease 1

Diagnostic Criteria

According to the 2010 ACR/EULAR classification criteria, a score of ≥6/10 is needed for definite RA diagnosis, based on:

1. Joint involvement (0-5 points)

   • Small joints (MCPs, PIPs, MTPs, wrists) involvement scores higher
   • 10+ joints with at least 1 small joint = 5 points

2. Serology (0-3 points)

   • High positive RF or anti-CCP (ACPA) = 3 points
   • Low positive RF or anti-CCP = 2 points
   • Negative for both = 0 points

3. Acute phase reactants (0-1 points)

   • Abnormal CRP or ESR = 1 point

4. Symptom duration (0-1 points)

   • ≥6 weeks = 1 point 1, 2

Laboratory Testing

• Anti-CCP antibodies: 67-78.5% sensitivity, 95-98% specificity (highest specificity) 2
• Rheumatoid factor: 69-84% sensitivity, 78-85% specificity 2
• Elevated ESR and CRP: Confirm inflammation 1, 4
• Synovial fluid analysis: Important to confirm inflammation and exclude other causes 5

Treatment Approach

Early Aggressive Treatment

• Early referral to rheumatologist: Within 6 weeks of symptom onset 2
• Treat-to-target principle: Aim for remission or lowest disease activity possible 1, 6
• Regular monitoring: Every 1-3 months until remission, then every 3-6 months 2

Medication Algorithm

1. First-line therapy:

   • Methotrexate (7.5-15mg weekly, escalating to 20-25mg) 2
   • Start early in patients at risk for persistent or erosive disease

2. Inadequate response to methotrexate monotherapy:

   • Add hydroxychloroquine and low-dose steroids for rapid symptom control 2
   • OR add biologic DMARDs (TNF inhibitors, abatacept, rituximab, tocilizumab) 2, 7

3. Monitoring disease activity:

   • Use validated measures: DAS28, SDAI, CDAI 1, 2
   • Adjust therapy if target not achieved

Important Medication Considerations

• Methotrexate with biologics: Methotrexate reduces adalimumab clearance but no dose adjustment needed 7
• Avoid combination of biologics: TNF blockers should not be combined with anakinra or abatacept due to increased infection risk 7
• Live vaccines: Avoid with biologic therapy 7

Prognosis and Complications

• Work disability: More than one-third of patients eventually experience work disability 1
• Employment rates: 80% at 2 years, 68% at 5 years after disease onset 1
• Life expectancy: Shortened by 3-5 years, especially with extra-articular disease 1
• Comorbidities: Heart disease, osteoporosis, infections 1, 2

Common Pitfalls to Avoid

• Delayed diagnosis: Leads to irreversible joint damage and worse outcomes 1, 2
• Inadequate treatment: Failure to achieve remission or low disease activity 1
• Misdiagnosis: Failure to consider other conditions like psoriatic arthritis, gout, or hemochromatosis 2
• Ignoring extra-articular manifestations: Can significantly impact morbidity and mortality 1
• Continuing high-risk DMARDs during infections: May worsen outcomes 2

Early diagnosis and aggressive treatment of RA are crucial for preventing joint destruction, preserving function, and improving quality of life and survival. The treat-to-target approach with regular monitoring and adjustment of therapy has transformed outcomes in RA management.