Presentation and Management of Rheumatoid Arthritis
Rheumatoid arthritis (RA) typically presents as symmetric polyarthritis with joint swelling, especially of the hands and feet, accompanied by morning stiffness lasting at least 1 hour, and requires early diagnosis and aggressive treatment with methotrexate as first-line therapy to prevent joint destruction and disability. 1
Clinical Presentation
Key Clinical Features
- Symmetric polyarthritis affecting multiple joints, particularly:
- Morning stiffness lasting ≥1 hour 1, 3
- Tender joint swelling on palpation with early severe motion impairment 2
- Fatigue, low-grade fever, weight loss, and malaise 1, 4
Extra-articular Manifestations
- Subcutaneous rheumatoid nodules
- Interstitial lung disease
- Vasculitis
- Inflammatory eye disease 1
Disease Course
- Insidious onset of pain with symmetric small joint swelling (most common)
- Acute or subacute onset (25% of patients)
- Palindromic onset (recurrent episodes of oligoarthritis)
- Monoarticular presentation
- Extra-articular synovitis (tenosynovitis, bursitis)
- Polymyalgic-like onset 2
Diagnosis
Classification Criteria
The 2010 ACR/EULAR classification criteria require a score of ≥6/10 for definite RA diagnosis, based on:
- Joint involvement pattern (0-5 points)
- Serology (0-3 points)
- Acute phase reactants (0-1 point)
- Symptom duration (0-1 point) 1, 3
Essential Laboratory Tests
- Anti-citrullinated protein antibodies (ACPA/anti-CCP): 67-78.5% sensitivity, 95-98% specificity
- Rheumatoid factor (RF): 69-84% sensitivity, 78-85% specificity
- C-reactive protein (CRP): preferred inflammatory marker
- Erythrocyte sedimentation rate (ESR)
- Complete blood count with differential
- Renal and hepatic function tests 3, 5
Imaging
- Plain radiography: standard for assessing anatomic changes
- Early findings: soft tissue swelling and juxtaarticular osteoporosis
- Ultrasonography: useful for detecting early synovitis, tendon and bursal involvement
- MRI: can detect early bone edema and erosions not visible on radiographs 1, 2
Management
Treatment Goals
- Achieve remission or lowest disease activity possible
- Prevent joint destruction
- Prevent comorbidities (heart disease, osteoporosis)
- Restore quality of life
- Preserve independence and ability to perform daily activities 1, 3
Pharmacological Treatment Algorithm
First-line therapy: Methotrexate (MTX) monotherapy
If inadequate response to MTX monotherapy:
- Add hydroxychloroquine and low-dose glucocorticoids (combination therapy)
- OR add biologic DMARDs such as TNF inhibitors, abatacept, rituximab, or tocilizumab 3
For patients with continued moderate to high disease activity:
- Switch to or add biologic DMARDs with different mechanisms of action 1
Monitoring Disease Activity
- Use validated composite measures:
- Monitor every 1-3 months until remission, then every 3-6 months
- Adjust therapy if target is not achieved 3
Non-pharmacological Management
- Patient education about disease and self-management skills
- Occupational therapy for joint protection and assistive devices
- Adequate rest during active disease phases
- Dynamic exercise programs incorporating aerobic exercise and resistance training
- Cognitive behavioral therapy for fatigue management 1
Special Considerations and Pitfalls
Common Pitfalls to Avoid
- Delayed referral to a rheumatologist (should be within 6 weeks of symptom onset)
- Inadequate consideration of differential diagnoses (psoriatic arthritis, gout)
- Failure to recognize masked symptoms in patients on biologics
- Continuing high-risk DMARDs during infections 1, 3
Comorbidity Management
- Temporarily pause methotrexate during active infections
- Consider continuing low-dose glucocorticoids if patient is on chronic therapy
- Consider Pneumocystis jirovecii pneumonia prophylaxis in patients on cyclophosphamide or glucocorticoids 3
Prognosis
- Life expectancy shortened by 3-5 years, especially in patients with extra-articular disease
- Work disability begins early: 80% working at 2 years, 68% at 5 years
- Early diagnosis and treatment significantly improve outcomes and reduce need for joint reconstructive surgery 1
Proper management requires a multidisciplinary approach involving rheumatologists, nurses, physical and occupational therapists, and primary care physicians to address all aspects of this complex disease 1.