What are the typical presentation and treatment of Rheumatoid Arthritis (RA)?

Rheumatoid Arthritis Presentation and Treatment

Rheumatoid arthritis typically presents as symmetric polyarthritis with joint swelling (especially of the hands and feet), 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.

Clinical Presentation

Key Symptoms

• Symmetric polyarthritis affecting small joints (metacarpophalangeal, proximal interphalangeal, metatarsophalangeal)
• Morning stiffness lasting ≥1 hour (characteristic feature)
• Fatigue, low-grade fever, weight loss, and malaise 1
• Joint swelling and tenderness to palpation 2
• Severe motion impairment in involved joints 3

Pattern of Joint Involvement

• Typically symmetric involvement (hallmark feature) 4
• Commonly affected joints:
  • Hands: MCPs, PIPs (wrists frequently involved)
  • Feet: MTPs
  • Other: knees, ankles, shoulders, elbows 1
• Distal interphalangeal joints, sacroiliac joints, and lumbar spine are rarely involved 3

Extra-articular Manifestations

• Subcutaneous nodules (marker of severe disease)
• Interstitial lung disease
• Vasculitis
• Inflammatory eye disease 2
• Reduced life expectancy by 3-5 years, especially in those with extra-articular disease 1

Diagnostic Approach

Laboratory Testing

• Essential blood work:
  • Rheumatoid factor (RF): 69-84% sensitivity, 78-85% specificity
  • Anti-citrullinated protein antibodies (anti-CCP): 67-78.5% sensitivity, 95-98% specificity (highest specificity)
  • Acute phase reactants: ESR and CRP (CRP generally better for disease activity) 1
  • Complete blood count and basic biochemistry

Classification Criteria

• 2010 ACR/EULAR classification criteria require score ≥6/10 for definite RA diagnosis, based on:
  • Joint involvement pattern
  • Serology (RF and anti-CCP)
  • Acute phase reactants
  • Symptom duration 1

Imaging

• Plain radiography: standard technique showing:
  • Early: soft tissue swelling, juxtaarticular osteoporosis
  • Later: marginal erosions, joint space narrowing 4
• Ultrasound: useful for detecting synovial thickening, joint effusion
• MRI: helpful for assessing disease activity and differentiating synovial fluid from inflammatory pannus 4

Treatment Algorithm

Treatment Goals

• Achieve remission or lowest disease activity possible
• Prevent joint destruction
• Prevent comorbidities
• Restore quality of life
• Preserve independence and ability to perform daily activities 1

First-Line Treatment

• Methotrexate is recommended as first-line DMARD for RA, with dosage of 7.5-15mg weekly, escalating to 20-25mg 1
• Should be started early in patients at risk for persistent or erosive disease

Treatment Intensification (If Inadequate Response to Methotrexate)

1. Combination therapy with methotrexate, hydroxychloroquine, and short-term steroids

   • Provides rapid symptom control and better radiographic outcomes 1

2. If moderate to high disease activity persists, add biologic DMARDs:

   • TNF inhibitors
   • Abatacept (CTLA4-Ig)
   • Rituximab (anti-CD20) - particularly effective in RF-positive patients 2, 5
   • Tocilizumab (anti-IL-6R) 1

Monitoring Disease Activity

• Use composite measures like:
  • Simplified Disease Activity Index (SDAI)
  • Clinical Disease Activity Index (CDAI)
  • Disease Activity Score using 28 joint counts (DAS28) 2
• Regular assessment of CRP levels 2

Treatment Tapering

• In patients achieving sustained remission (≥1 year), consider tapering therapy
• 15-25% may achieve sustained drug-free remission
• Factors favoring successful tapering: shorter symptom duration, absence of RF or anti-CCP, lower disease activity before remission 2

Common Pitfalls and Caveats

• Delayed diagnosis and treatment - should refer to rheumatologist within 6 weeks of symptom onset 1
• Inadequate treatment intensification - failure to escalate therapy when disease activity persists
• Overlooking comorbidities - cardiovascular disease, osteoporosis, infections
• Misdiagnosis - failure to consider other conditions with similar presentations (psoriatic arthritis, gout) 1
• Overreliance on composite scores - patients with fibromyalgia can have falsely elevated disease activity scores due to high tender joint counts 2
• Failure to recognize masked pneumonia in patients on biologics that suppress inflammatory markers 1

Patient Education and Self-Management

• Education about disease and self-management skills is essential
• Proper footwear, home exercises, and early recognition of exacerbations
• Occupational therapy for joint protection and assistive devices
• Adequate rest during active disease phases
• Dynamic exercise programs incorporating aerobic exercise and resistance training 1

Early diagnosis and aggressive treatment significantly improve outcomes, reduce disability, and decrease the need for joint reconstructive surgery. Work disability begins early, with 80% of patients working at 2 years and only 68% at 5 years, highlighting the importance of prompt intervention 2, 1.