Workup and Management for Rheumatoid Arthritis and Associated Disorders
The workup for rheumatoid arthritis should include clinical assessment of joint involvement pattern, serology (RF and anti-CCP antibodies), acute phase reactants (ESR/CRP), and imaging of affected joints, with urgent referral to rheumatology for patients with persistent synovitis affecting small joints of hands or feet, multiple joint involvement, or symptoms persisting ≥3 months. 1
Diagnostic Approach
Clinical Presentation
- Look for bilateral, symmetric joint involvement (unilateral joint pain suggests alternative diagnoses)
- Assess for morning stiffness lasting at least 1 hour
- Common sites: metacarpophalangeal, proximal interphalangeal, metatarsophalangeal joints, wrists, and knees
- Extra-articular manifestations may include fatigue, fever, weight loss, rheumatoid nodules, and vasculitis
Laboratory Testing
- Rheumatoid Factor (RF): 60% sensitivity, 70% specificity 1
- Anti-citrullinated protein antibody (anti-CCP): higher specificity than RF
- Inflammatory markers:
- Erythrocyte sedimentation rate (ESR)
- C-reactive protein (CRP)
- Monitor every 4-6 weeks after treatment initiation; monthly for active disease; every six months for sustained remission 1
- Complete blood count, liver function tests, and renal function tests (baseline assessment before initiating therapy) 1
- Consider ANA testing to exclude other autoimmune conditions 1
Imaging
- X-rays of affected joints (baseline assessment)
- Consider MRI or high-resolution ultrasonography with power Doppler to identify subclinical inflammation 1
- Advanced imaging (CT, scintigraphy) may be useful in selected cases 2
Disease Activity Assessment
Validated Composite Measures
- Disease Activity Score 28 (DAS28)
- Simplified Disease Activity Index (SDAI)
- Clinical Disease Activity Index (CDAI)
Disease activity should be measured regularly:
- Monthly for high/moderate disease activity
- Every 3-6 months for sustained low disease activity or remission 1
| Index | Remission | Low | Moderate | High |
|---|---|---|---|---|
| SDAI | ≤3.3 | ≤11 | ≤26 | >26 |
| CDAI | ≤2.8 | ≤10 | ≤22 | >22 |
Management Approach
Treatment Goals
- Primary target: clinical remission or low disease activity 1
- Adjust treatment at least every 3 months until target is reached 1
Nonpharmacologic Management
- Patient education about joint protection
- Occupational therapy for assistive devices, orthotics, and splints
- Adequate rest during periods of inflammation
- Dynamic exercise programs incorporating both aerobic and resistance training 3, 1
- Cognitive behavioral therapy for fatigue management 3
Pharmacologic Management
First-line Therapy
Treatment Escalation
If inadequate response to MTX monotherapy:
- Optimize MTX dosing
- Add or switch to other conventional DMARDs
- Add biologic agents (TNF inhibitors, IL-6 inhibitors) or JAK inhibitors
- Adalimumab (TNF inhibitor) is effective but requires monitoring for antibody development, which may affect efficacy 6
Safety Monitoring
- Complete baseline assessment (CBC, liver enzymes, renal function) before initiating therapy 1
- Regular monitoring for medication toxicity:
- MTX: liver function, CBC, renal function
- Biologics: screen for TB and viral hepatitis before initiation
- Annual screening for viral hepatitis and TB for patients on biologics >1 year 1
Associated Disorders and Complications
- Pulmonary involvement: interstitial lung disease, pulmonary fibrosis
- Cardiovascular disease: increased risk of atherosclerosis
- Ocular manifestations: scleritis, episcleritis
- Skin involvement: rheumatoid nodules, vasculitis
- Hematologic abnormalities: anemia, thrombocytosis, Felty's syndrome
Common Pitfalls and Caveats
Delayed Diagnosis: Early diagnosis and treatment within the first 3-6 months of symptom onset is crucial to prevent irreversible joint damage. Up to 90% of patients can avoid significant joint damage with early intervention. 5
Inadequate Treatment Monitoring: Failure to regularly assess disease activity using validated measures can lead to suboptimal treatment adjustments.
Undertreatment: Not escalating therapy when treatment targets aren't met within 3-6 months can lead to progressive joint damage.
Medication Interactions: When using MTX, be aware of potential interactions with other medications. Monitor patients on CYP450 substrates (e.g., warfarin, cyclosporine) when initiating or discontinuing adalimumab. 6
Infection Risk: Combination of TNF blockers with other biologics (anakinra, abatacept) increases infection risk without added benefit. 6
Vaccination Considerations: Avoid live vaccines with biologic therapies like adalimumab. 6