What is the workup and treatment for rheumatoid arthritis (RA)?

Workup and Treatment for Rheumatoid Arthritis

Early diagnosis and aggressive treatment of rheumatoid arthritis using a treat-to-target approach is essential to prevent joint destruction, disability, and reduce mortality, with the goal of achieving remission or low disease activity within 3-6 months of treatment initiation. 1

Diagnostic Workup

Clinical Assessment

• Evaluate for symmetric polyarthritis with joint swelling, especially of the hands and feet, although any appendicular joint may be involved 1
• Document morning stiffness lasting 1 hour or longer 1
• Look for characteristic subcutaneous nodules and extra-articular manifestations (interstitial lung disease, vasculitis, inflammatory eye disease) which indicate severe disease 1

Laboratory Testing

• Anti-citrullinated protein antibody (ACPA) - high specificity (90%) and moderate sensitivity (60%) for RA 1
• Rheumatoid factor (RF) - lower specificity (70%) with comparable sensitivity to ACPA 1
• Inflammatory markers: C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) 1, 2
• Complete blood count with differential 3
• Renal and hepatic function tests 3
• Screen for hepatitis B, hepatitis C, and tuberculosis in patients who may receive biologic therapy 3

Diagnostic Criteria

• Definite RA diagnosis requires confirmed synovitis in at least 1 joint not explained by another disease, and a score of ≥6 across 4 domains 1:
  • Number and site of involved joints (0-5 points)
  • Serologic abnormality (0-3 points)
  • Increased acute-phase response (0-1 points)
  • Symptom duration (0-1 points)

Treatment Approach

Guiding Principles

• Initiate early treatment to prevent joint damage and disability 1
• Use a treat-to-target approach with regular monitoring and treatment adjustment 1
• Target remission or low disease activity 1
• Reevaluate treatment within 3 months based on efficacy and tolerability 1
• Measure disease activity using validated composite measures such as SDAI, CDAI, or DAS28 1

First-Line Treatment

• Methotrexate (MTX) is the first-line DMARD for newly diagnosed RA 1, 2
• Start at appropriate dose and optimize before considering inadequate response 1
• Consider adding hydroxychloroquine and sulfasalazine (triple therapy) if MTX monotherapy is insufficient 1

Treatment Escalation

• If disease activity remains moderate to high despite optimized MTX:
  • Add a biologic agent (TNF inhibitor, abatacept, tocilizumab) or targeted synthetic DMARD (JAK inhibitor) 1
  • Consider rituximab particularly in RF-positive patients after inadequate response to TNF inhibitors 1, 4

Monitoring Disease Activity

• Use composite measures (SDAI, CDAI) to determine disease activity 1:
  • Remission: SDAI ≤3.3 or CDAI ≤2.8
  • Low disease activity: SDAI ≤11 or CDAI ≤10
  • Moderate/high disease activity: SDAI >11 or CDAI >10
• Monitor every 1-3 months during active disease 1
• Adjust therapy if target is not reached within 3-6 months 1

Treatment Tapering

• Consider tapering medication in patients with sustained remission (≥1 year) 1
• Taper glucocorticoids first, as long-term use beyond 1-2 years increases risk of adverse effects 1

Nonpharmacologic Management

• Patient education about disease pathophysiology and self-management 1
• Occupational therapy for joint protection techniques and assistive devices 1
• Dynamic exercise programs incorporating aerobic exercise and resistance training 1
• Adequate rest during periods of active inflammation 1
• Cognitive behavioral therapy for fatigue management 1

Special Considerations

• Screen for and address comorbidities, particularly cardiovascular disease 5
• Ensure vaccinations are up to date before starting immunosuppressive therapy 5
• Smoking cessation is critical as tobacco use predicts worse outcomes 1
• Multidisciplinary care involving rheumatologist, primary care physician, and allied health professionals 1

Potential Pitfalls

• Delayed diagnosis and treatment can lead to irreversible joint damage and disability 1
• Composite disease activity measures may be misleading in patients with fibromyalgia due to high tender joint counts 1
• Patients with persistent symptoms despite treatment should be evaluated to determine if symptoms are due to active inflammation versus other causes 6
• Non-adherence to medication can contribute to treatment failure 6