What is the rheumatoid arthritis (RA) work-up?

Rheumatoid Arthritis Work-Up

The rheumatoid arthritis work-up should include clinical assessment of disease activity, laboratory tests for inflammation markers and autoantibodies, and radiographic evaluation to assess joint damage. 1

Clinical Assessment

• Evaluate joint involvement with focus on symmetric polyarthritis, particularly in hands (metacarpophalangeal, proximal interphalangeal) and feet (metatarsophalangeal), wrists and knees 1, 2
• Document morning stiffness duration (typically ≥1 hour in RA) 1, 2
• Assess swollen and tender joint counts using standardized measures 1
• Evaluate patient and evaluator global assessments of disease activity 1
• Measure pain using visual analog scale (VAS) or numerical rating scale (NRS) 1
• Assess physical function using validated instruments (e.g., Health Assessment Questionnaire) 1
• Calculate composite disease activity scores (DAS28, SDAI, CDAI) to quantify disease activity 1, 3

Laboratory Tests

• Complete blood count (CBC) to assess for anemia of chronic disease 1, 4
• Acute phase reactants: erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) 1
• Rheumatoid factor (RF) - sensitivity ~70%, specificity ~70% 1
• Anti-citrullinated protein antibody (ACPA) - sensitivity ~60%, specificity ~90% 1
• Liver function tests (AST/ALT, alkaline phosphatase, albumin) 1
• Renal function (creatinine) 1
• Hepatitis B and C serology (prior to immunosuppressive therapy) 1

Imaging Studies

• Plain radiographs of hands, wrists, and feet to assess for:
  • Soft tissue swelling and juxtaarticular osteoporosis (early disease) 2
  • Joint space narrowing and erosions (established disease) 1
• Consider ultrasound to detect early synovitis, particularly in finger joints 2
• Consider MRI for early detection of bone marrow edema and synovitis when conventional radiographs are normal 2

Classification Criteria

• Apply the 2010 ACR/EULAR classification criteria for RA diagnosis 1
• Score domains include:
  • Number and site of involved joints (0-5 points)
  • Serologic abnormality (RF and/or ACPA) (0-3 points)
  • Elevated acute-phase reactants (ESR and/or CRP) (0-1 points)
  • Symptom duration (0-1 points)
  • Score ≥6/10 points indicates definite RA 1

Assessment of Comorbidities

• Screen for cardiovascular risk factors (hypertension, dyslipidemia, diabetes) 1, 4
• Assess for interstitial lung disease and other extra-articular manifestations 1
• Screen for osteoporosis 4
• Evaluate for depression and fatigue 1
• Document body mass index (BMI) 1
• Assess smoking status 1

Pre-Treatment Evaluation

• Chest radiograph (to rule out tuberculosis and other pulmonary conditions) 1
• Tuberculosis screening (prior to biologic therapy) 5
• Vaccination status assessment and updates 5
• Baseline quality of life measurement 1

Ongoing Monitoring

• Regular assessment of disease activity every 1-3 months in active disease and every 3-6 months in stable disease 1, 3
• Document treatment response using validated composite measures 1, 4
• Monitor for treatment-related adverse effects 1, 5
• Assess for disease flares characterized by increased joint inflammation, pain, and functional deterioration 3

Common Pitfalls to Avoid

• Delaying diagnosis and treatment, which can lead to irreversible joint damage 4, 6
• Failing to use standardized disease activity measures to guide treatment decisions 1, 4
• Overlooking extra-articular manifestations of RA 1, 2
• Not distinguishing RA from other inflammatory arthritides (psoriatic arthritis, systemic lupus erythematosus) 1
• Inadequate monitoring of disease activity and treatment response 1, 3
• Neglecting to screen for and manage comorbidities 1, 4