What are the symptoms and treatment options for rheumatoid arthritis?

Symptoms of Rheumatoid Arthritis

Rheumatoid arthritis characteristically presents with symmetric polyarthritis affecting the hands and feet, accompanied by morning stiffness lasting ≥1 hour, and these joint symptoms are the hallmark features that should prompt immediate evaluation and treatment. 1

Core Clinical Features

Joint Manifestations

• Symmetric polyarthritis with joint swelling is the defining feature, most commonly affecting the metacarpophalangeal (MCP) joints, proximal interphalangeal (PIP) joints, wrists, and metatarsophalangeal (MTP) joints 1
• Morning stiffness lasting 1 hour or longer before maximal improvement is a critical distinguishing symptom from non-inflammatory arthritis 1, 2
• Joint pain, tenderness, and swelling on examination (not just patient-reported tenderness) must be documented 2
• The distal interphalangeal joints are typically spared, helping differentiate from osteoarthritis 2
• Any appendicular joints may become involved as disease progresses 1

Extra-Articular Manifestations (Markers of Severe Disease)

• Subcutaneous rheumatoid nodules indicate more aggressive disease 1
• Interstitial lung disease occurs more frequently in patients with high rheumatoid factor levels 3
• Vasculitis represents severe extra-articular involvement 1
• Inflammatory eye disease (various forms) signals systemic disease activity 1

Functional Impact and Prognosis

Disability Burden

• More than one-third of patients eventually experience work disability due to the disease 1
• Loss of employment begins early: 80% are working at 2 years, declining to 68% at 5 years after diagnosis 1
• The disease impairs activities of daily living, vocational pursuits, and avocational activities 1

Mortality Impact

• Life expectancy is shortened by 3 to 5 years, particularly in patients with extra-articular disease manifestations 1, 3
• Patients with high rheumatoid factor levels (≥3× upper normal limit) have a 1.48-fold increased risk of extra-articular manifestations and reduced survival 3

Treatment Approach

Immediate Aggressive Therapy

• Start methotrexate 15-25 mg weekly immediately upon diagnosis as first-line disease-modifying antirheumatic drug (DMARD) therapy 3, 2
• Add prednisone 10-20 mg daily as bridging therapy for rapid symptom control while DMARDs take effect 3, 2
• NSAIDs and analgesics may be continued for symptomatic relief but do not modify disease progression 4, 5

Treatment Target

• The primary goal is remission, defined as Simplified Disease Activity Index (SDAI) ≤3.3 or Clinical Disease Activity Index (CDAI) ≤2.8 1, 3, 2
• Low disease activity (SDAI ≤11, CDAI ≤10) may be more appropriate in patients with severe, refractory, or long-established disease 1
• Reassess disease activity every 4-6 weeks using composite measures to guide treatment escalation 2

Escalation Strategy for Inadequate Response

• If inadequate response to methotrexate monotherapy, add a biologic agent such as TNF inhibitors (adalimumab, etanercept, infliximab) 3, 4
• If first TNF inhibitor fails, switch to an alternative mechanism: rituximab, abatacept, or tocilizumab 1, 3
• Combination therapy with methotrexate plus biologics is more effective than monotherapy 4

Critical Diagnostic Workup

Essential Laboratory Tests

• Anti-citrullinated protein antibody (ACPA) has 90% specificity and 60% sensitivity for RA 1, 3, 2
• Rheumatoid factor (RF) has 70% specificity and 60-80% sensitivity, with specificity increasing substantially at higher titers 3, 2
• C-reactive protein (CRP) is preferred over ESR as it correlates more closely with disease activity and is not age-dependent 3, 2
• Complete blood count and comprehensive metabolic panel to assess for cytopenias and organ function 2

Imaging Studies

• Bilateral hand, wrist, and foot X-rays at baseline to assess for erosions and establish monitoring baseline 2
• Radiographic findings include periarticular osteopenia, uniform joint space narrowing, and osseous erosions 2
• Ultrasound with power Doppler or MRI may detect subclinical synovitis and predict disease progression 2

Common Pitfalls to Avoid

• Do not delay DMARD therapy while waiting for definitive serologic confirmation—clinical synovitis with suggestive features warrants immediate treatment 3, 2
• Recognize that high disease activity scores may result from fibromyalgia (high tender joint counts without swollen joints or elevated CRP), which should not trigger biologic escalation 1
• Long-term corticosteroid use beyond 1-2 years carries risks (cataracts, osteoporosis, fractures, cardiovascular disease) that often outweigh benefits 1
• Monitor closely for extra-articular disease in patients with high RF or ACPA levels, including pulmonary, cardiovascular, and ophthalmologic complications 3, 2