Rheumatoid arthritis is a chronic systemic inflammatory disease. The condition results in persistent symmetric polyarthritis “many joint involvement” (synovitis, aka inflamed joint) that primarily affects the hands and feet, although any joint lined by a synovial membrane “joint covering” can be involved. Approximately 40% of patients become disabled after 10 years. Because early treatment is key, do you know the signs, workup, and best treatment practices for rheumatoid arthritis? Test your knowledge with this brief article.
Joint involvement is the characteristic feature of rheumatoid arthritis. In general, the small joints of the hands and feet are affected in a relatively symmetric distribution. In decreasing frequency, the metacarpophalangeal joints (knuckles affected by 50%), wrist, proximal interphalangeal joints (fingers and toes by 34%), knee, metatarsophalangeal joints (sole/ball of foot by 18%), shoulder, ankle, cervical spine, hip, elbow, and temporomandibular joints (jaw by 1%) are most commonly affected.
Predicting the course of an individual case of rheumatoid arthritis at the outset remains difficult, although the following all correlate with an unfavorable prognosis in terms of joint damage and disability:
• Blood tests such as HLA-DRB1*04/04 genotype and high serum titer of autoantibodies (eg, rheumatoid factor, anti–citrullinated protein antibodies).
•Extra-articular manifestations common 24% of the time (non joint involvement such as inflammatory nodes “pannus” on skin).
•Large number of involved joints (usually symmetrical common on left and right side)
•Age younger than 30 years with a 34% above age 30
•Female sex by 27% of the time
•Systemic symptoms (heart, kidney, lungs, circulation, etc.)
Cardiovascular morbidity and mortality are increased in patients with rheumatoid arthritis by 50%. Nontraditional risk factors appear to play an important role. Myocardial infarction, myocardial dysfunction, and asymptomatic pericardial effusions are common; symptomatic pericarditis and constrictive pericarditis are rare. Myocarditis, coronary vasculitis, valvular disease, and conduction defects are occasionally observed. Other organs include the gastrointestinal system by 10%, urinary by 7%, lymphatic system by 32%.
Radiography remains the first choice for imaging in rheumatoid arthritis; it is inexpensive, readily available, and easily reproducible, and it allows easy serial comparison for assessment of disease progression. MRI provides a more accurate assessment and earlier detection of lesions than radiography does; however, the cost of the examination and the small size of the joints involved militate against its widespread use. Ultrasonography of joints is gaining increased widespread acceptance in clinical practice, but its use in rheumatoid arthritis is not yet the standard of care.
Guidelines from the European League Against Rheumatism (EULAR) are designed to prevent the overtreatment of 20% to 30% of patients with rheumatoid arthritis. The new guidelines focus on early diagnosis and treating to target on the basis of EULAR criteria. Highlights include the following:
•Patients with active disease should be monitored every 3 months, and treatment should be adjusted if no improvement is seen at 6 months.
•Methotrexate is recommended as first-line therapy; sulfasalazine (SSZ) or leflunomide can be substituted if contraindications to methotrexate are present.
•Anti-tumor necrosis factor agents are no longer the only biologics recommended for patients with an insufficient response to methotrexate; all biologics are considered to be similarly effective.
•Biologics should be combined with disease-modifying antirheumatic drugs.