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Rheumatoid Arthritis

Anika Morgado

Background

  • Inflammatory disorder of synovial joints, typically polyarticular, that results in proliferation of synovial tissue leading to loss of articular cartilage and juxta articular bone

Presentation

  • Usually insidious onset of polyarticular, often symmetric joint pain and swelling; often with morning stiffness (i.e. >30min)
  • Most common joints: MCPs, PIPs, wrists, ankles, MTPs, knees; classically spares DIPs
  • Axial skeleton is usually spared, other than in severe disease when C1-C2 can be affected (pts usually need spinal imaging before surgical procedures or intubation)
  • Systemic symptoms: fatigue, widespread pain, comorbid psychiatric disease (depression)
  • Extra-articular manifestations: only in seropositive pts
  • Osteopenia, rheumatoid nodules (usually on skin but can form anywhere including lungs), sicca symptoms, scleritis, ILD, constrictive pericarditis, rheumatoid vasculitis, anemia, neutropenia (associated splenomegaly)
  • RA is an independent risk factor for CAD

Evaluation

  • Diagnosis: Clinical symptoms above with physical exam concerning for active synovitis/inflammatory joint changes
    • MCP subluxation, ulnar deviation, Swan and Boutonnieres deformities are late findings of untreated RA
  • ~75-80% of pts test positive for RF, anti CCP (more specific), or both. Up to ~20% seronegative
  • RF can be nonspecific, seen in any disease with chronic stimulation of humoral immune system (HBV, HC, Sjogren’s, lymphoma, cryoglobulinemia)
  • Labs: ESR and CRP (usually elevated in active disease and degree of elevation tends to correlate with disease activity, CBC, CMP, hep B, hep C, TB screening (treatment planning)
  • Imaging: hand and foot plain films

Management

  • Early diagnosis and use of DMARDs are key with goal of early remission or low disease activity. Most joint damage begins early in disease course
  • Start with MTX weekly (with folic acid) in most pts
  • NSAIDs/systemic glucocorticoids can be initiated simultaneously to rapidly reduce symptoms/disease activity while MTX takes effect (weeks to months for peak)
  • If pts cannot take MTX, trial HDQ, SSZ, or LEF
  • If poor response to MTX, usually trial combination therapy
  • MTX + SSZ and HCQ in resource limited settings or biologics contraindications
  • MTX + TNF inhibitor or JAK inhibitor