Definition
A.Rheumatoid arthritis (RA) is a chronic, inflammatory, symmetric polyarthritis that can have systemic effects on multiple organ systems with no clear etiology.
Incidence
A.Prevalence 1% with female to male ration of 3:1.
B.Peak onset for women is fourth to fifth decade.
C.Peak onset for men is sixth to eighth decade.
D.Annual incidence is 40 per 100,000.
E.Increased frequency of the disease in first-degree relatives and monozygotic twins.
Pathogenesis
A.No clear cause has been identified for RA; however, genetics and environment appear to contribute to the development of RA. The best characterized genetic risk factor is inheritance of the HLA DRB1 alleles encoding a shared epitope.
B.Chronic synovitis and joint destruction are characteristic of RA.
C.Pannus, destructive vascular granulation tissue, is a distinctive feature of RA and destroys adjacent cartilage, bone, ligaments, and tendons.
Predisposing Factors
A.Gender-specific risk factors.
1.Women: Nulliparity and postpartum state can increase acute flare.
2.Men: Below normal testosterone levels.
B.Genetic predisposition.
C.Cigarette smoking, heavy caffeine consumption, and oral contraception, particularly in patients carrying the shared epitope.
D.Infection (both bacterial and viral) has been hypothesized to trigger RA but no specific bacterial or viral pathogens have been identified.
E.Autoantibody carriers, specifically rheumatoid factor (RF) and anti-citrullinated peptide/protein antibodies (ACPA), increase the risk for development of RA.
F.Occupational exposures including dust and silica.
Subjective Data
A.Common complaints/symptoms.
1.Insidious onset of polyarticular inflammation and complaints of joint pain and stiffness is the most common presentation but some patients may present with acute symptoms.
2.Joint stiffness will last more than 30 minutes and is prominent in the morning, after periods of inactivity and after strenuous activity.
3.Systemic manifestations can also be present.
4.Symptoms tend to be reported in the small joints of the hands, wrist, and forefoot. All joints of the extremities can be affected. Typically, the axial skeleton except for the cervical spine will not be involved.
B.Common/typical scenario.
1.Systemic symptoms include dryness of the eyes and mucous membranes, presence of rheumatoid nodules, pulmonary symptoms including cough and dyspnea, weight loss, fatigue, and depression.
2.Felty syndrome is seen in advanced disease and is characterized by splenomegaly and neutropenia. (C).
C.Family and social history.
1.Family history of RA.
2.Social history.
a.Smoking.
b.Caffeine intake.
c.Occupational exposures.
D.Review of systems.
1.Joint pain and stiffness.
2.Swelling.
3.Presence of skin nodules.
4.Changes in skin color.
5.Dryness of mucous membranes.
6.Cough.
7.Dyspnea.
Physical Examination
A.Symmetrical, polyarticular swelling with pain, and tenderness is characteristic.
B.Boggy
feeling over the affected joints due to synovial thickening or effusion.
C.Palmar erythema may be present in acute flares.
D.Deformities are common in late disease and may be asymmetrical.
E.Decreased grip strength is noted in disease affecting the hands and can be an early indicator of disease.
F.Ulnar deviation, swan neck deformities (flexion of the distal interphalangeal [DIP] joint with extension of the proximal interphalangeal [PIP] joint) and Boutonniere deformities (hyperextension of the DIP joint with flexion of the PIP joint) of the fingers are common in chronic RA.
G.Tendon ruptures can occur.
H.Rheumatoid nodules are subcutaneous nodules found over bony prominences (most commonly), bursae, and tendon sheaths and are found in 20% of patients.
I.Ocular findings include scleritis and episcleritis.
Diagnostic Tests
A.Radiographs (most specific testing): Early images may be normal or show evidence of soft tissue swelling and juxta-articular demineralization. Later images will reveal joint space narrowing and erosions.
B.Elevated erythrocyte sedimentation rate (ESR) and C-reactive protein levels: Elevated in acute phases.
C.Anti-cyclic citrullinated peptide (anti-CCP) antibodies and RF: present in about 3/4 of patients with RA.
D.Synovial fluid analysis: Inflammatory effusion often performed to rule out septic arthritis.
Differential Diagnosis
A.Fibromyalgia.
B.Lyme disease.
C.Myelodysplastic syndrome.
D.Osteoarthritis.
E.Sarcoidosis.
F.Systemic lupus erythematosus.
Evaluation and Management Plan
A.General plan.
1.Goals.
a.Reduce pain and inflammation.
b.Preserve function.
c.Prevent deformity.
2.Nonpharmacologic.
a.Physical and occupational therapy.
b.Diet and exercise.
c.Smoking cessation.
d.Osteoporosis screening and treatment.
e.Immunizations to reduce risk of immunosuppressive therapies.
B.Patient/family teaching points.
1.Similar to nonpharmacological management.
2.Diet.
3.Exercise.
4.Smoking cessation.
5.Physical and occupational therapy.
6.Routine screening and immunizations.
C.Pharmacotherapy.
1.Nonsteroidal anti-inflammatory drugs (NSAIDs): For symptomatic relief, but not to be used as monotherapy.
2.Corticosteroids.
a.Used to bridge until disease-modifying antirheumatic drugs (DMARDs) are effective or during active disease.
b.Will decrease inflammation and slow articular erosion.
c.Recommended dose is prednisone 5 to 10 mg po daily.
i.Higher doses may be needed to treat extra-articular manifestations and should be tapered when discontinuing.
d.Intra-articular corticosteroids may be helpful to treat one to two symptomatic joints but may not be administered more than four times per year.
e.Recommended dose is triamcinolone 10 to 40 mg based on size of joint being treated.
3.DMARDs.
a.Begin as soon as RA is confirmed.
b.More efficacious when used in combination than as a monotherapy.
c.Most commonly used combination is methotrexate with a tumor necrosis factor (TNF) inhibitor.
i.Methotrexate: Initial synthetic DMARD of choice (7.5 mg po weekly); can see improvement in 2 to 6 weeks.
ii.TNF inhibitors: Added when patients do not respond to methotrexate.
Follow-Up
A.Patients should follow-up after starting or changes are made to medications.
Consultation/Referral
A.Rheumatology as early as possible to confirm diagnosis and manage disease.
Special/Geriatric Considerations
A.RA can be a debilitating disease that makes activities of daily living very difficult.
B.Geriatric patients may have increased risk associated with RA, such as:
1.Cognitive impairment.
2.Depression.
3.Falls.
4.Urinary incontinence.
5.Malnutrition.
Bibliography
Firestein, G. S. (2017, August 30). Pathogenesis of rheumatoid arthritis.In P. L. Romain (Ed.), UpToDate. Retrieved from https://www.uptodate.com/contents/pathogenesis-of-rheumatoid-arthritis
Hannon, R. A., & Porth, C. M. (Eds.). (2017). Porth pathophysiology: Concepts of altered health states (2nd ed.). Philadelphia, PA: Wolters Kluwer.
Moreland, L. W., & Cannella, A. (2018, May 31). General principles of management of rheumatoid arthritis in adults. In P. L. Romain (Ed.), UpToDate. Retrieved from https://www.uptodate.com/contents/general-principles-of-management-of-rheumatoid-arthritis-in-adults?source=search_result&search=treatment%20rheumatoid%20arthritis&selectedTitle=1
Papadakis, M. A. (2017). Current medical diagnosis & treatment 2017 (56th ed.). New York, NY: McGraw-Hill Education/Medical.
Venables, P. J. W. (2017, October 12). Clinical manifestations of rheumatoid arthritis. In P. L. Romain (Ed.), UpToDate. Retrieved from https://www.uptodate.com/contents/clinical-manifestations-of-rheumatoid-arthritis?source=search_result&search=rheumatoid%20arthritis&selectedTitle=2