Rheumatoid Arthritis: Diagnosis and Management

doi:10.1016/j.amjmed.2007.04.005

The American Journal of Medicine

Volume 120, Issue 11, November 2007, Pages 936-939

https://doi.org/10.1016/j.amjmed.2007.04.005 Get rights and content

Abstract

Accurate diagnosis of rheumatoid arthritis may be difficult early in its course and demands high clinical suspicion, astute examination, and appropriate investigations. Early use of disease-modifying antirheumatic drugs and biologics has improved outcomes but requires close monitoring of disease course and adverse events.

Section snippets

Diagnosis

The diagnosis of rheumatoid arthritis is primarily clinical. The typical presentation is polyarticular, with pain, stiffness, and swelling of multiple joints in a bilateral, symmetric pattern. A minority of patients present with oligoarticular asymmetric involvement.¹ The onset is usually insidious, with joint symptoms emerging over weeks-months and often accompanied by anorexia, weakness, or fatigue. Patients usually note morning stiffness lasting more than an hour. Commonly involved joints

Key Points: Diagnosis and Initial Management Decisions

There are 2 questions for the primary care physician when evaluating a patient with arthritis: Is the diagnosis of rheumatoid arthritis likely? Does the patient need early treatment or referral to a rheumatologist, or both? Findings making rheumatoid arthritis the likely diagnosis and prompting initiation of treatment are:

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Joint swelling (and pain) of 3 or more joints
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Metacarpal or metatarsal joint involvement (a positive squeeze test, ie, significant pain when squeezed across these joints)
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Treatment

A comprehensive approach to managing rheumatoid arthritis consists of patient education, physical/occupational therapy, and drug treatment. Patients should be educated about the disease and referred to these ancillary specialists to maintain joint function and delay disability. Drug treatment generally involves a 3-pronged approach: nonsteroidal anti-inflammatory drugs and low-dose oral or intra-articular glucocorticoids; disease-modifying antirheumatic drugs; and consideration of biologic

Key Points: Management

In managing chronic rheumatoid arthritis, the primary care physician should assess course (improvement or progression), net disability, and medication side effects (including osteoporosis with chronic steroid use). Ongoing surveillance for infection, tuberculosis, and malignancy (age-appropriate screening), osteoporosis and immunizations (influenza vaccine and pneumovax) are essential components of care. Cardiovascular risk factor reduction is warranted due to a higher risk for development of

Summary

Prompt and accurate diagnosis, early aggressive treatment, including disease-modifying antirheumatic drugs or biologics, symptom control, and close monitoring of disease state and medication toxicity are the keys to effective management of the patient with rheumatoid arthritis. Subspecialty referral should be considered in all patients with moderate-severe disease or demonstrating incomplete response.

References (5)

E.D. Harris
Clinical features of rheumatoid arthritis
G.S. Firestein
Etiology and pathogenesis of rheumatoid arthritis

There are more references available in the full text version of this article.

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