My sky: Rheumatoid Arthritis

TheBasics

SYMPTOMS: stiffness, swelling, destruction of cartilage and bone. Also extra-articular symptoms including pleurisy, pericarditis, pulmonary fibrosis. Rarely: vasculitis and renal amyloidosis

DIAGNOSIS:

• Test patients who have at least 1 joint with definite clinical synovitis not better explained by another disease.

• Definite RA is defined by a score of 6/10 of the following:
           A. Joint involvement: 1 large joint = 0
                                      2 - 10 large joints = 1
                                      1 - 3 small joints with or without involvement of large joints = 2
                                      4 - 10 small joints with or without involvement of large joints = 3
                                      >10 joints and at least 1 small joint = 5
           B. Serology (at least 1 test result is needed for classification)
                                      Negative RF and negative ACPA= 0
                                      Low-positive RF or low-positive ACPA = 2
                                      High-positive RF or high-positive ACPA = 3
           C. Acute-phase reactants (at least 1 test result is needed for classification)
                                      Normal CRP and normal ESR = 0
                                      Abnormal CRP or normal ESR = 1
                                      Duration of symptoms (6 weeks = 0; >6 weeks = 1)

Source: 2010 Rheumatoid Arthritis Classification Criteria (ACR/EULAR)

TREATMENT:

• Treat early and aggressively to lowest possible disease activity to improve outcomes

• Methotrexate (MTX) is the cornerstone of treatment

• Remission is possible for many patients taking MTX in combination with a tumor necrosis factor (TNF)-α inhibitor or mode of action (MOA) biologic agent

• See 2010 EULAR treatment algorithm

• Randomized trials also support exercise and self-management strategies.

• Regular monitoring of symptoms is crucial. (See MDHAQ)

GUIDELINES:

2010 Rheumatoid Arthritis Classification Criteria: An American College of Rheumatology/European League Against Rheumatism Collaborative Initiative

American College of Rheumatology/European League Against Rheumatism Provisional Definition of Remission in Rheumatoid Arthritis

EULAR Recommendations for the Management of Rheumatoid Arthritis With Synthetic and Biological Disease-Modifying Antirheumatic Drugs

EULAR Evidence-Based Recommendations for Cardiovascular Risk Management in Patients With Rheumatoid Arthritis and Other Forms of Inflammatory Arthritis

RESOURCES:

Managing RA in 2011: An Update
The Journal of Musculoskeletal Medicine, January 2011

A multidimensional health assessment questionnaire (MDHAQ) for all patients with rheumatic diseases to complete at all visits in standard clinical care
Bulletin of the NYU Hospital of Joint Diseases, January 2007

Effect of a treatment strategy of tight control for rheumatoid arthirits (the TICORA study): A single-blind randomised controlled trial
Lancet, July 2004