Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a symmetric, inflammatory, peripheral polyarthritis of unknown etiology

Diagnosis

  • Inflammatory arthritis involving three or more joints

  • Positive RF and/or anti-CCP

  • Elevated ESR/CRP

  • Exclusion of other diseases (particularly psoriatic arthritis, acute viral, gout, calcium pyrophosphate, and lupus)

  • Duration > 6 weeks

Evaluation

  • History and exam

  • Arthritis typically MCP and PIP joints of the hands, wrists, 2nd to 5th MTP

Blood tests

  • RF (positive in 80% of patients with RA, 10% of normal people, and 30% of SLE)

  • Anti-CCP (specificity 95+%)

  • ESR and CRP

  • ANA

  • FBC, UEC, LFT Uric acid, Urinalysis

  • Consider infective studies if needed

Imaging

  • XRAY hands, wrists, and feet

  • CXR if considering DMARD

Management

Early recognition and diagnosis

  • Achieving the benefits of early intervention with DMARDs depends upon making the diagnosis of RA as early as possible

  • Persistent synovial inflammation is a proliferative and destructive process in joint tissues

Rheumatologist

  • Benefit from early and ongoing care

Early use of DMARDs

  • Started as soon as possible

  • Much of the damage occurs early in the illness

Tight control

  • The therapeutic target is remission or a state of minimal disease activity

  • If resistant to DMARD then consider a combo e.g. MTX + Sulfasalazine

  • Consider NSAIDs and / or oral and intraarticular glucocorticoids as an adjunct to DMARDs as bridging therapy to maintain control of disease activity

Non Pharmacological Treatment

Patient Education

  • Important and individualised

Psychosocial interventions

  • CBT

Physical activity and exercise

  • Aerobic and anaerobic

  • Resistance

  • Improves fatigue, pain, and psychological wellbeing

  • Exercise for RA - Exercise Is Medicine Factsheet

  • Pai and stiffness lead to patients not using the joints

Physical and occupational therapy

  • Physical therapy goals are

    • Pain relief

    • Reduction of inflammation

    • Preservation of joint

  • If arthritis is under good control

    • Can participate in variable resistance exercise programs

  • Moderate inflammation

    • Isometric contractions

  • Severe inflammation

    • May require resting splints rather than exercise

Proper nutrition and diet

  • RA associated with anorexia and poor dietary intake

  • Obese patients should be encouraged to lose weight to decrease stress on joints

  • Dietary intervention for inflammatory arthritis

    • Diets rich in fish oil or omega-3 has evidence

    • Mediterranean diets, high in vegetables and fruit

Pharmacological Therapy

Pre-treatment evaluation

  • FBC, UEC, LFT, ESR, CRP, Hep B, Hep C

  • Opth review if hydroxycholoquine

  • TB if biologics or JAK inhibitors

Pre-treatment interventions

  • CV risk assessment

  • Immunisation

Choice of therapy

  • Factors affecting drug choices

    • Level of disease activity (eg, mild versus moderate to severe)

    • Presence of comorbid conditions

    • Stage of therapy (eg, initial versus subsequent therapy in patients resistant to a given intervention)

    • Regulatory restrictions (eg, governmental or health insurance company coverage limitations)

    • Patient preferences (eg, route and frequency of drug administration, monitoring requirements, personal cost, fertility planning)

    • Presence of adverse prognostic signs

  • DMARD

    • Non-biologic including MTX, HCQ, SSZ, LEF

    • Biological

    • Target e.g. JAK inhibitors

Approach to drug therapy

  • NSAID or Glucocorticoid depending on the severity

  • Then start MTX

  • DMARDS take weeks to months to achieve optimal results

Clinical assessment of disease and related testing

  • Patient history on the degree of joint pain, duration of morning stiffness, the severity of fatigue

  • Extra-articular manifestations such as fever, weight loss, malaise, eyes, lungs, heart

  • Functional capacity, ADLs, work, hobbies

Exam

  • Detailed exam

Labs

  • ESR and CRP for disease severity and monitoring

Imaging

  • Plain XR hands

  • Wrists (one PA view)

  • Forefeet including MCP joints (at least one AP view)

DMARD Therapy

  • Usually Methotrexate

  • Single weekly dose orally

  • 7.5 to 15mg once weekly for most patients e.g. 70yo weighing 55kg with moderately active disease an initial dose of 7.5mg once weekly whilst 30yo weighing 80kg with highly active disease would be started on 15mg once weekly

  • Lower dose if eGFR <60

  • Increase as needed and tolerated to control symptoms

  • Increase by 2.5mg every 4 weeks if needed

Anti-inflammatory Therapy

  • Rapidly control inflammation but do not provide adequate benefit for longer-term control

  • Chronic use leads to adverse effects, especially glucocorticoids

  • NSAIDs titrated up to maximum dose and continued for at least 2 weeks before switching agents, anti-inflammatory effect usually achieved within 10-14 days

  • 2400-3200mg Ibuprofen, 1000mg of Napoxen, 15mg on Meloxicam

  • Side effects on UeC and GIT symptoms

  • If using glucocorticoids doses are 5 to 20mg of Prednisolone

  • Most patients can be controlled on 5 to 10mg daily whilst starting a DMARD

  • Taper as rapidly as possible with the goal of discontinuation

Other drugs

  • Max Paracetamol if helpful

References: