Rheumatoid Arthritis Overview

Contents

Overview
Clinical Manifestations
Diagnosis
Clinical Remission
Principles of Treatment
Non-Pharmacological Therapy
Pharmacological Therapy
Surgery
Follow-Up
Patient Education
Guideline References

OVERVIEW

  • Rheumatoid Arthritis (RA) is a chronic, inflammatory arthritis of unknown etiology
    • Also considered an autoimmune rheumatic disorder; most common form of inflammatory arthritis
    • Persistent synovitis leads to joint destruction & deformity
  • Signs & symptoms include joint pain & swelling, morning stiffness lasting >1 hr, myalgia, weight loss, & low-grade fever
Early RA
  • Onset of signs and symptoms is < 6 mnths from time of diagnosis
Established RA
  • Onset of signs and symptoms is > 6 mnths from time of diagnosis & meets the classification criteria for RA
Palindromic Rheumatism
  • Follows an episodic pattern
    • Joints may be affected for hr to days followed by symptom-free periods lasting for days to mth
Monoarthritis
  • May indicate onset of a polyarticular disease
    • Interval between monoarthritis & polyarthritis may extend from days to wk in patients w/ progressive disease
  • Large joints are frequently affected (eg shoulder, wrist, hip, knee, ankles)
  • History of joint trauma may be the initiating event
Extra-articular Involvement
  • Anemia, fatigue, pleuropericarditis, neuropathy, scleritis, Sjogren’s syndrome, vasculitis
  • Subcutaneous rheumatoid nodules on extensor surfaces of elbows & over Achilles tendons
  • Splenomegaly, renal disease

Refer to Symptoms for more information on Rheumatoid Arthritis

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Diagnosis

Classification of rheumatoid arthritis is based on the criteria developed by the American College of Rheumatology (ACR) Board of Directors & European League Against Rheumatism (EULAR) Executive Committee, depending on the following points:
  • Number and site of involved joints
  • Serological abnormality
  • Acute-phase reactants abnormality
  • Symptom duration
Diagnosis is based on clinical signs & symptoms, lab results & imaging features
Laboratory tests used to diagnose rheumatoid arthritis include:
  • Rheumatoid factor (RF)
  • Anti-citrullinated protein antibody (ACPA)
  • Acute phase reactants
  • Complete blood count
  • Synovial fluid analysis

Imaging studies used to confirm the diagnosis of rheumatoid arthritis include x-ray, MRI and ultrasound

Refer to Diagnosis for more information

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Treatment

  • Management of rheumatoid arthritis aims for control of signs & symptoms, limit radiographic damage, & reduce functional limitations & permanent joint damage 
  • Therapeutic agents used for the management of rheumatoid arthritis depends on the severity of the disease
  • Therapeutic options include non-biological DMARDs (gold salts, Hydroxychloroquine, Chloroquine, Leflunomide, Methotrexate, Sulfasalazine) & biological DMARDs (TNF inhibitors, non-TNF biologicals)
    • TNF inhibitors used for rheumatoid arthritis include Adalimumab, Certolizumab pegol, Etanercept, Infliximab, Golimumab
    • Non-TNF biologicals used for rheumatoid arthritis include Abatacept, Rituximab, Tocilizumab, Tofacitinib
  • Combination therapy with DMARDs is considered as first-line treatment
  • Adjunctive agents that may be used to manage symptoms of rheumatoid arthritis include analgesics, corticosteroids, & NSAIDs
  • Exercise, physical therapy, occupational therapy, nutritional therapy & weight management, & splints may be considered

Refer to Non-pharmacological Therapy for information on Non-pharmacological Therapy

Refer to Pharmacological Therapy for more information on Pharmacological Therapy

Below is the overview of disease management of Rheumatoid Arthritis:
 

Rheumatoid_Arthritis1

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Rheumatoid_Arthritis2

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Rheumatoid_Arthritis3

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Rheumatoid Arthritis Symptoms▶

Version: 7 Sep 2015

Guideline References:

  1. Aletaha D, Neogi T, Silman AJ, et al. 2010 Rheumatoid arthritis classification criteria: an American College of Rheumatology/ European League Against Rheumatism collaborative initiative. Ann Rheum Dis. 2010 Sep;69(9):1580-1588. doi: 10.1136/ard.2010.138461. PMID: 20699241
  2. Felson DT, Smolen JS, Wells G, et al. American College of Rheumatology/European League Against Rheumatism provisional definition of remission in rheumatoid arthritis for clinical trials. Arthritis Rheum. 2011 Mar;63(3):573-586. doi: 10.1002/art.30129. PMID: 21294106
  3. Furst DE, Breedveld FC, Kalden JR, et al. Updated consensus statement on biological agents for the treatment of rheumatic diseases, 2007. Ann Rheum Dis. 2007 Nov;66(Suppl 3):iii2-iii22. PMID: 17934088
  4. Majithia V, Geraci SA. Rheumatoid arthritis: diagnosis and management. Am J Med. 2007 Nov;120(11):936-939. PMID: 17976416
  5. National Institute for Health and Care Excellence. Abatacept for treating rheumatoid arthritis after the failure of conventional disease-modifying anti-rheumatic drugs (rapid review of technology appraisal guidance 234). NICE website. http://www.nice.org.uk/nicemedia/live/14155/63676/63676.pdf. Apr 2013. Accessed 04 Jul 2013.
  6. National Institute for Health and Care Excellence. Adalimumab, etanercept, and infliximab for the treatment of rheumatoid arthritis. NICE website. http://www.nice.org.uk/guidance/ta130/resources/guidance-adalimumab-etanercept-and-infliximab-for-the-treatment-of-rheumatoid-arthritis-pdf. Sep 2010.
  7. National Institute for Health and Care Excellence. Adalimumab, etanercept, infliximab, rituximab and abatacept for the treatment of rheumatoid arthritis after the failure of a tumour necrosis factor inhibitor. NICE website. http://www.nice.org.uk/guidance/ta195/resources/guidance-adalimumab-etanercept-infliximab-rituximab-and-abatacept-for-the-treatment-of-rheumatoid-arthritis-after-the-failure-of-a-tnf-inhibitor-pdf. Aug 2010.
  8. National Institute for Health and Care Excellence. Certolizumab pegol for the treatment of rheumatoid arthritis. NICE website. http://www.nice.org.uk/guidance/ta186/resources/guidance-certolizumab-pegol-for-the-treatment-of-rheumatoid-arthritis-pdf. Feb 2010.
  9. National Institute for Health and Care Excellence. Rheumatoid arthritis: the management of rheumatoid arthritis in adults. NICE website. http://www.nice.org.uk/guidance/cg79/resources/guidance-rheumatoid-arthritis-pdf. Feb 2009.
  10. National Institute for Health and Care Excellence. Tocilizumab for the treatment of rheumatoid arthritis. NICE website. http://www.nice.org.uk/guidance/ta198/resources/guidance-tocilizumab-for-the-treatment-of-rheumatoid-arthritis-pdf. Aug 2010.
  11. Saag KG, Teng GG, Patkar NM, et al. American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis. Arthritis Rheum. 2008 Jun;59(6):762-784. doi: 10.1002/art.23721. PMID: 18512708
  12. Schur PH, Maini RN, Gibofsky A. Nonpharmacologic and preventive therapies of rheumatoid arthritis. UptoDate Web Site. http://www.uptodate.com/index. Dec 2010.
  13. Schur PH, Maini RN, Moreland LW. General principles of management of rheumatoid arthritis. UptoDate Web Site. http://www.uptodate.com/index. Feb 2011.
  14. Scottish Intercollegiate Guidelines Network. Management of early rheumatoid arthritis. SIGN. http://www.sign.ac.uk. Feb 2011
  15. Singh JA, Furst DE, Bharat A, et al. 2012 update of the 2008 American College of Rheumatology recommendations for the use of disease-modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis. Arthritis Care Res (Hoboken). 2012 May;64(5):625-639. doi: 10.1002/acr.21641. PMID: 22473917
  16. Smolen JS, Breedveld FC, Burmester GR, et al. Treating rheumatoid arthritis to target: 2014 update of the recommendations of an international task force. Ann Rheum Dis. 2015 May. http://ard.bmj.com/content/early/2015/05/12/annrheumdis-2015-207524.full.pdf. Accessed 04 Sep 2015. PMID: 25969430
  17. Smolen JS, Landewé R, Breedveld FC, Buch M, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2013 update. Ann Rheum Dis. 2014 Mar;73(3):492-509. doi: 10.1136/annrheumdis-2013-204573. PMID: 24161836
  18. Smolen JS, Landewe R, Breedveld FC, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs. Ann Rheum Dis. 2010 Jun;69(6):964-975. doi: 10.1136/ard.2009.126532. PMID: 20444750
  19. UCB Pharma Inc. Certolizumab pegol: Highlights of prescribing information. http://www.accessdata.fda.gov/drugsatfda_docs/label/2012/125160s0142lbl.pdf. 2008. Accessed 05 Jul 2013
  20. Venables PJW, Maini RN. Clinical features of rheumatoid arthritis. UptoDate Web Site. http://www.uptodate.com/index. Feb 2011.
  21. Venables PJW, Maini RN. Diagnosis and differential diagnosis of rheumatoid arthritis. UptoDate Web Site. http://www.uptodate.com/index. Nov 2010.