Rheumatoid Arthritis: Diagnosis and Treatment

Diagnosis

The diagnosis of rheumatoid arthritis is largely based on the characteristic symptoms and physical examination. No single laboratory or imaging study is definitive.

The American Rheumatism Association has established seven clinical signs, four of which must be present for diagnosis:

• Morning stiffness in or around joints, lasting at least one hour
• Swelling and pain of three or more joint areas lasting at least six weeks
• Swelling of the finger, hand, or wrist joints lasting at least six weeks
• Symmetric swelling (arthritis) lasting at least six weeks
• Rheumatoid nodules
• A positive blood test for rheumatoid factor, which is found in about 85 percent of patients
• X-rays that show typical findings of rheumatoid arthritis, including erosions of bone and loss of bone in the joint areas

Treatment

Treatment of rheumatoid arthritis generally includes physical therapy, dietary intervention (see Nutritional Considerations), anti-inflammatory medication, and disease-modifying agents:

• Weight loss should be encouraged for overweight patients to decrease stress on the weight-bearing joints. Adequate rest and smoking cessation are also beneficial. Surgery is reserved for severe, debilitating disease.
• Physical therapy: Regular low-impact exercise, including aerobic exercises, strength training, and range-of-motion exercises, are important for preserving joint function. Heat therapy, relaxation techniques, and passive and active joint exercises are also helpful.
  
• Anti-inflammatory medications are first-line treatments. Patients who do not respond to nonsteroidal anti-inflammatory medications (e.g., ibuprofen) may find relief with steroids (e.g., prednisone). Steroids are more effective for pain relief and suppression of inflammation; however, they should be used carefully, as they can lead to bone loss, among other complications. When steroids are used, vitamin D and calcium supplementation should be instituted.
  
• Disease-modifying antirheumatic drugs (DMARDs) are an important treatment that may prevent joint damage, preserve joint integrity and function, reduce health costs, and maintain normal quality of life. These drugs include hydroxychloroquine, sulfasalazine, methotrexate, leflunomide, gold salts, D-penicillamine, azathioprine, and cyclosporine. However, many DMARDs have potentially serious side effects and require close monitoring.
  
• Newer agents that have proven beneficial for rheumatoid arthritis include anti-tumor necrosis factor α (TNF-α)  agents (e.g., etanercept, infliximab, and adalimumab), and interleukin-1 receptor antagonists (e.g., anakinra). Other biological agents that target the immune system are expected to be approved in the near future.