Rheumatoid Arthritis: Diagnosis and Treatment

Diagnosis

The diagnosis of rheumatoid arthritis is largely clinical; no single laboratory or imaging study is definitive. The American Rheumatism Association has established 7 clinical signs, 4 of which must be present for diagnosis:

• Morning stiffness in/around joints, lasting at least 1 hour before maximal improvement.
• Soft tissue swelling and pain of three or more joint areas lasting at least 6 weeks.
• Swelling of the proximal interphalangeal, metacarpophalangeal, or wrist joints lasting at least 6 weeks.
• Symmetric swelling (arthritis) lasting at least 6 weeks.
• Rheumatoid nodules.
• Positive rheumatoid factor (found in about 85% of patients).
• Radiographic erosions and/or periarticular osteopenia in hand and/or wrist joints.

Treatment

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

Extra-articular manifestations are treated according to the specific syndrome (eg, lubricating eye drops for dry eye syndrome).

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, judicious strength training, and range-of-motion exercises, are important for preserving joint function and preventing contractures and muscle atrophy.

Heat and hydrotherapy, relaxation techniques, and passive and active joint exercises are also helpful.

Pharmacologic Therapy

Anti-inflammatory medications are first-line treatments. Steroids are more effective than NSAIDs for pain relief and suppression of inflammation; however, they should be used carefully, as patients are at significant risk for bone loss, among other complications. When steroids are used, dietary supplementation with vitamin D and calcium should be instituted. Patients who require steroid therapy beyond 3 months may benefit from the addition of a bisphosphonate such as alendronate.

Disease-modifying antirheumatic drugs (DMARDs) are a mainstay of rheumatoid arthritis therapy and may prevent joint damage, preserve joint integrity and function, reduce health costs, and maintain economic productivity.¹ These drugs include hydroxychloroquine, sulfasalazine, methotrexate, leflunomide, gold salts, D-penicillamine, azathioprine, and cyclosporine. 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 (etanercept, infliximab, adalimumab), and interleukin-1 receptor antagonists (anakinra). Other biological agents targeting key cellular constituents of the immune system or cytokines are expected to be approved in the near future.