Rheumatoid Arthritis

Rheumatoid Arthritis:

  • Sx: Morning stiffness***
  • Associated systemic Sx: myalgia, fatigue, low-grade fever, weight loss
  • PE: Symmetric tenderness of multiple small joints in the hands and a small effusion of a knee

2010 American College of Rheumatology/European League Against Rheumatism classification criteria for RA

  • Requires ALL of the following for diagnosis:
    • Symptoms > 6 weeks
    • Inflammatory arthritis > 3 joints
    • Positive rheumatoid factor (RF):
      • RF is positive in 70-80% of RA patients.
      • RF is also positive in 5-10% healthy individuals, 20-30% of SLE patients, and nearly all patients with mixed cryoglobinemia.
    • Positive anti-cyclic citrullinated peptide (anti-CCP) Abs***
      • Anti-CCP abs have similar sensitivity to RF but are much more specific for RA (95-98%)
      • High anti-CCP titers can help with diagnosis of RA and predict erosive RA.
    • Elevated CRP or ESR – inflammatory markers
      • Predicts poorer functional outcomes in RA.
    • Exclusion of other similar conditions:
      • Psoriatic arthritis
      • Acute viral polyarthritis
      • Polyarticular gout or calcium pyrophosphate deposition disease
      • SLE: anti-double stranded (ds)DNA abs.
    • Note: Patients with seronegative, recent-onset, or inactive RA may NOT meet ALL of these criteria.
    • Prognostic factors for Erosive RA:
  1. Positive anti-CCP ab and RF
  2. Early development of multiple-joint inflammation
  3. Radiographic erosions
  4. Severe functional limitations.
  5. Lower socioeconomic status and less education
  6. Elevated ESR and CRP
  7. Persistent joint inflammation > 12 weeks.
    • Early identification of predictive factors for erosive RA can lead to more aggressive therapy with disease-modifying anti-rheumatic drugs (DMARDs) to prevent irreversible injury.
      • Factors such as anti-CCP abs and/or joint erosions seen on x-ray are associated with poor prognosis and more aggressive disease.
      • X-ray: radiographic erosions (“marginal erosion”) – marginal bony erosions and carpal crowding
        • Picture (below): Left 3rd metacarpopharlangeal joint in this patient (blue arrow): can suggest RA and indicate underlying erosive RA.
        • These erosions eventually lead to joint inflammation and loss of joint space (red arrows).
      • Inflammatory arthritis: active synovitis (effusion of knee) and positive x-ray findings.

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