Rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic inflammatory disorder that primarily affects joints but can also have systemic manifestations. Here’s an overview of its diagnosis, differential diagnosis, and management:

Diagnosis:

  • Clinical Assessment:
    • Symptoms: Joint pain, swelling, stiffness (especially in the morning or after periods of inactivity), and symmetrical joint involvement.
    • Physical Examination: Evidence of synovitis (swelling within the joint), tenderness on palpation, and reduced range of motion.
  • Laboratory Tests:
    • Antibodies:
      • Rheumatoid Factor (RF)
      • Anti-Cyclic Citrullinated Peptide (anti-CCP)
      • These markers often present in RA but can be seen in other diseases as well.
    • Inflammatory Markers: Elevated Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP) levels.
  • Imaging:
    • X-rays: May show joint space narrowing, erosion, and osteopenia near the joint (periarticular osteopenia).
    • Ultrasound or MRI: Can detect early joint inflammation and damage before it’s visible on X-rays.

Differential Diagnosis:

  • Osteoarthritis (OA): Typically presents with joint pain and stiffness that worsens with activity, not with rest.
  • Psoriatic Arthritis: Similar to RA but often with skin manifestations (psoriasis) and sometimes a different joint distribution.
  • Gout and Pseudogout: Acute episodes of joint inflammation caused by crystal deposition.
  • Systemic Lupus Erythematosus (SLE): May have joint symptoms similar to RA but with a broader range of systemic symptoms.
  • Spondyloarthropathies: Such as ankylosing spondylitis, which affects the spine and sacroiliac joints.
  • Viral Arthritis: Joint symptoms following an infection, often self-limiting.

Management:

  • Non-Pharmacologic Treatments:
    • Physiotherapy: To maintain joint function and muscle strength.
    • Occupational Therapy: To assist with adaptation of daily activities.
    • Patient Education: On the nature of the disease, treatment options, and lifestyle modifications.
  • Pharmacologic Treatments:
    • Disease-Modifying Antirheumatic Drugs (DMARDs): Methotrexate is the most commonly used first-line DMARD for RA.
    • Biologic Agents: TNF inhibitors, interleukin-6 (IL-6) receptor blockers, and other biologics are options for patients who do not respond adequately to traditional DMARDs.
    • Janus Kinase (JAK) Inhibitors: A newer class of oral medications for RA.
    • Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) and Corticosteroids: Used for symptom control but do not alter disease progression.
  • Surgical Interventions:
    • Synovectomy: Removal of inflamed joint tissue.
    • Joint Replacement: For advanced joint damage, particularly in hips and knees.
  • Lifestyle Modifications:
    • Exercise: To maintain joint flexibility and muscle strength.
    • Smoking Cessation: Smoking is a known risk factor for RA and can worsen the disease.
    • Diet: Some evidence suggests that a diet rich in omega-3 fatty acids and antioxidants may be beneficial.
  • Regular Monitoring:
    • Frequent monitoring for disease activity, medication side effects, and comorbid conditions.

RA management is typically a combined effort of rheumatologists, GPs, physiotherapists, and other health professionals. It aims to reduce inflammation, control symptoms, prevent joint and organ damage, improve physical function and overall well-being, and reduce long-term complications.