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April 20, 2021 01:22pm
By Aislinn Antrim, Associate Editor
Physical examination of patients presenting with symptoms should include the cervical spine, lower and upper extremities, and rheumatoid nodules.
Rheumatoid arthritis (RA) is a chronic inflammatory disease of unknown underlying cause that often results in joint damage and physical disability.1Symptoms may include depression, fatigue, fever, joint stiffness that is worsened by periods of inactivity, loss of appetite, malaise, stiffness lasting for more than an hour first thing in the morning, and swollen, tender, and warm joints, notably the metacarpophalangeal and proximal interphalangeal joints.1,2Other joints may be affected, including the ankles, elbows, and wrists, with associated pain during palpation and range-of-motion exercises.3
Extra-articular manifestations of RA may include cardiac, endocrinal, gastrointestinal, hematological, neurological, ocular, oral, pulmonary, renal, and skeletal presentations, which develop during the course of the illness, likely because of a history of smoking, early onset of significant disability associated with RA, and presence of rheumatoid factor (RF).1
Although the underlying cause of RA is unknown, genetics and infection may play a part. Infection may be a trigger in patients who are genetically susceptible. However, the underlying infections that cause RA have not been determined.3The presence of human leukocyte antigen DRw4 is more common in patients with RA, as well as in those with genetic variants of PTPN22.
Physical examination of patients presenting with RA symptoms should include, but are not limited to, the evaluation of the cervical spine to assess for the presence of deformity, extra-articular manifestations, limited range of motion, pain with range-of-motion exercises, stiffness, swelling, tenderness, and rheumatoid nodules.4
Laboratory and radiography tests, alongside presenting factors, help aid the provider in diagnosing RA. Patients who are female, are in their 40s and 50s with a mean age of 50 to 55, have symmetric arthritis for longer than 6 weeks, and present with joint pain and swelling should be given a differential diagnosis. The female versus male ratio for RA is 2:1, which narrows with increased age, so RA should also be considered in male patients.3
Laboratory testing includes positive RF and anticyclic citrullinated peptide (anti-CCP antibody).3Other lab tests include an antinuclear antibody assay, complete blood count, C-reactive protein level, and erythrocyte sedimentation rate.4Differential diagnoses may include gout, infectious arthritis, psoriatic arthritis, osteoarthritis, and systemic lupus erythematosus.3
Radiography of the cervical spine, elbows, feet, hands, hips, shoulders, wrists, and other joints, depending on patient presentation, can be completed to evaluate for erosions upon diagnosis and for monitoring the progression of RA. Ultrasonography may also be used to evaluate joints and tendon sheaths and to detect more erosions than radiography; it is also more cost-effective than magnetic resonance imaging (MRI).1,3,4
For the detection of early bone marrow changes, joint effusions, and synovitis, an MRI has greater sensitivity. Synovial fluid analysis may be used to evaluate white blood cell counts and an inflammatory state of RA versus other forms of arthritis, such as gout and osteoarthritis.1
The American College of Rheumatology/European League Against Rheumatism collaborative initiative 2010 RA classification criteria and the American Rheumatism Association 1987 revised criteria for the classification of RA may be used to diagnose the condition in a patient who presents with RA symptoms.4
Early aggressive treatment, having tight control of disease activity, and targeting remission are mainstays of therapy to improve physical function, prevent joint and organ damage, reduce long-term complications, relieve symptoms, and stop inflammation associated with RA.5Complications may include an increased risk of coronary artery disease, disability, joint replacement surgery, and mortality.3
Analgesics, biologic non—tumor necrosis factor (TNF) disease-modifying antirheumatic drugs (DMARDs), biologic TNF-inhibiting DMARDs, or nonbiologic DMARDs may be prescribed to manage RA.4,5Nonpharmacologic options include cold and heat therapy, education on energy conservation and joint protection, following healthy diet guidelines, and occupational therapy3,5
Complementary and integrative therapies include dietary supplements, such as cat’s claw, deer or elk antler velvet, feverfew, flaxseed oil, gamma-linolenic acid, green-lipped mussel, omega-3 fatty acids, probiotics, rose hip, and thunder god vine. However, limited studies have been done on dietary supplements, which may have serious adverse effects. Those with thunder god vine include decreases in bone density and male infertility. Mind-body approaches, such as acupuncture, massage, mindfulness mediation, relaxation techniques, Tai Chi, and yoga can also be used, although research supporting their benefits is limited.6
Although RA is incurable, it can be managed with a combination of nonpharmacologic and pharmacologic treatments. Collaboration between the primary care provider and the rheumatologist is essential to achieve optimal results and minimize complications.1 New therapies are emerging for RA for patients with moderate to severe RA, including Olumiant (baricitinib), a Janus kinase inhibitor for patients who did not have an adequate response to 1 or more TNF antagonist therapies.7,8
Hopefully, breakthroughs will occur for patients to have better control of their RA, experience fewer adverse effects during their treatments, and reach remission in their disease course.
Katarzyna LaLicata, MSN, FNP-C, FNP-BC, is a nurse practitioner at CVS Minute Clinic and an associate clinical assistant professor at National University in San Diego, California.