Rheumatoid Arthritis: Diagnosis and Management for PLAB 1
Rheumatoid Arthritis (RA) is a chronic autoimmune disease that primarily affects the joints, causing inflammation, pain, stiffness, and potential joint damage. Understanding its diagnosis and management is crucial for PLAB 1 preparation, focusing on UK guidelines and clinical best practices.
Understanding Rheumatoid Arthritis
RA is characterized by the immune system mistakenly attacking the body's own tissues, particularly the synovium, the lining of the membranes that surround joints. This leads to inflammation, which can eventually erode cartilage and bone, causing joint deformity and loss of function. While it commonly affects the hands and feet, it can also impact other joints and organs.
Diagnostic Criteria and Clinical Presentation
Accurate diagnosis relies on a combination of clinical assessment, laboratory investigations, and imaging. The American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) 2010 classification criteria are widely used.
| Symptom/Sign | Typical Presentation in RA | Distinguishing Features |
|---|---|---|
| Joint Involvement | Symmetrical, polyarticular, small joints (MCPs, PIPs, wrists, MTPs) | Often spares distal interphalangeal (DIP) joints, unlike osteoarthritis. |
| Morning Stiffness | Prolonged (>30-60 minutes) | Improves with activity. |
| Pain | Worse with rest, improves with activity | Can be severe and persistent. |
| Swelling | Synovitis, boggy joints | Often accompanied by warmth and tenderness. |
| Systemic Symptoms | Fatigue, malaise, low-grade fever, weight loss | Can indicate active disease or extra-articular involvement. |
Morning stiffness in RA is prolonged (over 30-60 minutes) and improves with activity, whereas in OA it is typically shorter and improves with rest.
Investigations for Rheumatoid Arthritis
A comprehensive workup includes blood tests and imaging to confirm diagnosis and assess disease activity.
Key investigations for RA diagnosis include:
- Inflammatory markers: Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP) are elevated, indicating inflammation.
- Autoantibodies: Rheumatoid Factor (RF) is present in about 70-80% of patients, and Anti-CCP antibodies are more specific for RA and often appear earlier.
- Complete Blood Count (CBC): May show anemia of chronic disease.
- Imaging: X-rays can reveal erosions and joint space narrowing in later stages. Ultrasound and MRI can detect synovitis and early erosions, aiding in early diagnosis and monitoring.
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Anti-cyclic citrullinated peptide (anti-CCP) antibodies.
Management of Rheumatoid Arthritis (UK Guidelines)
Management aims to control inflammation, relieve pain, prevent joint damage, and maintain function. A multidisciplinary approach is essential.
Pharmacological Management
Treatment typically follows a stepwise approach, starting with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and escalating as needed.
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The cornerstone of RA treatment is Methotrexate, usually initiated as the first-line csDMARD. Other csDMARDs include Sulfasalazine and Leflunomide. If csDMARDs are insufficient or not tolerated, biologic DMARDs (e.g., TNF inhibitors like Adalimumab, Etanercept) or targeted synthetic DMARDs (e.g., JAK inhibitors like Tofacitinib) are considered.
Early and aggressive treatment with DMARDs is critical to prevent irreversible joint damage and improve long-term outcomes.
Non-Pharmacological Management
Lifestyle modifications and supportive therapies are vital components of RA management.
This includes:
- Physiotherapy and Occupational Therapy: To maintain joint mobility, muscle strength, and teach joint protection strategies.
- Exercise: Regular, low-impact exercise (e.g., swimming, cycling) helps maintain fitness and joint function.
- Pain Management: Analgesics (e.g., paracetamol) and NSAIDs can be used for symptom relief, but NSAIDs should be used cautiously due to potential gastrointestinal and cardiovascular side effects.
- Patient Education and Self-Management: Empowering patients with knowledge about their condition and coping strategies.
Monitoring and Follow-up
Regular monitoring is essential to assess disease activity, treatment response, and potential side effects. Tools like the Disease Activity Score 28 (DAS28) are used to quantify disease activity. Patients should be monitored for adverse effects of DMARDs, including infections, liver function abnormalities, and cytopenias.
Disease Activity Score 28 (DAS28).
Learning Resources
Provides comprehensive guidelines on the management of rheumatoid arthritis in adults, covering diagnosis, treatment, and monitoring.
An accessible overview of rheumatoid arthritis, its symptoms, causes, diagnosis, and treatment options from the UK's National Health Service.
A clinical update and learning module on the diagnosis and management of rheumatoid arthritis, often used by healthcare professionals.
The official publication detailing the 2010 classification criteria for rheumatoid arthritis, essential for understanding diagnostic thresholds.
Information from a UK-based charity offering patient-focused insights into rheumatoid arthritis, its impact, and management.
An in-depth, evidence-based review of rheumatoid arthritis, covering pathophysiology, diagnosis, and treatment strategies (requires subscription, but often accessible via institutional access).
Explains the role of various imaging modalities (X-ray, Ultrasound, MRI) in the diagnosis and monitoring of rheumatoid arthritis.
Patient-friendly information about methotrexate, a key DMARD for RA, explaining its use, benefits, and potential side effects.
Guidance and information for patients living with rheumatoid arthritis, focusing on self-management and support.
A video explaining the underlying mechanisms of rheumatoid arthritis and its current treatment approaches in a clear and concise manner.