50 HOSPITAL REVIEW: RHEUMATOID ARTHRITIS
Rheumatoid Arthritis Clinical Presentation, Diagnosis and Pharmacological Treatment (DMARD’s) Written by Theresa Lowry-Lehnen (PhD)
Rheumatoid arthritis (RA) is a chronic systemic inflammatory autoimmune condition with periods of exacerbation and remission, characterized by synovitis and joint destruction mediated by cytokines, chemokines, and metalloproteases. RA can affect any body part but most commonly the peripheral joints, interphalangeal, metacarpophalangeal and wrist, as well as the ankles and metatarsophalangeal joints, leading to progressive destruction of articular structures and accompanied by systemic symptoms. Triggers and etiology of RA are unclear but hormones, genetics, stress, smoking and environmental factors are thought to be contributing factors. An autoimmune etiology is currently the most widely accepted.
Criteria for diagnosis of rheumatoid arthritis
Therefore, a knowledge of lifestyle factors is also important in the diagnosis and treatment of RA.
A diagnosis of RA is based on CNS, GPN, RNP and National PRO Physical examination is a key specific clinical, laboratory and Irish General Practice Nurses part of the assessment process. imaging features and the ACR/ Educational Association illnesses will be discussed as some medical problems tend to occur along to with RA and may be In addition checking general EULAR Classification Criteria. vital signs, including temperature, suggestive of the disease. A family medical history is important due to the hereditary The ACR ‘RA Disease Activity blood pressure, pulse rate, heart Measures’, the ranges component to RA, and information aboutdefine any close relative with the condition or any other and lung function, the doctor will and level of disease activity. autoimmune disease will provideAllmore information onRA the individual’s risk.patient’s Smoking isina high evaluate the joints patients with suspected detail, paying particular attention should the be referred to a risk factor, and alcohol which effects liver, urgently can promote inflammation and interact with to function, swelling, and pain. The rheumatologist. some NSAID and methotrexate medication. Therefore, a knowledge of exam lifestyle factors is also physical will help determine Medical history refers to current the severity of the illness and help important in the diagnosis and treatment of RA. presenting symptoms, past guide treatment decisions. medical history, family medical blood tests required history, medications including Physical examination is a key part of the assessment process. InLaboratory addition to checking general to determine a diagnosis any OTC medications, allergies vital signs, including temperature, rate, suggestive heart andof lung the RA or function, inflammatory and blood lifestyle pressure, factors suchpulse as disease include: smoking andinalcohol intake. doctor will evaluate the patient’s joints detail, paying particular attention to function, Presenting symptom history • Rheumatoid (RF)and help swelling, and pain. The physical includes exam will help determine the severity of thefactor illness questions about the type, duration, location and pattern of guide treatment decisions. • Anti-citrullinated protein (synovitis) which affects the hands pain experienced, how it affects antibodies and/or feet, although any joint mobility and lifestyle, and whether (ACPA) (including anti-CCP and lined by a synovial membrane Laboratory blood tests requiredit to determine diagnosis of RA or inflammatory is affecting sleepaand causing suggestive anti-MCV antibody tests) may be involved. Severity fatigue. Past medical history disease include: • Erythrocyte sedimentation rate fluctuates over time, but chronic and other medical illnesses will (ESR) • Rheumatoid factor (RF) be discussed as some medical RA results in the progressive development of various degrees problems tend to occur along with • Anti-citrullinated protein antibodies (ACPA) (including anti-CCP and anti-MCV antibody • C-reactive protein (CRP) tests) of joint destruction, deformity, and RA and may be suggestive of the • Erythrocyte rate (ESR) a significant decline insedimentation functional • Antinuclear antibody (ANA) disease. A family medical history status. involvement • Extra-articular C-reactive protein (CRP) is important due to the hereditary • Full blood count (FBC) of organs such as the skin, heart, • and Antinuclear antibody (ANA)component to RA, and information lungs, eyes can also be about any close relative with the Imaging tests include x-rays • Full blood count (FBC) significant. condition or any other autoimmune taken of symptomatic joints disease will provide more which can reveal signs of joint Patients with RA are at an information on the individual’s involvement (inflammation) andjoint increased tests risk of co-morbidities Imaging include x-rays taken of symptomatic joints which can reveal signs of risk. Smoking is a high risk factor, damage (bone erosion) indicative such as CVD, severe infections, involvement (inflammation) andand damage erosion) of Other RA. Other imaging tests alcohol(bone which effects the indicative of RA. imaging tests and over-lapping autoimmune can promote inflammation usefuland in diagnosis of RA include disease,ine.g. mixed connective useful diagnosis of RA includeliver, magnetic resonance imaging (MRI) ultrasound. magnetic resonance imaging (MRI) and interact with some NSAID tissue diseases, autoimmune and ultrasound. and methotrexate medication. thyroiditis and lymphoma.
The ACR/EULAR Classification Criteria, is associated with a point value. Diagnosis of RA can be made when a total of 6 points or more is reached across the separate criteria.
Clinical features and presentation of rheumatoid arthritis Approximately 10% of patients with rheumatoid arthritis have an abrupt onset, but in most cases onset is insidious and initial presenting symptoms can be vague, including fatigue, malaise, morning stiffness, weight loss and low-grade fever. Progression of the illness leads to joint inflammation and swelling which causes difficulty performing activities of daily living, such as dressing, standing, walking, or use of the hands. Clinical features of RA are persistent symmetric polyarthritis
AUGUST - 2021 • HPN | HOSPITALPROFESSIONALNEWS.IE
