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RHEUMATOLOGY FOCUS: RA
Rheumatoid Arthritis: Clinical Presentation, Diagnosis and Pharmacological Treatment (DMARD’s) Interview with Theresa Lowry Lehnen (GPN, RNP, PhD) Clinical Nurse Specialist and Associate Lecturer South East Technological University (SETU)
Theresa adds, “A diagnosis of RA is based on specific clinical, laboratory and imaging features and the ACR/EULAR Classification Criteria. The ACR ‘RA Disease Activity Measures’, define the ranges and level of disease activity. All patients with suspected RA should be referred urgently to a rheumatologist.” Medical history refers to current
Physical examination is a key part of the assessment process. “In addition to checking general vital signs, including temperature, blood pressure, pulse rate, heart and lung function, the doctor will evaluate the patient’s joints in detail, paying particular attention to function, swelling, and pain. The physical exam will help determine the severity of the illness and help guide treatment decisions,” she adds.
Smoking is a high risk factor, and alcoholsymptoms, which effects presenting past the liver, can promote inflammation blood required to and interact with some NSAID medical and methotrexate medication.Laboratory Therefore, a tests knowledge of history, family medical determine a diagnosis suggestive of history, medications including lifestyle factors is also important in the diagnosis and treatmentRA of or RA.” inflammatory disease include:
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. We spoke with Theresa LowryLehnen (PhD) CNS, GPN, RNP and National PRO Irish General Practice Nurses Educational Association who told us more about this condition.
any OTC medications, allergies and lifestyle factors such as • Rheumatoid factor (RF) smoking alcohol intake. She “In addition to checking general Physical examination is a key part of theand assessment process. • Anti-citrullinated protein continues, “Presenting symptom vital signs, including temperature, blood pressure, pulse rate, heart and lung function, antibodies (ACPA) (includingthe history includes questions about anti-CCP and anti-MCV doctor will evaluate the patient’s joints in detail, paying the type, duration, location and particular attention to function, antibody tests) of pain experienced, how swelling, and pain. The physical pattern exam will help determine the severity of the illness and help it affects mobility and lifestyle, • Erythrocyte sedimentation rate which the hands and/ guideaffects treatment decisions,” sheand adds. whether it is affecting sleep (ESR) or feet, although any joint lined and causing fatigue. Past medical by a synovial membrane may • C-reactive protein (CRP) and other medical illnesses Laboratory blood fluctuates tests requiredhistory to determine a diagnosis suggestive of RA or inflammatory be involved. “Severity will be discussed as some medical • Antinuclear antibody (ANA) over time, but chronic RA results disease include: problems tend to occur along with in the• progressive development RA and may be suggestive of the • Full blood count (FBC) Rheumatoid factor (RF) of various degrees of joint disease. A family medical history • Anti-citrullinated anti-CCPImaging and anti-MCV antibody tests include x-raystests) taken destruction, deformity, and aprotein antibodies is important(ACPA) due to (including the hereditary of symptomatic joints which can • Erythrocyte sedimentationcomponent rate (ESR) to RA, and information significant decline in functional reveal signs of joint involvement status. involvement • Extra-articular C-reactive protein (CRP) about any close relative with the (inflammation) and damage (bone condition or any other autoimmune of organs such as the skin, heart, • Antinuclear antibody (ANA)disease will provide more erosion) indicative of RA. Other lungs, and eyes can also be imaging tests useful in diagnosis • Full blood count (FBC) information on the individual’s significant.,” she explains. of RA include magnetic resonance risk. Smoking is a high risk factor, imaging (MRI) and ultrasound. Patients with RA are at an and alcohol which effects the Imaging risk tests include x-rays taken of promote symptomatic joints which can reveal signs of joint increased of co-morbidities liver, can inflammation The ACR/EULAR Classification such as CVD, severe infections, interact(bone with some NSAIDindicative involvement (inflammation) andand damage erosion) of RA. Other imaging tests Criteria, is associated with a point and over-lapping autoimmune and methotrexate medication. value.and Diagnosis of RA can be useful in diagnosis of RA include magnetic resonance imaging (MRI) ultrasound. disease, e.g. mixed connective Therefore, a knowledge of lifestyle made when a total of 6 points tissue diseases, autoimmune factors is also important in the or more is reached across the separate thyroiditis and lymphoma. diagnosis is and treatment ofwith RA.”a point The ACR/EULAR Classification Criteria, associated value.criteria. 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. According to Theresa, clinical features of RA are persistent symmetric polyarthritis (synovitis)
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