Rheumatoid Arthritis (RA)

45 y/o F with h/o smoking presents with pain/stiffness in the proximal interphalangeal/metacarpophalangeal joints, wrists, and knees. Reports fatigue, weight loss, dry eyes, dry mouth, SOB, and morning stiffness in affected joints lasting greater than 1 hour. Denies distal interphalangeal joint pain, lumbar spine pain. Reports family h/o rheumatic disease, including RA. Conjunctival injection, joint swelling of PIPs, and rheumatoid nodules on exam.

• Obtain ESR, CRP, IgM rheumatoid factor, and anti-citrullinated protein antibody level

• Obtain CBC to rule out anemia

• Screen for hepatitis B/C and tuberculosis if not already performed

• Treatment

  • Start methotrexate 10 mg once weekly; increased by 5 mg every 4 weeks to maximum dose of 20 mg once weekly

  • Symptom resolution not achieved with 20 mg weekly; refer to rheumatology

• Pt informed that DMARD may be tapered or discontinued once 6 months of symptom remission is achieved

• Pt counseled that symptom remission with methotrexate monotherapy is only achieved in approximately 40% of patients

Notes

• Earlier diagnosis and treatment of RA with disease-modifying antirheumatic drugs (DMARDs) dramatically improves outcomes

  • Mean age at onset: 48 years

  • Rheumatoid nodules and radiographic erosive changes are no longer criteria for diagnosis

  • Differential includes systemic lupus erythematosus, systemic sclerosis, psoriatic arthritis, sarcoidosis, crystal arthropathy, and spondyloarthropathy

• Extra-articular manifestations

  • Include keratoconjunctivitis sicca, interstitial lung disease, and pleural effusions

  • May manifest as complaints of eye redness, dry eyes, dry mouth, and/or SOB

• Methotrexate

  • Patients must be screened for hepatitis and tuberculosis before starting DMARDs

  • Toxicity risk increases with doses greater than 20 mg weekly