Rheumatoid Arthritis: Diagnosis and Management for the Family Physician

Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease that causes joint inflammation, erosion, and deformity. The prevalence of RA in North America is 0.5% to 1%. RA is associated with significant morbidity and disability and an increased mortality rate. The disease should be suspected in patients who present with joint inflammation, especially those who have polyarthritis. Additional characteristic features include symmetrical small joint polyarthritis, morning stiffness, and constitutional symptoms. Extra-articular manifestations are common and may affect multiple body systems. Application of a decision tool, such as the Leiden clinical prediction rule for undifferentiated arthritis, may facilitate early diagnosis of RA. Useful diagnostic tests include inflammatory markers such as C-reactive protein, rheumatoid factor, and anti-cyclic citrullinated peptide antibody. Initial therapy routinely includes oral methotrexate. The American College of Rheumatology and European Alliance of Associations for Rheumatology recommend a treat-to-target approach, including rapid interventions to reduce disease activity and achieve remission. Although RA remains incurable, patient quality of life has improved dramatically with biologic disease-modifying antirheumatic drugs (DMARDs) and targeted synthetic DMARDs. All DMARDs increase the risk of infection; therefore, routine vaccinations should be up to date in patients taking these drugs. Because patients with RA have increased risk of cardiovascular disease, addressing other cardiovascular risk factors may reduce morbidity and mortality.