Arthritis: Rheumatoid Arthritis

Key principles of rheumatoid arthritis (RA) management include early patient evaluation by a rheumatologist and early initiation of pharmacologic therapy in patients at risk for chronic disease. Early diagnosis and appropriate management are essential to prevent joint damage. Patients with RA usually report pain and swelling in multiple joints and prolonged stiffness in the morning that improves with activity. Joint involvement typically is bilateral and symmetric. RA affects large and small joints, particularly the metacarpophalangeal and proximal interphalangeal joints of the hands. Patients with RA may be started on nonsteroidal anti-inflammatory drugs, glucocorticoids, or conventional synthetic disease-modifying antirheumatic drugs (DMARDs) before evaluation by a rheumatologist. Patients who have a poor response to conventional synthetic DMARDs or aggressive arthritis at initial evaluation may be prescribed biologic or targeted synthetic DMARDs. Anti-tumor necrosis factor alpha agents also may be used. Patients typically are managed with a treat-to-target strategy to achieve and maintain low disease activity or remission. Regular monitoring visits using formal assessment of disease activity have been shown to improve outcomes. RA and the medications used in its treatment are associated with increased risks of infections and malignancy. Integrative medicine therapies with limited evidence include acupuncture, mind-body therapies (eg, yoga, tai chi), and dietary supplements.