I’ve embedded the podcast from The Curbsiders in this post for my convenince, #147 Rheumatoid Arthritis for the Internist [Direct Link To The Podcast and Show Notes.] APRIL 8, 2019 By Dr. ELENA GIBSON:
Here are the The Rheumatoid Arthritis Pearls From The Show Notes:
Rheumatoid Arthritis Pearls from Dr. McLean
Consider two polyarthritis categories: inflammatory arthritis vs. mechanical/degenerative arthritis.
Evaluate for morning stiffness by asking “How do you feel in the morning?” or “What do your feet feel like in the morning?”. At least 30-60 minutes of morning stiffness points towards an inflammatory arthritis such as rheumatoid arthritis (RA).
RA presents in a bimodal distribution: young females and the elderly.
Order a CRP and ESR to evaluate for inflammation and look for ESR >30. Avoid ordering cardioselective high-sensitivity CRP. Order a rheumatoid factor and anti-CCP to assess for RA, and look for levels ~3x the upper limit of normal. CBC and CMP can check for other causes of systemic disease.
Avoid ordering excessive laboratory tests (e.g., ANA, HLA-B27, ANCA) when not clinically appropriate.
Palpate joints for synovial thickening and tenderness. Examine joints for full range of active and passive motion. Patents may have a mild flexion contracture of the elbow. Examine the metatarsophalangeal (MTP) joints for pain by applying pressure to the ball of the foot.
RA is a clinical diagnosis! Consider it if a patient has any/all of the following: 1) small joint arthritis (often symmetric) 2) elevated ESR/CRP levels 3) positive rheumatoid factor or anti-CCP.
Initial treatment for most patients with RA will be NSAIDs and/or steroids. Treatment will then be escalated to immunomodulators, methotrexate, or biologics (DMARDs).
Before a patient starts a biologic agent, administer zoster, pneumonia, flu, hepatitis B and HPV vaccinations. Check hepatitis serologies and TB testing prior to treatment with a TNF inhibitor.
Patients on methotrexate require folic acid substitution and monitoring for leukopenia. Avoid combining Trimethoprim-sulfamethoxazole and methotrexate (MTX). This drug interaction increases MTX levels & risk for toxicity.
There is not great evidence for anti-inflammatory diets. However, if patients want to try a diet, encourage them to try elimination and reintroduction.