musculoskeletal and connective tissue disorders
Rheumatoid Arthritis (RA)
Key Points
Rheumatoid arthritis is a systemic inflammatory disorder. The most characteristic manifestation is a symmetric polyarthritis involving peripheral joints such as wrists and metacarpophalangeal and metatarsophalangeal joints, often with constitutional symptoms. Extra-articular findings can include rheumatoid nodules, vasculitis causing leg ulcers or multiple mononeuropathy, pleural or pericardial effusions, pulmonary nodules, pulmonary infiltrates or fibrosis, pericarditis, myocarditis, lymphadenopathy, Felty syndrome, Sjögren syndrome, scleromalacia, and episcleritis. X-rays are helpful, but early diagnosis is primarily by recognizing specific clinical findings and demonstrating abnormal laboratory test results, including autoantibodies (serum rheumatoid factor and anti-cyclic citrullinated peptide antibody) and acute-cell phase reactants (erythrocyte sedimentation rate or C-reactive protein). Diagnosis requires documented joint inflammation and should not be based on laboratory testing alone. Rheumatoid arthritis decreases life expectancy by 3 to 7 years (eg, due to gastrointestinal bleeding, infection, or coronary heart disease) and causes severe disability in 10% of patients. Treat almost all patients aggressively early, primarily with drugs that modify disease activity. Drugs that modify disease activity include traditional DMARDs (particularlymethotrexate), biologic agents such as tumor necrosis factor (TNF)-alpha antagonists or other non-TNF biologic agents, and other drugs that are immunomodulatory, cytotoxic, or immunosuppressive. 