Evaluating the Patient with RA

We evaluate patients with rheumatoid arthritis for the following purposes: (1) to establish diagnosis; (2) to rule out other diseases; (3) to assess organ dysfunction due to RA and co-morbid disease; (4) to monitor disease progression and response to treatment; and, (5) to monitor for treatment-related adverse events and/or toxicity.

Based on the 2002 Guidelines for the Management of Rheumatoid Arthritis, the following evaluations should be done at baseline:

SUBJECTIVE

  • Degree of joint pain (assessed using a 100 mm Visual Analogue Scale)

  • Duration of morning stiffness

  • Duration of fatigue

  • Degree of physical limitation (often referred as Patient’s Global Assessment of Function)

PHYSICAL EXAMINATION

  • Actively inflamed joints – tender and swollen joint counts

  • Mechanical joint problems – limitation of motion, crepitus, instability, malalignment and/or deformity

  • Extra-articular manifestations

LABORATORY EVALUATION

  • Markers of inflammation (ESR/ C-reactive protein)

  • Rheumatoid factor (if initial test is negative, may be repeated after 6-12 months of disease onset)

  • Complete blood count

  • Liver function tests – SGPT, SGOT, albumin

  • Creatinine and electrolyte panel

  • Urinalysis

  • Stool guiac test (fecal occult blood)

  • Synovial fluid analysis – to rule out other differentials

OTHERS

  • Functional status (QOL) using a standardized questionnaire

  • Physician’s global assessment of disease activity

  • Patient’s global assessment of disease activity

  • Radiographs of affected joints (usually both hands APO)

And on every follow-up, the following evaluations should be performed:

  • Degree of joint pain (using a 100 mm visual analogue scale)

  • Duration of morning stiffness

  • Duration of fatigue

  • Tender and swollen joint counts on exam

  • Evidence of disease progression on physical exam (loss of motion, instability, malalignment and deformity)

  • Limitation of function

  • ESR or C-reactive protein changes

  • Parameters related to drug toxicity / adverse reactions – varies depending on the drugs given to the patient

  • Physician’s global assessment of disease activity

  • Patient’s global assessment of disease activity

  • Functional status (QOL) assessment using a standardized questionnaire

Describing baseline disease activity and clinical factors that impact on prognosis are also important guides in the selection of optimal treatment. Disease duration, activity and the presence of poor prognostic factors were used by the ACR in formulating practical recommendations in selecting the appropriate DMARD to control disease activity and prevent complications.

DISEASE DURATION

  • <6 months – equivalent to early disease

  • 6-24 months – equivalent to intermediate disease duration

  • >24 months – considered long disease duration

DISEASE ACTIVITY (based on any of the clinical indices listed below stratified as mild, moderate and high)

DAI

PRESENCE OF POOR PROGNOSTIC FACTORS

  • Functional disability based on Health Assessment Questionnaire (HAQ)

  • Presence of extra-articular disease

  • Rheumatoid Factor positivity and/or Presence of Anti-Citrullinated Protein Antibodies (ACPA)

  • Presence of bony erosions on radiography

References:

  1. ACR Subcommittee on RA Guidelines. Guidelines on the Management of RA – 2002 Update. Arthritis & Rheum 2002; 46(2): 328-46.

  2. Saag K, Teng G, Patkar NM, et al. ACR 2008 Recommendations on the use of non-biologic and biologic DMARDs in RA. Arthritis & Rheum 2008; 59 (6): 762-84.

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