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Rheumatoid Arthritis (RA) Patient Management
Diagnosing RA relies on input from a variety of sources, including findings from a detailed patient history, results of serological testing, and clinical observation. {LINK HAI 2.2.6} From there, it is likely to be the patient’s signs and symptoms that are most helpful in guiding the long-term management of his or her disease. Approximately 75% of patients with RA sustain joint damage within the first two years.1 A combination of pharmacological therapy, access to specialist care, and periodic follow ups contingent on disease flares will all contribute to individual management of RA.
As you develop and implement this plan, ongoing serological testing can help you evaluate and optimize it as needed to help the patient best control his or her symptoms and achieve optimal quality of life.
Several well-established clinical guidelines can help facilitate the creation of a management plan that can then be personalized to meet that patient’s needs:
Prognosis
Following the diagnosis of RA, the patient’s prognosis will vary depending on his or her disease manifestations. Early intervention and treatment may potentially improve patient prognosis.2
As RA progresses, patients typically experience escalating degrees of joint destruction. 1,3 A link has also been found to early mortality.4
Prognosis and long-term outlook may improve if early treatment is implemented. Early identification and management of RA can:5,6
- Positively affect the course of the disease
- Prevent the development of potentially debilitating joint erosion
- Ameliorate progression of erosive and overlapping diseases
Prognosis in RA patients has improved considerably with the use of highly effective medications, early detection, and close monitoring of patient symptoms, however, the potential for comorbidities may shorten the lifespan of patients with RA.4
Comorbidities
Your initial clinical evaluation may have uncovered signs and symptoms that led to the diagnosis of RA but that could also point to the coexistence of several autoimmune diseases within your patient. For example, joint damage, morning stiffness, swelling and inflammation can also be associated with other autoimmune diseases, and it may be beneficial to investigate potentially overlapping symptoms.
Most commonly, patients with RA are at risk for cardiovascular comorbidities, with coronary artery disease topping the list because of its link to premature mortality in autoimmune rheumatic diseases. Patients with RA experience double the risk of developing CVD when compared to the general population.7
Just as laboratory evaluations aided in the initial diagnosis of RA, they can also be used to uncover other autoimmune conditions in a patient with a RA diagnosis. Though less frequently seen than cardiovascular comorbidities, research has shown definitive serological overlap between RA and:8
Systemic lupus erythematosus (SLE) - observed in 10% of RA patients8
Hashimoto’s disease - detected in up to 11% of patients with RA9
Sjögren's Syndrome - detected in up to 26% of patients with RA10
Precise Management - An Approach Unique to each Patient
Unfortunately, RA is chronic and incurable. However, an effective management plan can help reduce symptom flares and improve overall quality of life. Remission may even be possible if the disease is detected and treated early.
As with all of your patients, keeping an open line of communication about exercise, anti-inflammatory diet, and medication adherence can help them manage the disease. This is especially important if his or her overall quality of life is suffering or if he or she develops any of the following symptoms, as these may indicate the presence of additional disorders or disease progression:11,12
- Fever
- Rash
- Raynaud’s disease
- Anemia
- Renal disorders
- Oral ulcerations
- Pulmonary arterial hypertension
Optimal monitoring of cardiovascular risk factors, (blood pressure, blood glucose level, low-density lipoprotein (LDL) cholesterol level), may aid in the management of RA, and is recommended in those with a history of cardiovascular events.13
Continued or worsening symptoms may indicate the presence of associated autoimmune diseases. If new or other autoimmune diseases are present, you may want to consider follow-up care.
Continued Testing and Monitoring
Any long-term management plan should be tailored to the signs and symptoms presented by each patient. If your patient displays persistent or worsening symptoms, you may find that increased follow up or referral to a specialist is needed. Patients with RA should have ongoing access to a multidisciplinary team. This should provide the opportunity for periodic assessments of the effect of the disease on their lives (such as pain, fatigue, everyday activities, mobility, ability to work or take part in social or leisure activities, quality of life, mood, impact on sexual relationships) and help to manage the condition.14,15 Access to periodic occupational therapy, physiotherapy, and psychological interventions can help your patients with RA adjust to living with their condition.14,15
Long-term follow-up care may also include the evaluation of additional or related disorders. Annual evaluation of cardiovascular risk is recommended to aid in the management of RA in patients with an intermediate to high risk for cardiovascular events, and EULAR guidelines recommend an assessment of RA patients once every 5 years if their risk of cardiovascular disease is low to moderate.7,11 As you continue to monitor your patient’s overlapping symptoms and clinical events, you may find that subsequent diagnostic testing is needed. These results can help you modify the management plan and help your patient achieve the best possible outcomes.
Could your RA patient be suffering from more than one disease?
Tests
Diagnostic tests give reliable results that support primary care physicians as well as specialists in providing optimal patient management.
- Van der Heijde DM. Joint erosions and patients with early rheumatoid arthritis. Br J Rheumatol. 1995;34(Suppl2):74-78.
- Heidari B. Rheumatoid Arthritis: Early diagnosis and treatment outcomes. Caspian J Intern Med. 2011;2(1):161-170.
- Fuchs HA, Kaye JJ, Callahan LF, et al. Evidence of significant radiographic damage in rheumatoid arthritis within the first 2 years of disease. J Rheumatol. 1989;16:585-91.
- Kelly C, Hamilton J. What kills patients with Rheumatoid arthritis? Rheumatology (Oxford). 2007;46(2):183-184.
- Raza K, Buckley CE, Salmon M, et al. Treating very early rheumatoid arthritis. Best Pract Res Clin Rheumatol. 2006(5):849-863.
- Demoruelle MK, Deane KD. Treatment strategies in early rheumatoid arthritis and prevention of rheumatoid arthritis. Curr Rheumatol Rep. 2012;14(5):472-480.
- Gualtierotti, R., Ughi, N., Marfia, G. et al. Rheumatol Ther (2017) 4: 293. https://doi.org/10.1007/s40744-017-0068-0
- AlFadhli S, Nizam R. Rhupus: A crosswalk between lupus and rheumatoid arthritis. OA Arthritis 2014 Feb 10;2(1):3.
- Robazzi TC, Adan LF. Autoimmune thyroid disease in patients with rheumatic diseases. Rev Bras Reumatol. 2012;52(3):417-30.
- Lockshin MD, Levine AB, Erkan D. Patients with overlap autoimmune disease differ from those with ‘pure’ disease. Lupus Science. Medicine 2015;2:e000084. doi: 10.1136/lupus-2015-000084
- Cojocaru M, Cojocaru IM, Silosi I, et al. Extra-articular Manifestations in Rheumatoid Arthritis. Mædica. 2010;5(4):286-291.
- Arthritis Research and Therapy. 4th World Congress on Arthritis in Montreal. 2004. https://arthritis-research.biomedcentral.com/articles/10.1186/ar1411. Accessed December 2017.
- Dougados M, Soubrier M, Antunez A, et al. Prevalence of comorbidities in rheumatoid arthritis and evaluation of their monitoring: results of an international, cross-sectional study (COMORA). Ann Rheum Dis. 2014;73(1):62-8.
- National Institute for Health and Clinical Excellence. Rheumatoid arthritis. https://www.nice.org.uk/guidance/cg79/chapter/Recommendations#communication-and-education. Accessed December 2017.
- National Collaborating Centre for Chronic Conditions (UK). Rheumatoid Arthritis: National Clinical Guideline for Management and Treatment in Adults. London: Royal College of Physicians (UK); 2009 Feb. NICE Clinical Guidelines, No. 79.
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