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Rheumatoid arthritis

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Updated 2023 ACR guidelines for nonpharmacological management of rheumatoid arthritis.

Background

Overview

Definition
RA is a chronic, systemic inflammatory disorder of autoimmune origin, which most prominently affects the lining of synovial joints.
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Pathophysiology
The pathogenesis of RA involves a complex interplay between genotype and environmental triggers. Twin studies implicate genetic factors in RA, and an association with the HLA-DRB1 locus has been established. Smoking and other forms of bronchial stress increase the risk of RA among persons with certain susceptibility. Infectious agents (such as EBV, CMV, proteus species, and E. coli) have been associated with RA, possibly through a mechanism involving molecular mimicry. The onset of RA is also linked with adverse life events, an association that is postulated to occur via neuroimmunologic interactions.
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Epidemiology
The prevalence of RA in the US is estimated at 410-450 persons per 100,000 population.
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Disease course
Synovitis occurs when leukocytes infiltrate the synovial compartment, a process mediated by leukocyte migration and endothelial activation in synovial microvessels, which upregulates the expression of adhesion molecules and chemokines. Over time, chronic synovial inflammation leads to destruction of articular cartilage and bony erosions.
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Prognosis and risk of recurrence
RA is associated with progressive disability, premature death, and high socioeconomic costs. Approximately 75-80% of patients achieve remission and low disease activity with modern medical therapies.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of rheumatoid arthritis are prepared by our editorial team based on guidelines from the American College of Rheumatology (ACR 2023,2021,2016,2010), the European League Against Rheumatism (EULAR 2022), the Japan College of Rheumatology (JCR 2022), the Royal Dutch Society for Physiotherapy (KNGF 2021), the Royal College of Ophthalmologists (RCOphth 2020), and the ...
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Screening and diagnosis

Indications for testing: as per ACR 2010 guidelines, test for RA in patients who have at least one joint with definite clinical synovitis, in whom the synovitis is not better explained by another disease.
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Diagnostic investigations

Diagnostic imaging
As per ACR 2017 guidelines:
Obtain radiography (often showing characteristic disease distribution and imaging findings) as initial imaging in patients with suspected RA.
E
Obtain ultrasound or MRI to complement radiography by showing synovitis and identifying additional erosions.
E

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  • Pretreatment evaluation

Medical management

Goals of treatment: as per EULAR 2022 guidelines, aim to reach a target of sustained remission or low disease activity.
A

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  • DMARD monotherapy (general principles)

  • DMARD monotherapy (low disease activity)

  • DMARD monotherapy (moderate-to-high disease activity)

  • DMARD monotherapy (mode of administration and dosing)

  • Adding/switching DMARDs

  • Tapering/discontinuing DMARDs

  • Corticosteroids

  • Denosumab

  • NSAIDs

Nonpharmacologic interventions

Self-management programs: as per ACR 2023 guidelines, consider offering a standardized self-management program in patients with RA.
C

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  • Physical therapy

  • Occupational therapy

  • Splinting and orthoses

  • Joint protection and energy conservation

  • Assistive devices

  • Dietary modifications

  • Psychosocial interventions

  • Alternative and complementary therapies

Specific circumstances

Elderly patients: as per JCR 2022 guidelines, use methotrexate with full safety consideration in elderly patients with poor prognostic factors.
B
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  • Patients with renal impairment

  • Patients with HF

  • Patients with MASLD

  • Patients with subcutaneous nodules

  • Patients with pulmonary disease

  • Patients with previous serious infections

  • Patients with NTM pulmonary disease

  • Patients with hepatitis B

  • Patients with hepatitis C

  • Patients with HTLV-1 infection

  • Patients with hypogammaglobulinemia

  • Patients with malignancy

Patient education

General counseling: as per KNGF 2021 guidelines, consider providing customized information and advice to support effective self-management and optimize health and well-being in patients with RA. Provide information about RA and its possible consequences, advise on the importance of exercise and a healthy lifestyle (including decreasing stress and fatigue and the way this lifestyle can be achieved and maintained), and discuss treatment options.
C

Preventative measures

Routine immunizations: as per ACR 2023 guidelines, consider offering high-dose or adjuvanted influenza vaccination, rather than regular-dose influenza vaccination, in ≥ 65 years old patients with rheumatic or musculoskeletal diseases and in 18-65 years old patients with rheumatic or musculoskeletal diseases on immunosuppressive medications.
C
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  • Prophylaxis for P. jirovecii pneumonia

Follow-up and surveillance

Assessment of treatment response: as per EULAR 2022 guidelines, monitor patients with active disease every 1-3 months. Adjust therapy if there is no improvement by at most 3 months after the initiation of treatment or the target has not been reached by 6 months.
B

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  • Management of difficult-to-treat disease

  • Monitoring of hydroxychloroquine/chloroquine treatment