RA Quiz: Can you identify early rheumatoid arthritis?

The diagnosis of early rheumatoid arthritis must be confirmed by signs of joint erosion and rheumatoid nodules. True or False?

Re:  "2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis"

False. In patients with early rheumatoid arthritis, the classic signs of established RA---such as joint erosion and rheumatoid nodules---are not evident. These are signs usually seen in patients with longstanding, poorly controlled disease.

The initial evaluation of a possible early RA case, should include a patient history, physical examination, and laboratory testing for anti-cyclic citrullinated peptide (CCP) antibodies, rheumatoid factor (RF), and acute phase reactants. Repeated testing may be required to confirm an RA diagnosis. Joint paint, swollen or tender peripheral joints, limited range of motion, the presence of rheumatoid nodules and morning stiffness lasting more than 30 minutes are signs of RA. The longer symptoms persist, the more likely an RA diagnosis.

Re:  "2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis"

Which of the following laboratory tests are recommended  for an early RA diagnosis?

a.) RF and anti-CCP antibodies?
b.) Erythrocyte sedimentation rate (ESR) and serum C-reactive protein (CRP) levels
c.) Antinuclear antibody (ANA) testing
d.) Complete blood count (CBC).
e.) Radiographs of the hands, wrists, and feet

RE: PJW Venables, MA, MB BChir, MD, FRCP. "Diagnosis and differential diagnosis of rheumatoid arthritis." UpToDate. February 2020. 

For initial examination, the RF and anti-CCP antibody test, and the ESR and CRP test, will help arrive at a diagnosis. However, for up to 50 percent of patients, both tests can be negative and will remain negative during follow-up in 20 percent of cases.

ANA, CBC and radiographs should be performed in select cases. A negative ANA test can be used to exclude other rheumatic conditions, such as systemic lupus, but a positive test suggests RA for one-third of patients with RA.

An abnormal CBC due to chronic inflammation may suggest RA. Liver and kidney testing abnormalities indicate a disorder other than RA, perhaps comorbid conditions that may influence therapeutic choices or drug dosing. Radiographs of the hands, wrists, and feet are usually recommended during the initial evaluation primarily for establishing a baseline.

PJW Venables, MA, MB BChir, MD, FRCP. "Diagnosis and differential diagnosis of rheumatoid arthritis." UpToDate. February 2020. 

A newly diagnosed case of early rheumatoid arthritis does not require treatment. It's better to wait until the signs of join erosions begin to show. True or False?

Re: "2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis"

This answer is false. Studies have shown that it's best to treat the disease agressively and early in order to achieve remission and to prevent joint injury and disability.

Re:  "2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis"

What is the preferred initial DMARD for most early RA cases?

a.) Methotrexate
b.) Leflunomide
c.) Hydroxychloroquine
d.) Sulfasalazine
e)  Cyclophosphamide

Re:  "2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis"

Methotrexate.

Re:  "2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis"

Researchers have found that outcomes improve in patients with established RA when a treat-to-target approach is used, so the ACR recommended adopting this strategy to early RA cases. True or False?

Re:  "2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis"

a.) True. Many studies have been published on the effectiveness of a treat-to-target strategy in rheumatoid arthritis. Among the more recent studies, includes an international study of 571 rheumatoid arthritis patients that was published in February in the Annals of the Rheumatic Diseases. Researchers found that sustained treat-to-target treatment lead to an increased likelihood of achieving DAS44 remission with similar results seen in DAS28-ESR remission. Treat-to-target, as defined by CDAI, SDAI and ACR/EULAR Boolean remission, was consistently positively associated with remission. Sustained treat-to-target had a more pronounced effect on remission.

RE:  Sofia Ramiro, Robert BM Landewé, Désirée van der Heijde, et al. "Is treat-to-target really working in rheumatoid arthritis? a longitudinal analysis of a cohort of patients treated in daily practice (RA BIODAM)," Annals of the Rheumatic Diseases. Feb. 23, 2020. DOI:10.1136/annrheumdis-2019-216819

In 2015, the ACR issued seven recommendations for the treatment of symptomatic early rheumatoid arthritis. Which of the following are not among the seven recommendations?

Re:  "2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis"

1. Use a treat-to-target strategy regardless of disease activity level.

2. In DMARD naive early RA patients with low disease activity, use DMARD monotherapy (methotrexate preferred) over double or triple therapy.

3. In DMARD naive early RA patients with moderate or high disease activity, use DMARD monotherapy over double or triple therapy.

4. In early RA patients with moderate or high disease activity who have tried DMARD monotheray (with or without glucocorticoids), add a TNFi or non-TNFi biologic to existing DMARD therapy. The therapy can include or exclude methotrexate.

5. In early RA of moderate or high activity level that has been treated with DMARDs, opt for TNFi monotherapy over tofacitinib monotherapy. Or, adopt a combination treatment strategy of TNFi and methotrexate over tofacitinib and methotrexate.

6. Add low-dose glucocorticoids (less than or equal to 10 mg/day of prednisone or equivalent) to the treatment early RA of moderate or high disease activity that continues despite ongoing treatment with DMARDs or biologic therapies.

7. For disease flares, add a short-term glucocorticoid to the existing treatment at the lowest possible dose (less than or equal to 10 mg/day) for the shortest possible duration (less than three months). The treatment target should be low disease activity or remission.

Re:  "2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis"

1. Use a treat-to-target strategy regardless of disease activity level.

2. In DMARD naive early RA patients with low disease activity, use DMARD monotherapy (methotrexate preferred) over double or triple therapy.

3. In DMARD naive early RA patients with moderate or high disease activity, use DMARD monotherapy over double or triple therapy.

4. In early RA patients with moderate or high disease activity who have tried DMARD monotheray (with or without glucocorticoids), add a TNFi or non-TNFi biologic to existing DMARD therapy. The therapy can include or exclude methotrexate.

5. In early RA of moderate or high activity level that has been treated with DMARDs, opt for TNFi monotherapy over tofacitinib monotherapy. Or, adopt a combination treatment strategy of TNFi and methotrexate over tofacitinib and methotrexate.

6. Add low-dose glucocorticoids (less than or equal to 10 mg/day of prednisone or equivalent) to the treatment early RA of moderate or high disease activity that continues despite ongoing treatment with DMARDs or biologic therapies.

7. For disease flares, add a short-term glucocorticoid to the existing treatment at the lowest possible dose (less than or equal to 10 mg/day) for the shortest possible duration (less than three months). The treatment target should be low disease activity or remission.

Re:  "2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis"

All of the above seven recommendations are included in the 2015 ACR RA guidelines specific to the treatment of symptomatic early rheumatoid arthritis.

Re:  "2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis"