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The Primary Care Provider’s Role in Diagnosing and Treating Rheumatoid Arthritis

PCPs should work closely with the rheumatologist to manage comorbid conditions with special attention to cardiovascular risk, depression, and osteoporosis.
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Rheumatoid arthritis (RA) is the most common systemic, inflammatory polyarthritis. It affects between 0.5% and 1.0% of the population between age 20 and 50.1 However, RA occurs in all age groups, including children and older adults. While both men and women may develop RA, women are more susceptible to the condition.

Although the exact cause of RA is unknown, there have been major breakthroughs in understanding disease mechanisms over the past 20 years. This has resulted in significant therapeutic advances for RA. A disease that was once disabling and crippling has become very manageable and often asymptomatic.

The earlier RA therapy is initiated, the better the long-term outcome. Joint task forces of rheumatologists in the United States and United Kingdom recommend that patients should see a rheumatologist within 6 weeks of noticing RA  symptoms.2 Therefore, a timely diagnosis is central to optimal RA management. In general, primary care providers (PCPs) will be responsible for recognizing possible RA early and providing a rapid referral to a rheumatologist.

The second important role for PCPs is the ongoing management of the key comorbidities in patients with RA. These include cardiovascular risk factors, mood and sleep disturbances, and osteoporosis. Some rheumatologists elect to manage the “total patient,” but the general medical care of the RA patient is often provided by the PCP.

Role of primary care provider in identifyiing and treating rheumatoid arthritis.

Primary Care Evaluation of Possible RA

RA should be immediately considered in any patient presenting with polyarthritis of at least 6 weeks in duration. The small joints of the hands, such as the proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joints, and feet, such as the metatarsophalangeal (MTP) joints, are typically involved. Many patients will be systemically ill with fatigue, weight loss, and low-grade fever. Generally, RA patients are very stiff and sore for hours in the morning, or when they are inactive.

The paramount finding on examination is joint inflammation. Polyarthralgias or generalized myalgias are never sufficient for a diagnosis of probable RA. RA cannot be strongly suspected if observable joint inflammation (redness, warmth, and swelling) is not detected on examination. A major problem with this caveat is that many PCPs have received little training in performing a joint examination. They are often uncomfortable searching for subtle signs of joint inflammation.

In addition, patients with early RA often do not present with the classic, symmetrical polyarthritis involving the hands, wrists, feet, and ankles. Initially, RA often begins with just 1 or 2 inflamed joints. Other joints typically become inflamed over time. Early on, RA joint swelling may come and go, and there are few systemic symptoms. Atypical joints, such as the jaw, will be painful, mimicking temporomandibular joint disorder (TMJD). Subcutaneous nodules are rarely seen in early RA.

Laboratory testing is of limited diagnostic use in early RA, but the acute phase reactants—either an erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP)—should be elevated, indicating a systemic inflammatory disorder. A modest anemia and thrombocytosis also reflect the presence of an inflammatory disease.

Rheumatoid serology, either the rheumatoid factor or the anti-citrullinated peptide (anti-CCP) antibody, are present in 70% to 80% of RA patients. However, because of their relatively poor specificity, they do not need to be obtained by the PCP but could wait until rheumatology consultation. Indeed, there is evidence that a positive rheumatoid factor obtained in primary care performs badly in excluding the diagnosis of RA and delays rheumatology referral.3 In contrast, the anti-CCP antibody has greater specificity for RA and may be reasonable to test for in primary care.

Realistically, the PCP could limit initial testing in suspected RA to a complete blood count and an acute phase reactant. X-rays and imaging should not be routinely ordered during the initial evaluation of suspected RA, as radiographic changes take months to develop.

This scenario is directed to an early diagnosis of RA in the primary care setting. The longer the duration of the symmetrical polyarthritis, the more likely RA will be diagnosed and the more characteristic the presentation will be. However, a timely diagnosis and early rheumatology referral are most important. Therefore, it is incumbent on the PCP to think strongly about RA in patients who may not have yet developed the classic small-joint symmetrical polyarthritis (Table 1).

For the PCP, RA should be suspected in any patient with:

  • Joint swelling and inflammation in 2 or more joints
  • Symptoms present for more than 6 weeks
  • Signs of systemic inflammation, such as fever, anemia, weight loss, and fatigue
  • Morning stiffness
  • Elevated acute phase reactants

Although any joint may be involved in early RA, the joint swelling often begins in the PIP and MCP joints, which should be examined for warmth, swelling, tenderness, and limited range of motion. The swelling often feels spongy when the PIPs are palpated. Grip strength is usually reduced. Squeezing the MTPs often produces severe tenderness, even in the absence of visible swelling. Wrists and knees often demonstrate joint effusions.

The differential diagnosis may seem complex at first but can be subdivided into 3 discernible categories: inflammatory arthritis, non-inflammatory arthritis, and non-articular pain (Figure 1).

Inflammatory Arthritis

This includes joint infection and crystal-induced arthritis (gout or pseudogout). These both usually affect 1 or 2 joints, and are definitively diagnosed exclusively by a synovial fluid analysis. Therefore, the PCP (if qualified) should perform a joint aspiration with synovial fluid culture, crystal analysis, and cell count if infection or crystal-induced arthritis is suspected.

The persistence of symptoms for more than 1 month will generally exclude an infectious etiology for the polyarthritis. Most forms of non-gonococcal bacterial arthritis involve a single joint and present early with severe pain, swelling, and fever. Gonococcal arthritis may present rather insidiously and is often polyarticular. Skin lesions and tenosynovitis are seen in most cases of disseminated gonococcal infection. Viral polyarthritis may mimic early RA but usually is self-limited, spontaneously resolving within 2 to 4 weeks.

Gout and pseudogout will occasionally be polyarticular. The tophi present in chronic, poorly treated gout may mimic the subcutaneous nodules of RA. Pseudogout usually affects the knees, shoulders, or wrists.

Last updated on: September 26, 2017
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