0521779407-18 CUNY1086/Karliner 0 521 77940 7 June 13, 2007 8:1
Rheumatoid Arthritis 1301differential diagnosis
■Hand & foot joint disease: SLE, viral diseases (eg, hepatitis C, par-
vovirus B19)
■Spine & few joints: psoriatic arthritis, Reiter’s disease, other spondy-
loarthropathies
■Fibromyalgia not in differential. It has central pain & no swelling.management
What to Do First
■Begin pt education w/ Arthritis Foundation (or similar) pamphlets
■Communicate emotion-laden label in increments: “arthritis,” “a type
of inflammatory arthritis,” “likely rheumatoid arthritis”
■Stratify risk by the following prognostic criteria:
➣Work loss in first 6 weeks
➣Joint count >20
➣Early radiographic changes
➣Positive rheumatoid factor
➣Elevated ESR
➣Family history
■Consultation to confirm diagnosis & begin disease-modifying
antirheumatic drug (DMARD) in first 3 months
General Measures
■Team approach: primary care, subspecialist, orthopedist, therapists,
family
■Physical therapy & occupational (hand) therapy as tolerated
■Surgery for destroyed joints or contractures
specific therapy
Indications
■Symptoms & joint damage (erosions & joint space narrowing) drive
treatment. Suppress both.
Treatment Options
■NSAID &/or acetaminophen for pain
■Low-dose prednisone to control disease temporarily
■DMARDs
➣Need a consult to choose appropriate agent
➣Begin DMARD w/in 3 months of onset for best results (most joint
damage occurs in the first 2 years)
➣Good prognosis: sulfasalazine (SSZ), hydroxychloroquine
(HCQ), minocycline