Signs and Symptoms
- Malaise, fatigue
- Generalized musculoskeletal pain
- After weeks to months, patients develop swollen, warm, painful joints
- Often worse in morning (morning stiffness)
- Joint involvement usually symmetric and polyarticular
- Starting in small joints of hand s and feet:
- Later wrists, elbow, and knees
- Distal interphalangeal (DIP) joints of hand generally not involved:
- Presence of swelling in these joints should suggest another type of arthritis
- Synovitis is typically gradual
- Classic joint findings in long-stand ing disease:
- Metacarpophalangeal (MCP) swelling with ulnar deviation
- Swan neck and boutonniere deformities
- Extra-articular complications:
- SC nodules
- Vasculitis
- Pericarditis or myocarditis
- Pulmonary fibrosis
- Pneumonitis
- Sjögren syndrome
- Mononeuritis multiplex
- Evidence of mild pericarditis on echocardiogram is found in up to 1/3 of patients
- Consider ECG evaluation in these patients
- Patients usually present to ED owing to exacerbations of the disease or complication in other organ systems:
- Airway obstruction from cricoarytenoid arthritis or laryngeal nodules
- Heart block, constrictive pericarditis, pericardial effusion with possible tamponade or myocarditis
- Pulmonary fibrosis, pleuritis, intrapulmonary nodules, or pneumonitis
- Hepatitis
- Neurologic findings may result from cervical spine subluxation or ocular manifestations such as scleritis and episcleritis:
- Can also have retinal vasculitis in periphery and recurrent iritis - consider in patients with photophobia, red eye, and decreased vision. These patients need ophthalmologic evaluation
- Complications of chronic steroid use:
- Infections
- Steroid-induced osteopenia and fractures
- Insulin resistance
- Glaucoma or IOP elevation, accelerated cataracts
- Patients may present with side effects related to chronic salicylate or NSAID use such as GI bleeding
- Drugs such as methotrexate, gold, or d-penicillamine also have toxic side effects, most commonly GI but also neuropathic
Essential Workup
- Primary diagnosis of rheumatoid arthritis (RA) is rarely made in the ED
- Synovitis should be present for at least 6 wk; a minimum of 4 of the following 7 criteria as established by the American Rheumatism Association must be met to make the diagnosis:
- Stiffness of the involved joints in the morning for at least 1 hr
- Arthritis in 3 or more joints with effusion or soft-tissue swelling
- Arthritis of joint in hand (wrist, MCP, or proximal interphalangeal [PIP] joint)
- Symmetric arthritis
- Rheumatoid nodules on extensor surfaces or juxta-articular surfaces
- Significantly elevated rheumatoid factor
- Characteristic radiographic changes include erosions and decalcification (not attributable to osteoarthritis)
- Other pertinent history: Malaise, weakness, weight loss, myalgias, bursitis, tendonitis, fever of unknown cause
- Initial workup should focus on demonstrating that other causes of arthritis are not present, especially septic arthritis, reactive arthritis, or gout
- Arthrocentesis of a joint effusion may be required
Diagnostic Tests & Interpretation
ECG, chest radiograph, C-spine or extremity radiograph, and hemoglobin testing are helpful if patient presents with complications of RA
Lab
- CBC: Mild anemia with leukocytosis and thrombocytosis
- Erythrocyte sedimentation rate (ESR): Often >30. Guide for elevation is age/2 in men, (age + 10)/2 in women. Consider GCA in patients with elevated markers and RA with vision loss that is acute
- C-reactive protein correlates with erosive disease
- Antinuclear antibodies (ANA) 30-40% positive screening tool
- Rheumatoid factor: Elevated in ∼70% of cases
- Joint fluid analysis:
- Typically between 2,000 and 25,000 white cells
- Neutrophil predominance
- Microscopic Gram stain of fluid should show no organisms and no crystals
- ECG: Conduction defects are rare, but heart block may be seen. May see evidence of pericarditis
Imaging
- Joint radiograph:
- Joint effusion
- Juxta-articular erosions and decalcification
- Narrowing of joint space
- Loss of cartilage
- MRI of joints can detect early inflammation before plain radiograph
- US may be used for estimating the degree of inflammation and the amount of inflamed tissue
- CXR reveal pulmonary fibrosis, pleural changes, nodular lung disease, or pneumonitis:
- Cardiac silhouette may show changes related to myocarditis
- Cervical spine radiograph:
- Atlantoaxial joint subluxation may occur
Differential Diagnosis
- Osteoarthritis
- Septic arthritis
- Reactive arthritis
- Gonococcal arthritis
- Lyme disease
- Gout
- Connective tissue disorders
- Systemic lupus erythematosus (SLE), dermatomyositis, polymyositis, vasculitis, Reiter syndrome, and sarcoid
- Rheumatic fever
- Malignancy
Prehospital
Cervical spine immobilization and airway support as indicated
Initial Stabilization/Therapy
- ABCs:
- Manage airway with attention to C-spine immobilization during intubation
- Treat complications of RA as appropriate
ED Treatment/Procedures
- NSAIDs are first-line treatment for RA in the ED:
- If 1 NSAID fails, another NSAID from a different chemical class may work better
- Prompt referral to rheumatology for initiation of steroids or disease-modifying antirheumatic drug (DMARD) therapy
- Most patients should receive a DMARD as soon as possible after diagnosis
- Early treatment of RA is important as joint changes may be most progressive during the first 18 mo
- RA flares of single joints may be treated with intra-articular steroids
Medication
- Oral glucocorticoids, methotrexate, and other second-line therapies should be initiated by a rheumatologist
- Aspirin (ECASA): Adult: 900 mg PO q.i.d (2.6-5.4 g/d); peds: 60-90 mg/kg/d q.i.d up to 3.6 g
- Note: Enteric-coated aspirin has delayed absorption and its analgesic effects will be delayed compared to regular aspirin. Doses of aspirin needed for anti-inflammatory effect approach toxic doses. Patients should be closely monitored and dose carefully titrated to avoid toxicity. Monitor serum salicylate levels. Upper-end therapeutic concentration approaches toxic level around 25 mg/dL. Make sure units are correct when interpreting levels
- Auranofin: 3-9 mg/d (peds: 0.15 mg/kg/d up to 9 mg) divided b.i.d
- Celecoxib (Celebrex): 100-200 mg PO b.i.d; peds: N/A
- Hydroxychloroquine: Adult: 200-600 mg/d divided b.i.d
- Ibuprofen (Ibuprin, Advil, Motrin): 200-800 mg (peds: 10 mg/kg) PO q6h
- Leflunomide: 100 mg PO daily for 3 d, then maintenance dose of 10-20 mg PO daily; peds: N/A
- Methotrexate: 7.5 mg once/wk
- Prednisone: Maintenance: 5-10 mg PO daily; acute exacerbations: 20-50 mg PO daily; peds: Maintenance: 0.1 mg/kg/d PO, acute exacerbations: 2-5 mg/kg/d PO
- Sulfasalazine: Adult: 500-1,000 mg PO b.i.d; peds: 30-60 mg/kg/d b.i.d. Up to 2 g
- Not recommended in children <6 yr
- NSAIDs and tramadol for breakthrough pain
- Triamcinolone (Kenalog intra-articular): 5 mg small joint, 15 mg large joint up to 40 mg/site max
- Newer DMARDs and monoclonals need to be dosed by a rheumatologist and should likely not be prescribed in the ED: Abatacept, adalimumab, anakinra, etanercept, infliximab, rituximab, tocilizumab
ALERT |
| Recent studies have shown possibly increased risk of cardiovascular event with NSAID medications, particularly with COX-2 inhibitors |
Disposition
Admission Criteria
- Patients with severe or life-threatening presentations of RA and its complications should be admitted to hospital
- Admission is warranted when diagnosis is unclear and serious illnesses such as septic joint or systemic vasculitis may be present or cannot be ruled out
- Admission may be required for pain control
- Admission may be required if patient has inadequate social support and is unable to maintain activities of daily living
- Pediatric patients with fever and arthritis should be strongly considered for admission
Discharge Criteria
Patients without serious complications may be managed as outpatients with appropriate medications and follow-up
Issues for Referral
All patients should have primary physician for further therapy and care as well as appropriate specialty care referral such as rheumatologists, cardiologists, and orthopedics
ICD9
714.0 Rheumatoid arthritis
ICD10
M06.9 Rheumatoid arthritis, unspecified
M06.049 Rheumatoid arthritis without rheumatoid factor, unsp hand
M06.079 Rheumatoid arthritis w/o rheumatoid factor, unsp ank/ft
M06.069 Rheumatoid arthritis without rheumatoid factor, unsp knee
M05.849 Oth rheumatoid arthritis with rheumatoid factor of unsp hand
M05.869 Oth rheumatoid arthritis with rheumatoid factor of unsp knee
M05.879 Oth rheumatoid arthritis w rheumatoid factor of unsp ank/ft
M05.9 Rheumatoid arthritis with rheumatoid factor, unspecified
M06.08 Rheumatoid arthritis without rheumatoid factor, vertebrae
SNOMED
69896004 Rheumatoid arthritis (disorder)
287007001 Rheumatoid arthritis - hand joint
287008006 Rheumatoid arthritis of ankle and /or foot (disorder)
201777003 Rheumatoid arthritis of knee (disorder)
201764007 Rheumatoid arthritis of cervical spine (disorder)