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The Road to Remission in RA

MedPage Today—April 11, 2012

In a video interview with Nancy Walsh from MedPage Today, Dr. Vivian Bykerk discusses the clinical approach for diagnosing rheumatoid arthritis when confronted with a patient with undifferentiated arthritis, as well as offering several treatment options.

See an excerpt below:

WALSH: I'm Nancy Walsh from MedPage Today, here in New York at Hospital for Special Surgery with rheumatologist Dr. Vivian Bykerk. Good morning.

BYKERK, MD: Good morning, Nancy.

WALSH: So, when you first see a patient with undifferentiated arthritis, what is your approach?

BYKERK: We go back to basic medical school principles: Take a really good history and physical.

By history, we're really already in our minds trying to figure out what bucket the patient fits into. For instance, seropositive rheumatoid arthritis, lupus, Sjogren's, anything that has an antibody associated with it. Might they be somebody who fits in the spondyloarthropathy bucket? Will they have psoriatic arthritis, ankylosing spondylitis, a variant of any of these? Will they have some kind of reactive arthritis? Was there a preceding infection?

And then we think is this going to be something chronic or self-limited. Is this seropositive disease versus seronegative disease? Is there a potential infectious origin that we should be thinking about? And, particularly in the Northeast, we would think of Lyme disease, but I think if you lived in South America, you would think of a different infection. So that is what's going through our head.

Tagging on to the other side of that is the physical: What's the pattern of joint involvement? Did it start with a few joints; i.e., oligoarticular, and then become polyarticular? What time course has occurred since the onset? Did it start out palindromic and then become persistent? Is it predominantly large joint, or small joint, or mixed? Is it involving DIPs, which puts it more in the seronegative bucket? Is the joint pattern involving the neck or spine, which would put it more in the seronegative bucket?

Are there prominent extra-articular features, and then are there systemic features? So if there are a lot of fevers, rashes, sweats, it's more likely to be a connective tissue disease, such as lupus maybe, even vasculitis.

So those are the kinds of things we're thinking from the beginning.

The next would be to think how are we going to confirm our findings. And depending on how long symptoms have been going on, we'll want to do some sort of laboratory investigation. So we'll want to know are there signs of inflammation in the lab, is the CRP high, is the ESR high, is the hemoglobin low? You know, what degree of signs of inflammation is there?

If we think about the new ACR criteria for rheumatoid arthritis, if you already have an erosion, by definition, you have rheumatoid arthritis; then you don't need to do anything else beyond history and physical. If you don't have an erosion, then you need to count joints, look at serology, look at acute phase reactants, and use all of that to make a diagnosis, or a classification, anyway.


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