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. However, because of their relatively poor specificity, they do not need to be obtained by the PCP but could wait until rheumatology consultation. Rheumatoid serology, either the rheumatoid factor or the anti-citrullinated peptide (anti-CCP) antibody, are present in 70% to 80% of RA patients. A modest anemia and thrombocytosis also reflect the presence of an inflammatory disease. 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. Subcutaneous nodules are rarely seen in early RA. Atypical joints, such as the jaw, will be painful, mimicking temporomandibular joint disorder (TMJD). Early on, RA joint swelling may come and go, and there are few systemic symptoms. Other joints typically become inflamed over time. Initially, RA often begins with just 1 or 2 inflamed joints. In addition, patients with early RA often do not present with the classic, symmetrical polyarthritis involving the hands, wrists, feet, and ankles. They are often uncomfortable searching for subtle signs of joint inflammation. A major problem with this caveat is that many PCPs have received little training in performing a joint examination. RA cannot be strongly suspected if observable joint inflammation (redness, warmth, and swelling) is not detected on examination. Polyarthralgias or generalized myalgias are never sufficient for a diagnosis of probable RA. The paramount finding on examination is joint inflammation. Generally, RA patients are very stiff and sore for hours in the morning, or when they are inactive. Many patients will be systemically ill with fatigue, weight loss, and low-grade fever. 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. RA should be immediately considered in any patient presenting with polyarthritis of at least 6 weeks in duration.
Some rheumatologists elect to manage the “total patient,” but the general medical care of the RA patient is often provided by the PCP. These include cardiovascular risk factors, mood and sleep disturbances, and osteoporosis. The second important role for PCPs is the ongoing management of the key comorbidities in patients with RA. In general, primary care providers (PCPs) will be responsible for recognizing possible RA early and providing a rapid referral to a rheumatologist. 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. The earlier RA therapy is initiated, the better the long-term outcome. A disease that was once disabling and crippling has become very manageable and often asymptomatic. This has resulted in significant therapeutic advances for RA. Although the exact cause of RA is unknown, there have been major breakthroughs in understanding disease mechanisms over the past 20 years.
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