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The primary objectives in treating rheumatoid arthritis are reduction of inflammation and pain, preservation of function, and prevention of deformity Success requires early, effective pharmacologic intervention and ongoing input by physical and occupational therapists Disease-modifying antirheumatic drugs (DMARDs) should be started as soon as the diagnosis of rheumatoid disease is certain and then adjusted with the aim of suppressing disease activity In advanced disease, surgical intervention may help improve function of damaged joints and to relieve pain
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The differentiation of rheumatoid arthritis from other joint conditions and immune-mediated disorders can be difficult In contrast to rheumatoid arthritis, osteoarthritis spares the wrist and the MCP joints Osteoarthritis is not associated with constitutional manifestations, and the joint pain is characteristically relieved by rest, unlike the morning stiffness of rheumatoid arthritis Signs of articular inflammation, prominent in rheumatoid arthritis, are usually minimal in degenerative joint disease Although gouty arthritis is almost always intermittent and monarticular in the early years, it may evolve with time into a chronic polyarticular process that mimics rheumatoid arthritis Gouty tophi resemble rheumatoid nodules both in typical location and appearance The early history of intermittent monarthritis and the presence of synovial urate crystals are distinctive features of gout Lyme disease typically involves only one joint, most commonly the knee, and is associated with positive serologic tests (see 34) Human parvovirus B19 infection in adults can mimic early rheumatoid arthritis However, arthralgias are more prominent than arthritis, rash on the cheeks, torso, or extremities is common, IgM antibodies to parvovirus B19 are present, and the arthritis usually resolves within weeks Infection with hepatitis C can cause a chronic nonerosive polyarthritis associated with rheumatoid factor; tests for anti-CCP antibodies are negative Malar rash, photosensitivity, discoid skin lesions, alopecia, high titer antibodies to double-stranded DNA, glomerulonephritis, and central nervous system abnormalities point to the diagnosis of SLE Polymyalgia rheumatica occasionally causes polyarthralgias in patients over age 50, but these patients remain rheumatoid factor negative and have chiefly proximal muscle pain and stiffness, centered on the shoulder and hip girdles Rheumatic fever is characterized by the migratory nature of the arthritis, an elevated antistreptolysin titer, and a more dramatic and prompt response to aspirin; carditis and erythema marginatum may occur in adults, but chorea and subcutaneous nodules virtually never do Finally, a variety of cancers produce paraneoplastic syndromes, including polyarthritis One form is hypertrophic pulmonary osteoarthropathy most
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NSAIDs provide some symptomatic relief in rheumatoid arthritis but do not prevent erosions or alter disease progression They are not appropriate for monotherapy and should only be used in conjunction with DMARDs A large number of NSAIDs are available; all appear equivalent in terms of efficacy (see Table 5 3) NSAIDs work in arthritis by the same mechanism that causes side effects: inhibition of COX, the enzyme that converts arachidonic acid to prostaglandins Although prostaglandins play important roles in promoting inflammation and pain, they also help maintain homeostasis in several organs especially the stomach, where prostaglandin E serves as a local hormone responsible for gastric mucosal cytoprotection The discovery that COX exists in two isomers COX-1 (which is expressed continuously in many cells and is responsible for the salutary effects of prostaglandins) and COX-2 (which is induced by cytokines and expressed in inflammatory tissues) was initially of little practical consequence since all traditional NSAIDs inhibit both isomers Celecoxib, a selective COX-2 inhibitor, is FDA-approved for the treatment of osteoarthritis and rheumatoid arthritis Compared with traditional NSAIDs, COX-2 inhibitors are as effective for treating rheumatoid arthritis but less likely in some circumstances to cause upper gastrointestinal tract adverse events (eg, obstruction, perforation, hemorrhage, or ulceration) Long-term use of COX-2 inhibitors, particularly in the absence of concomitant aspirin use, has been associated with an increased risk of cardiovascular events, leading to the removal of some COX-2 inhibitors from the US market and intense scrutiny of all drugs in that class 1 Gastrointestinal side effects For traditional NSAIDs that inhibit both COX-1 and COX-2, gastrointestinal side effects, such as gastric ulceration, perforation, and gastrointestinal hemorrhage, are the most common serious side effects The overall rate of bleeding with NSAID use in the general population is low (1:6000 users or less) but is increased by long-term use, higher NSAID dose, concomitant corticosteroids or anticoagulants, the presence of rheumatoid arthritis,
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