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INTRODUCTION

Rheumatoid arthritis (RA) is a chronic inflammatory disease of unknown etiology characterized by a symmetric polyarthritis and is the most common form of chronic inflammatory arthritis. Since persistently active RA often results in articular cartilage and bone destruction and functional disability, it is vital to diagnose and treat this disease early and aggressively before damage ensues. RA, a systemic disease, may also lead to a variety of extraarticular manifestations, including fatigue, subcutaneous nodules, lung involvement, pericarditis, peripheral neuropathy, vasculitis, and hematologic abnormalities, which must be managed accordingly.

Insights gained by a wealth of basic and clinical research over the past two decades have revolutionized the contemporary paradigms for the diagnosis and management of RA. Testing for serum antibodies to anti-citrullinated protein antibodies (ACPA) and rheumatoid factor continues to be valuable in the diagnostic evaluation of patients with suspected RA, and these antibodies serve as biomarkers of prognostic significance. Advances in imaging modalities assist clinical decision-making by improving the detection of joint inflammation and monitoring the progression of damage. The science of RA has taken major leaps forward by illuminating new disease-related genes, environmental interactions, and the molecular components and pathways of disease pathogenesis in even more detail. The relative contribution of these cellular and inflammatory mediators in disease pathogenesis has been further brought to light by the observed benefits of an expanded pipeline of biologic and targeted synthetic disease-modifying therapies. Despite this progress, incomplete understanding of the initiating events of RA and the factors perpetuating the chronic inflammatory response remains a barrier to its cure and prevention.

The past 20 years have witnessed a remarkable improvement in the outcomes of RA. The crippling arthritis of years past is encountered much less frequently today. Much of this progress can be traced to the expanded therapeutic armamentarium and the adoption of early treatment intervention. The shift in treatment strategy dictates a new mindset for primary care practitioners—namely, one that demands early referral of patients with inflammatory arthritis to a rheumatologist for prompt diagnosis and initiation of therapy. Only then will patients achieve their best outcomes.

CLINICAL FEATURES

The incidence of RA increases between 25 and 55 years of age, after which it plateaus until the age of 75 and then decreases. The presenting symptoms of RA typically result from inflammation of the joints, tendons, and bursae. Patients often complain of early morning joint stiffness lasting >1 hour that eases with physical activity. The earliest involved joints are typically the small joints of the hands and feet. The initial pattern of joint involvement may be monoarticular, oligoarticular (≤4 joints), or polyarticular (>5 joints), usually in a symmetric distribution. Some patients with inflammatory arthritis will present with too few affected joints to be classified as having RA—so-called undifferentiated inflammatory arthritis. Those with an undifferentiated arthritis who are most likely to be diagnosed later with RA have a higher number of tender ...

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