Key concepts

Comorbidities with the greatest impact on morbidity and mortality associated with rheumatoid arthritis (RA) are: (a) cardiovascular disease; (b) infections; (c) malignancy; and (d) osteoporosis.

O1 Both osteoarthritis and RA are prevalent in the U.S. population, but they differ significantly in presentation.

The most clinically important features associated with poor long-term outcomes include: (a) functional limitation (defined by use of standard measurement scales such as the Health Assessment Questionnaire [HAQ] score); (b) extraarticular disease; (c) positive rheumatoid factor; (d) positive anticyclic citrullinated peptide (anti-CCP) antibodies; and/or (e) bony erosions by radiography.

'O' The goals of treatment for RA are to: (a) reduce or eliminate pain; (b) protect articular structures; (c) control systemic complications; (d) prevent loss of joint function; and (e) improve or maintain quality of life.

It is imperative that the initiation of one or more disease-modifying antirheumatic drugs (DMARDs) occurs in all patients within the first 3 months of diagnosis to reduce joint erosion.

© Most clinicians favor the "step-down" approach to slow or reverse the early articular damage as soon as possible.

Methotrexate is the nonbiologic DMARD of choice because of its documented efficacy and safety profile when monitored appropriately.

® The risk of infection in patients treated with biologic DMARDs must be considered when selecting and monitoring therapy.

© Women of childbearing potential and their partners must be counseled to: (a) use proper birth control while undergoing treatment for RA; and (b) discontinue medications at least 3 months before conception.

© In addition to designing an individualized therapeutic regimen to control the progression of RA, the clinician must evaluate the presence of comorbidities and implement measures to control the increased risk.

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