RA and Primary Care: 8 Looks to the Future

1. Altered Diagnosis, Treatment Landscape.

A better way to reduce RA morbidity and mortality has emerged: a combination of early diagnosis and appropriate therapy, ideally within 6 months of symptoms onset. But with a growing shortage of rheumatologists, management of RA by PCPs will become increasingly necessary

2. Expanding Role for PCPs.

Given the growing understanding that early diagnosis and treatment of RA can lead to long-term improved outcomes, PCPs can contribute by recognizing the signs and symptoms of RA early so that appropriate referrals and treatment can be implemented. Primary care also may play a greater role in initiating and managing long-term therapy.

3. Classification Criteria Guide Diagnosis.

The 2 sets of established classification criteria, the 1987 American College of Rheumatology criteria and 2010 ACR/European League Against Rheumatism criteria, provide valuable understanding of RA and both are appropriate to use in diagnosis. The 2010 criteria are becoming more popular in clinical practice because they can identify patients earlier and they incorporate newer autoantibody tests.

4. The History and Exam Will be Key.

The physician can use the diagnostic history and examination to differentiate between inflammatory and noninflammatory causes to determine the source of pain or other joint symptoms. Patients with RA frequently report pain in and around their joints, often with stiffness and swelling. Typically involved: PIP, MCP, and MTP joints and wrists. With appropriate evaluation, PCPs can ensure earlier diagnosis.

5. Imaging Will Enhance the Diagnostic Picture.

The physical exam is the current “gold standard” in clinic for identifying the synovitis of RA, but imaging with ultrasound or MRI is being used more and more in managing many forms of inflammatory arthritis, including RA. For a PCP, plain radiography of symptomatic joints is an acceptable starting point in the initial diagnostic workup.

6. An Explosion of RA Therapies.

There has been an explosion of RA therapies, including synthetic DMARDs and biologic DMARDs, since the late 1990s. Most PCPs will not initiate these agents, but familiarity with them and their mechanisms of action may be useful. Anti–tumor necrosis factor therapies (etanercept, infliximab, adalimumab, certolizumab pegol, golimumab) block the action of TNF, a powerful driver of inflammation in RA joints.

7. PCPs and Rheumatologists Working as Comanagers.

RA disease assessment has long been thought to be in the purview of rheumatologists, but with the growing use of patient-reported outcomes in RA and in particular methods that can electronically capture a patient’s symptoms, these measurements may soon become available to PCPs. Areas of RA comanagement: disease activity, medication toxicity, cardiovascular disease, vaccinations.

8. Prevention on PCP Horizon.

PCPs may soon participate in identification and treatment of patients who are candidates for RA prevention, much like their participation in cardiovascular disease prevention through discussion of lifestyle modifications and administration of statins, antihypertensives, and other medications