Question
How do you approach a patient with rheumatoid arthritis (RA) who is clinically doing well without symptoms on medications but has elevated markers of inflammation? I have a patient with seropositive RA on methotrexate (20 mg weekly) who is doing clinically well, but his erythrocyte sedimentation rate (ESR) remains elevated in the 80s. His CRP is 12. X-rays do not show erosions. Would you increase treatment based on ESR, or leave him where he is because he is feeling fine?
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Response from Stephen Paget, MD Professor of Medicine, Weill Cornell Medical College, New York, NY; Physician-in-Chief, Center for Rheumatology, Hospital for Special Surgery, New York, NY |
The phrase "clinically doing well without symptoms" can mean a lot of things. Current state-of-the-art rheumatoid arthritis (RA) care demands sensitive clinical and laboratory measurements in order to define the true state of RA and its response to therapy. These measurements include:
Assessment of Function
Serial health assessment questionnaires (HAQs) can demonstrate that the patient has moved from a degree of functional limitation when his disease was active to an improved one on medication. Half of the HAQ reflects damage, deformities, and actual mechanical issues secondary to RA and the other half reflects active inflammation.
Disease Activity Scale
One can use the Disease Activity Score in Rheumatoid Arthritis (DAS28), the Clinical Disease Activity Index (CDAI), or the Simplified Disease Activity Index (SDAI) disease activity scales to define the state of the patient's RA inflammation. All of these correlate well with each other and can be effectively and practically used in everyday practice. They include physician and patient assessment of disease activity, tender and swollen joint counts, and in some, erythrocyte sedimentation rate and C-reactive protein (CRP) tests. These are very helpful in defining not only the state of the "inflammatory thermostat," but also the response to treatment.
Hemoglobin and Platelet Counts
Active RA is often associated with anemia and thrombocytosis, both of which are excellent guides to the state of the patient's inflammation.
Imaging Study
Given the very high sedimentation rate and CRP in a patient with RA, I would recommend an ultrasound of the hand and wrist to see whether the patient has active joint or tendon inflammation, or new erosions.
The Patient's General Medical State. Is the patient up-to-date on his age-appropriate cancer assessments, such as colonoscopy, prostate exam, testicular exam, etc? Might he have an infection somewhere (eg, gall bladder, colon, urine, prostate)? An elevated sedimentation rate and CRP are very nonspecific tests and could reflect the patient's RA or an underlying malignancy or infection.
The treatment of RA has moved from "clinically doing well without symptoms" to a better place where the disease activity and functional state are followed closely, just as one would follow a hemoglobin A1c in diabetes, cholesterol levels in the patient with hypercholesterolemia, and blood pressure in a patient with hypertension. Only with such tight control can we optimally control RA and its attendant joint damage, functional limitation, premature atherosclerosis, osteoporosis, and shortened lifespan.