In this month’s Q&A, the panelists emphasize the fundamentals of a proper patient workup and share their insights on key diagnostic tests for rheumatoid arthritis (RA). They also discuss the controversial use of steroids in treating RA as well as making the decision to switch from one TNF-a drug to another.

Q: How do you “work up” a patient in whom you suspect the diagnosis of rheumatoid arthritis?
A: The most critical parts of the evaluation are the history and physical examination, says Daniel L. Kirby, MD.

“Carefully listening to the patient describe his or her symptoms and performing a careful and complete musculoskeletal examination usually reveals the diagnosis,” insists Dr. Kirby.

Nathan Wei, MD, FACP, FACR, concurs. Despite the new technologies that many clinicians have these days, Dr. Wei says these advances should not replace a complete and through history and physical examination.

“These are the most important tools in our arsenal,” maintains Dr. Wei. “(The patient history and physical exam) are important not only from a diagnostic perspective but also from the perspective of a practitioner who engenders trust in the patient. … People don’t care how much you know until they know how much you care.”

The more information that a clinician can gather from the patient, the better he or she is able to determine the severity of the disease and the possible impact upon his or her life, according to Dr. Kirby. He adds that this knowledge of the patient also enables one to discern special circumstances that may affect one’s therapeutic choices and how they may impact the possible prognosis of the disease.

When Dr. Kirby has a high index of suspicion for RA, he pursues key laboratory tests and radiographic evaluations to confirm the diagnosis. He says helpful laboratory tests include a complete blood count (CBC), chemistry and hepatic profiles as well as disease markers such as the rheumatoid factor and anti-CCP antibodies.

Dr. Kirby also orders inflammatory markers like the c-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). He says these are often helpful for measuring disease activity and are useful in monitoring the progress of treatment.



Dr. Kirby says radiographs are often directed by the patient history and exam findings. Usually, the most helpful radiographs are films of the hands, wrists and feet, according to Dr. Kirby.

“The sensitivity of films is greater in these areas because of the number of joints you can assess per film and the higher likelihood of detecting early involvement in smaller joints,” explains Dr. Kirby. “The presence of erosive changes can predict more aggressive rheumatoid disease and may suggest that directing therapy toward slowing the progression of disease is justified.”

Another helpful diagnostic tool is magnetic resonance imaging (MRI), which is “the most sensitive and specific indicator for synovitis and erosions,” according to Dr. Wei.

Dr. Wei adds that ultrasound is another valuable diagnostic tool. With the assistance of power Doppler, ultrasound “is probably as sensitive as MRI for detecting inflammation,” maintains Dr. Wei.

While arthroscopy is not a standard diagnostic procedure for RA as of yet, Dr. Wei says it is “very helpful” in assessing biomarkers of disease.

“In the future, biomarkers will help us establish a patient profile and this profile will allow us to specifically target therapies to individual patients,” notes Dr. Wei. He adds there will be a couple of interesting studies presented on this subject at the American College of Rheumatology conference in November.

Q: When and how do you use steroids in treating RA?
A: The use of steroids remains controversial in rheumatology circles, according to Dr. Wei. Alan Kivitz, MD, says he reserves steroids for those with RA in instances in which he needs to “cool things off,” even if temporarily. In these cases, Dr. Kivitz will utilize a tapered oral steroid regimen in the form of a Medrol dosepak.

Dr. Wei concurs. When patients present with “red hot” RA, Dr. Wei opts for pulse dosing of intravenous methylprednisolone 1,000 mgs for one dose to “quiet things down” while he starts the patient on a DMARD at the same time.

When Dr. Kivitz starts a patient on a new regimen of DMARD or a biologic, he sometimes prescribes low doses of prednisone (5 to 7.5 mg, occasionally 10 mg/day) as an interim measure until the remittive therapy becomes effective. Then Dr. Kivitz says one should attempt to wean the patient off the steroid in the ensuing months.

When it comes to managing a patient who presents with chronic pain from RA, Dr. Wei may prescribe 5 mgs of prednisone as a single morning dose. Dr. Wei says this is “probably less harmful than a daily NSAID.”

Dr. Wei emphasizes the importance of counseling patients about the long-term effects of corticosteroids. In his practice, Dr. Wei notes patients sign an informed consent form after being educated about the benefits and risks of these medications. He says clinicians should monitor for potential side effects such as osteoporosis.

While Dr. Wei has not seen any significant problems with the aforementioned 5 mg prednisone dosing, he does taper the steroid use once the patient is under good control with the DMARD or biologic.

Q: How do you make the decision to switch from one TNF-alpha blocker to another? Do you go through all three?
A: When it comes to this topic, there is a lack of clarity when it comes to making this decision, says Ronald J. Rapoport, MD. While a clinician might think that switching from a monoclonal antibody to the receptor would be prudent (or vice versa), Dr. Rapoport says the literature is “hazy” on this subject. Dr. Wei concurs, stating there is no clear-cut evidence that switching from a receptor antagonist to a monoclonal antibody is any better than changing from one antibody to another.

Drs. Rapoport and Wei also concede there is a lack of consensus on this in clinical practice.
“In real life, we all will switch around and try to do whatever works,” notes Dr. Wei.

Dr. Rapoport says he will start with etanercept (Enbrel, Wyeth), substitute it with adalimumab (Humira, Abbott) or infliximab (Remicade, Centocor), and then go back to etanercept. He notes he has also started with adalimumab or infliximab, and subsequently switched to etanercept.

Drs. Kirby and Wei strongly emphasize the importance of obtaining a thorough patient history and physical exam. Dr. Wei says how one approaches these tasks can also foster the patient’s trust. “People don’t care how much you know until they know how much you care,” says Dr. Wei.

“I do not usually go to a third anti-TNF drug,” offers Dr. Rapoport. “I will usually go to a second-line biologic such as a B-cell depleter like rituximab (Rituxan, Genentech) after a patient has failed or lost effect from two anti-TNF drugs,” notes Dr. Rapoport.

Similar to Dr. Rapoport, Dr. Wei will usually go to a second line biologic instead of a third anti-TNF drug. He adds that some rheumatologists may switch some patients who have failed the two available second-line drugs (rituximab, abatacept) to the third anti-TNF drug they have not been exposed to as of yet.

“It is pretty clear we have a lot to go through before settling in on clear-cut ways to use biologic therapies,” summarizes Dr. Wei. “New ones are coming down the pike as we speak.”

Dr. Kivitz is a board-certified rheumatologist. He is the Director of the Altoona Arthritis Center in Altoona, Pa.

Dr. Kirby works at Arthritis and Osteoporosis Consultants of the Carolinas in Charlotte, N.C.

Dr. Rapoport works in a private practice in Fall River, Mass.

Dr. Wei is a board-certified rheumatologist. He is the Clinical Director of the Arthritis and Osteoporosis Center in Frederick, Md.