Clinical Commander

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rheum.rheumatoid-arthritis.core.v1

Rheumatoid arthritis

rheumatologychronicadultoutpatientinpatient
Start encounter →Print handoutPRODUCTION

Manifest pointer is a PLACEHOLDER (prisma/seed/manifests/rheum.gca.chronic.v1.ts) — no dedicated RA manifest or problem-package folder authored yet; tracked in design-brief Open gaps. RxNav RxCUI validation deferred — no rxcui fields on any RegimenDrug per current authoring policy; backfill via npm run research:rxnav:validate before PRODUCTION. calc.das28_crp drives treat-to-target severity classification; CDAI/SDAI alternatives not yet discrete registry calculators — DAS28-CRP is the primary risk-stratification surface. Bayesian LRs for anti-CCP/RF seropositivity vs differential (PsA, gout, SLE) to be wired into the differential phase (design-brief Open gaps).

Entry points (5)

  • symptom
    Symmetric small-joint polyarthritis (MCP/PIP/wrist) + morning stiffness >30–60 min (2010 ACR/EULAR Aletaha)
    symmetric_inflammatory_polyarthritis
  • lab_abnormality
    Positive RF and/or anti-CCP/ACPA with joint symptoms (2010 ACR/EULAR Aletaha)
    seropositive_rf_or_anti_ccp
  • lab_abnormality
    Elevated ESR/CRP with inflammatory arthralgia pattern (EULAR 2023 Smolen)
    elevated_acute_phase_with_arthralgia
  • problem_list
    Established RA — treat-to-target titration / disease-activity visit (ACR 2021 Fraenkel; EULAR 2023 Smolen)
    established_ra_treat_to_target_visit
  • history
    Early undifferentiated inflammatory arthritis referred for rheumatology stratification (EULAR 2023 Smolen — refer within 6 weeks)
    undifferentiated_inflammatory_arthritis_referral

Required inputs (15)

  • agerequired
    demographic • used at CONTEXT
    Age >65 (or CV/cancer risk) is a JAKi boxed-warning modifier (ORAL Surveillance Ytterberg NEJM 2022); informs frailty + DMARD choice
  • pregnancy_statusrequired
    demographic • used at CONTEXT
    Methotrexate + leflunomide CONTRAINDICATED in pregnancy/conception — washout; certolizumab/HCQ/sulfasalazine/low-dose prednisone compatible (EULAR 2023 Smolen; ACR 2020 reproductive health)
  • joint_count_and_distributionrequired
    symptom • used at INITIAL_WORKUP
    Tender/swollen joint count + small-joint symmetric pattern drives 2010 ACR/EULAR classification and DAS28/CDAI/SDAI
  • morning_stiffness_durationrequired
    symptom • used at ENTRY
    Inflammatory stiffness >30–60 min distinguishes RA from osteoarthritis (2010 ACR/EULAR Aletaha)
  • symptom_durationrequired
    symptom • used at CONTEXT
    Symptom duration ≥6 weeks is a 2010 classification axis and defines early vs established RA window (Aletaha 2010)
  • rheumatoid_factorrequired
    lab • used at INITIAL_WORKUP
    RF positivity (low vs high titre) scores 2010 criteria and is a poor-prognosis marker (Aletaha 2010; EULAR 2023 Smolen)
  • anti_ccp_acparequired
    lab • used at INITIAL_WORKUP
    Anti-CCP/ACPA is the most specific RA antibody and a strong poor-prognosis / erosive marker (Aletaha 2010; EULAR 2023 Smolen)
  • crprequired
    lab • used at INITIAL_WORKUP
    Acute-phase reactant scores classification, drives DAS28-CRP / CDAI / SDAI treat-to-target composite (ACR 2021 Fraenkel)
  • esr
    lab • used at INITIAL_WORKUP
    Alternate acute-phase reactant for classification + DAS28-ESR; discordance vs CRP informs IL-6 therapy interpretation
  • hepatitis_b_c_serologyrequired
    lab • used at INITIAL_WORKUP
    HBsAg/anti-HBc + HCV mandatory before immunosuppression — biologic/JAKi can reactivate HBV (EULAR 2023 Smolen; ACR 2021 Fraenkel)
  • tb_igrarequired
    lab • used at INITIAL_WORKUP
    Latent TB (IGRA) screen mandatory before TNFi/biologic/JAKi — treat LTBI ≥1 month before start (ACR 2021 Fraenkel; EULAR 2023 Smolen)
  • extra_articular_disease
    history • used at CONTEXT
    ILD, rheumatoid nodules, vasculitis, Felty, secondary Sjögren, scleritis change drug selection + monitoring (EULAR 2023 Smolen)
  • cardiovascular_riskrequired
    history • used at CONTEXT
    Accelerated ASCVD is the leading cause of death in RA; mandates aggressive CV risk modification + IL-6/JAKi lipid monitoring (EULAR 2022 CV risk; ORAL Surveillance Ytterberg NEJM 2022)
  • cervical_spine_symptoms
    history • used at RED_FLAGS
    Atlanto-axial instability / cervical myelopathy — pre-operative C-spine flexion-extension imaging before intubation (EULAR 2023 Smolen)
  • current_dmards_and_steroidsrequired
    medication • used at CONTEXT
    Current csDMARD/bDMARD/tsDMARD + glucocorticoid dose/duration drives add-vs-switch and perioperative hold logic (ACR 2021 Fraenkel; ACR/AAHKS 2022 perioperative)

12-phase flow (12)

  1. 1FRAME
    Adult chronic autoimmune symmetric inflammatory polyarthritis; scope = early + established RA, seropositive vs seronegative, treat-to-target with composite disease activity (ACR 2021 Fraenkel; EULAR 2023 Smolen)
    advance: RA scope confirmed (not crystal / spondyloarthritis / connective-tissue mimic)
  2. 2ENTRY
    Recognise inflammatory pattern: symmetric small-joint (MCP/PIP/wrist) synovitis + morning stiffness >30–60 min + fatigue; refer to rheumatology within 6 weeks (EULAR 2023 Smolen window-of-opportunity)
    inputs: morning_stiffness_duration
    advance: inflammatory polyarthritis pattern recognised; rheumatology referral triggered
  3. 3CONTEXT
    Capture symptom duration, pregnancy/conception plan, extra-articular/systemic disease (ILD, nodules, vasculitis, Felty, secondary Sjögren, scleritis), accelerated ASCVD risk, comorbidities (CKD, hepatic, infection, malignancy), current DMARDs/steroids (ACR 2021 Fraenkel; EULAR 2023 Smolen)
    inputs: age, pregnancy_status, symptom_duration, extra_articular_disease, cardiovascular_risk, current_dmards_and_steroids
    advance: prognostic + comorbidity + reproductive profile captured
  4. 4RED_FLAGS
    Septic arthritis superimposed on an RA joint (STAT arthrocentesis), cervical myelopathy / atlanto-axial instability, MTX pneumonitis or cytopenia, biologic/JAKi serious infection or TB reactivation, pregnancy on teratogenic DMARD (ACR 2021 Fraenkel; EULAR 2023 Smolen)
    inputs: cervical_spine_symptoms, pregnancy_status
    actions: workup.septic_arthritis, calc.qsofa
    advance: septic joint / myelopathy / drug toxicity / teratogen-in-pregnancy screened and addressed
  5. 5INITIAL_WORKUP
    RF, anti-CCP/ACPA, CRP, ESR, CBC, CMP/LFT; hand+wrist+feet radiographs (erosions); apply 2010 ACR/EULAR classification (joint count, serology, acute-phase, duration ≥6 wk, score ≥6 = definite RA); pre-immunosuppression hepatitis B/C + TB IGRA (ACR 2021 Fraenkel; EULAR 2023 Smolen; Aletaha 2010)
    inputs: joint_count_and_distribution, rheumatoid_factor, anti_ccp_acpa, crp, esr, hepatitis_b_c_serology, tb_igra
    actions: workup.polyarthritis, panel.inflammation, panel.cbc, panel.cmp
    advance: 2010 classification applied; baseline + pre-biologic screening labs sent
  6. 6BRANCHING_WORKUP
    Atypical / persistently mono-oligoarticular or systemic features: synovial aspiration to exclude crystal/septic; HRCT chest if RA-ILD suspected; MSK ultrasound / MRI for subclinical synovitis; cervical flexion-extension films pre-op; anti-Sjögren / cryoglobulin / ANCA if vasculitis/Felty suspected (EULAR 2023 Smolen)
    inputs: extra_articular_disease
    actions: workup.joint_pain, panel.synovial
    advance: subtype + extra-articular workup queued
  7. 7DIFFERENTIAL
    Psoriatic arthritis / spondyloarthritis, gout/CPPD, SLE, polymyalgia rheumatica, viral (parvovirus B19, hepatitis C, chikungunya) arthritis, sarcoid, paraneoplastic, osteoarthritis; seropositive vs seronegative RA phenotyping (EULAR 2023 Smolen; Aletaha 2010)
    inputs: anti_ccp_acpa, rheumatoid_factor
    advance: mimics excluded; seropositive/seronegative phenotype assigned
  8. 8RISK_STRATIFICATION
    Composite disease activity (DAS28-CRP, CDAI, SDAI) sets remission/low/moderate/high; poor-prognosis markers (high-titre RF/anti-CCP, early erosions, high acute-phase, high swollen-joint count, failure of ≥1 csDMARD) accelerate escalation (ACR 2021 Fraenkel; EULAR 2023 Smolen treat-to-target)
    inputs: joint_count_and_distribution, crp, anti_ccp_acpa
    actions: calc.das28_crp, calc.news2
    advance: baseline disease-activity category + poor-prognosis profile set; target (remission preferred, low disease activity acceptable) chosen
  9. 9TREATMENT
    Start csDMARD ASAP at diagnosis — methotrexate anchor (+ folic acid; titrate to 15–25 mg/wk; SC if GI/inadequate) ± short-term bridging glucocorticoid (lowest dose, shortest course, tapered — NOT chronic); if target not met at 3 months / not achieved by 6 months → add or switch to bDMARD (TNFi, IL-6R tocilizumab/sarilumab, abatacept, rituximab) or tsDMARD JAKi (with boxed MACE/VTE/malignancy/serious-infection caution, esp age >65 / CV / cancer risk — ORAL Surveillance Ytterberg NEJM 2022); triple therapy (MTX+SSZ+HCQ) is a cost-effective alternative; taper in sustained remission (do not stop MTX abruptly); vaccinate before immunosuppression with live-vaccine timing; screen/treat latent TB + HBV; perioperative DMARD management; pregnancy/lactation-compatible regimen (MTX/LEF washout; certolizumab/HCQ/SSZ/low-dose pred); aggressive CV risk modification (ACR 2021 Fraenkel; EULAR 2023 Smolen)
    inputs: current_dmards_and_steroids, pregnancy_status, tb_igra, hepatitis_b_c_serology, cardiovascular_risk
    advance: csDMARD anchor started (or escalation chosen by target), bridging steroid plan + screening + CV modification in flight
  10. 10DISPOSITION
    Predominantly outpatient rheumatology-led; admit for septic arthritis, severe systemic vasculitis/serositis, MTX pneumonitis or severe cytopenia, cervical myelopathy requiring surgery, or serious biologic-associated infection (ACR 2021 Fraenkel; EULAR 2023 Smolen)
    advance: level of care set; rheumatology ownership confirmed
  11. 11MONITORING
    Disease activity (DAS28-CRP/CDAI/SDAI) q1–3 months until target then q3–6 months; CBC + LFT + creatinine on MTX schedule (q2–4 wk during titration → q8–12 wk stable); lipids 4–8 wk after IL-6R/JAKi start; periodic TB/HBV surveillance; radiographic progression annually early; CV risk reassessment (ACR 2021 Fraenkel; EULAR 2023 Smolen)
    inputs: crp, joint_count_and_distribution
    actions: calc.das28_crp, panel.inflammation, panel.cbc, panel.cmp, panel.metabolic
    advance: target (remission / low disease activity) sustained; monitoring cadence stable
  12. 12FOLLOWUP
    Lifelong rheumatology follow-up; treat-to-target re-titration, taper in sustained remission, vaccination maintenance (avoid live vaccines on biologics/JAKi), aggressive lipid/BP/smoking CV modification, bone health, PT/OT + functional assessment, pre-conception planning, surgical referral for joint destruction (ACR 2021 Fraenkel; EULAR 2023 Smolen)
    advance: long-term treat-to-target + CV + functional + reproductive plan documented