Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease which affects many organs, but predominantly attacks the synovial tissues and joints.
RA has an overall prevalence of 0.5-1%. There is a female predominance, with the disease being 2-3 times more common in women1.
Onset is generally in adulthood, peaking in the 4th and 5th decades. The paediatric condition, juvenile rheumatoid arthritis, will be discussed separately.
Onset may be insidious or abrupt, and the early features commonly include tiredness, malaise and generalised aches. Usually arthritic symptoms first develop in the hands and wrists in a characteristic symmetric , proximal distribution. Feet and large joints may also be involved.
Aetiology is unknown, and probably multifactorial. It is generally considered that a genetic predisposition (HLA DR4) and an environmental trigger lead to an autoimmune response that is directed primarily against synovial structures.
The inflammatory response leads to synovial hyperplasia, pannus formation and destruction of cartilage and subchondral bone 2,3.
Diagnosis is based on a combination of clinical, radiographic and serological criteria. The American College of Rheumatology revised criteria require that 4 out of 7 of the following are present 4:
- morning stiffness lasting at least 1 hour before maximal improvement
- soft tissue swelling of 3 or more joints observed by a physician
- swelling of the proximal interphalangeal, metacarpophalangeal, or wrist joints
- symmetric swelling
- rheumatoid nodules
- the presence of rheumatoid factor; and
- radiographic erosions and/or periarticular osteopenia in hand and/or wrist joints.
Non-musculoskeletal features of RA tend to occur late in the disease and include:
- pulmonary involvement
- please refer to the article on respiratory manifestations of rheumatoid arthritis
- cardiovascular disease
- cutaneous involvement
- rheumatoid nodules are usually seen in pressure areas : elbows, occiput, lumbosacral3. They generally occur in RF positive patients 9.
There are several serological markers for rheumatoid arthritis -
- Rheumatoid Factor (RF) : RF is a traditional marker, rather nonspecific. It is associated with several autoimmune and chronic infectious diseases.
- Anti-cyclic citrulinated peptide (anti-CCP): It is more than 80% sensitive and more than 95% specific11.
- Elevated ESR or C-reactive protein.
- Felty syndrome - rheumatoid arthritis, splenomegaly and neutropenia
- Caplan syndrome 7 - rheumatoid arthritis + pneumoconiosis
Musculoskeletal manifestations are generally the earliest and the dominant features of rheumatoid arthritis.
For further details, please refer to : musculoskeletal manifestations of rheumatoid arthritis
Please refer to the article : respiratory manifestations of rheumatoid arthritis
Treatment and prognosis
Treatment of RA is aimed at improving the symptoms and slowing disease progression. Therapy is with a combination of corticosteroids, NSAIDs, DMARDs (Disease Modifying Anti-Rheumatic Drugs) and TNF antagonists. The anti-TNF treatments and variants of, which supress the immune system, are known collectively as biological therapies.
The disease carries a significant burden of disability. There is also a reduction in life expectancy, with excess mortality usually related to its non-articular manifestations 5,6.
- 1. Gabriel SE. The epidemiology of rheumatoid arthritis. Rheum. Dis. Clin. North Am. 2001;27 (2): 269-81. - Pubmed citation
- 2. Sommer OJ, Kladosek A, Weiler V et-al. Rheumatoid arthritis: a practical guide to state-of-the-art imaging, image interpretation, and clinical implications. Radiographics. 25 (2): 381-98. doi:10.1148/rg.252045111 - Pubmed citation
- 3. Robbins SL, Kumar V, Abbas AK et-al. Robbins and Cotran pathologic basis of disease. W.B. Saunders Company. (2010) ISBN:1416031219. Read it at Google Books - Find it at Amazon
- 4. Arnett FC, Edworthy SM, Bloch DA et-al. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum. 1988;31 (3): 315-24. - Pubmed citation
- 5. Chehata JC, Hassell AB, Clarke SA et-al. Mortality in rheumatoid arthritis: relationship to single and composite measures of disease activity. Rheumatology (Oxford). 2001;40 (4): 447-52. doi:10.1093/rheumatology/40.4.447 - Pubmed citation
- 6. Young A, Koduri G, Batley M et-al. Mortality in rheumatoid arthritis. Increased in the early course of disease, in ischaemic heart disease and in pulmonary fibrosis. Rheumatology (Oxford). 2007;46 (2): 350-7. doi:10.1093/rheumatology/kel253 - Pubmed citation
- 7. Caplan A. Certain unusual radiological appearances in the chest of coal-miners suffering from rheumatoid arthritis. Thorax. 1953;8 (1): 29-37. doi:10.1136/thx.8.1.29 - Free text at pubmed - Pubmed citation
- 8. Turesson C, Jacobsson L, Bergström U. Extra-articular rheumatoid arthritis: prevalence and mortality. Rheumatology (Oxford). 1999;38 (7): 668-74. doi:10.1093/rheumatology/38.7.668 - Pubmed citation
- 9. Ziff, Morris. Arthritis & Rheumatism. doi:10.1002/art.1780330601
- 10. Reddy SC, Rao UR. Ocular complications of adult rheumatoid arthritis. Rheumatol. Int. 1996;16 (2): 49-52. - Pubmed citation
- 11. Fischer, C. Master the boards USMLE Step 2 CK. 2nd Ed. NY: Kaplan Medical; 2013. Find it at Amazon
Synonyms & Alternative Spellings
|Synonyms or Alternative Spelling||Include in Listings?|
|Rheumatoid arthritis (RA)||✗|
|Rheumatoid arthritis (General)||✗|