Summary

Rheumatoid arthritis (RA) is a chronic, systemic autoimmune disease characterised by symmetric inflammatory polyarthritis, primarily affecting the small joints of the hands and feet. Left untreated, it causes progressive joint destruction, deformity, and disability. Early aggressive treatment with disease-modifying anti-rheumatic drugs (DMARDs), primarily methotrexate, following a "treat-to-target" strategy aims for remission or low disease activity. Biologic and targeted synthetic DMARDs (anti-TNF, IL-6 inhibitors, JAK inhibitors) are used for inadequate response to conventional DMARDs.

Key Facts

• Definition: Chronic autoimmune inflammatory arthritis
• Prevalence: ~1% of adults; Female:Male 3:1
• Hallmarks: Symmetric polyarthritis of MCP/PIP/wrist; morning stiffness >1 hour
• Serology: RF and Anti-CCP (anti-CCP more specific)
• First-Line DMARD: Methotrexate
• Target: Remission (DAS28 <2.6) or Low Disease Activity

Clinical Pearls

"Windows of Opportunity": Early aggressive DMARD therapy within 3-6 months of symptom onset achieves better long-term outcomes. Delays lead to irreversible joint damage.

Anti-CCP is Highly Specific: Anti-CCP antibodies have ~95% specificity for RA and predict erosive disease. Can be positive years before clinical RA develops.

RA is a Systemic Disease: Don't forget extra-articular manifestations — interstitial lung disease (10-30%), cardiovascular disease (leading cause of death), anaemia, osteoporosis, vasculitis.

Why This Matters Clinically

RA affects ~1% of the population and causes significant pain, disability, and reduced quality of life. Modern treatment strategies have transformed outcomes, but early diagnosis and aggressive management are key to preventing irreversible joint damage.

Structured Approach

General:

• Signs of systemic disease (pallor, weight loss)
• Functional assessment (hand grip, mobility)

Hands and Wrists:

• Look: Swelling, deformity, nodules, muscle wasting
• Feel: Warmth, synovial thickening, tenderness (squeeze test MCPs/MTPs)
• Move: Range of motion, grip strength

Other Joints:

• Examine commonly affected joints (feet, knees, elbows, shoulders)

Extra-Articular:

• Rheumatoid nodules (elbows, fingers)
• Eyes: Red eye (scleritis/episcleritis)
• Lungs: Crackles (ILD)

Key Findings

Natural History

Untreated RA leads to progressive joint destruction, deformity, disability, and reduced life expectancy (5-10 years less). Modern treat-to-target strategies have dramatically improved outcomes.

Outcomes with Treatment

Prognostic Factors

Poor Prognosis:

• High anti-CCP/RF titre
• Early erosions
• Many involved joints
• High disease activity
• Extra-articular features
• Delayed treatment

Key Guidelines

1. EULAR Recommendations for RA Management (2022) — Treat-to-target, DMARD escalation.

2. ACR/EULAR 2010 Classification Criteria — Diagnostic criteria.

3. NICE NG100: Rheumatoid Arthritis in Adults (2018) — UK pathway.

Landmark Trials

TICORA (2004) — Tight control

• Intensive vs routine management
• Key finding: Tight control (treat-to-target) improved outcomes
• Clinical Impact: Established treat-to-target paradigm

COMET (2008) — Early combination

• Methotrexate + etanercept vs methotrexate alone
• Key finding: Combination superior for remission
• Clinical Impact: Supports early biologic use

Evidence Strength

What is Rheumatoid Arthritis?

Rheumatoid arthritis (RA) is a condition where your immune system mistakenly attacks the lining of your joints, causing inflammation, pain, and swelling. It mainly affects the small joints of your hands and feet, but can also affect other joints and organs.

Why does it matter?

If not treated early and effectively, RA can permanently damage your joints, leading to deformity and disability. However, with modern treatments, most people with RA can live active lives and prevent joint damage.

How is it treated?

1. Disease-modifying drugs (DMARDs): The cornerstone of treatment. Methotrexate is usually the first choice. These drugs slow or stop joint damage.

2. Biologic medicines: If DMARDs alone don't work, more powerful medicines that target specific parts of the immune system may be added.

3. Steroids: Sometimes used short-term to quickly reduce inflammation.

4. Pain relief: Paracetamol and anti-inflammatory tablets for symptoms.

5. Physiotherapy and occupational therapy: Help you stay active and manage daily tasks.

What to expect

• You'll have regular appointments to check your disease activity
• Blood tests to monitor medication side effects
• The goal is remission — minimal or no symptoms
• Many people achieve remission with treatment
• Treatment is usually lifelong

When to seek help

See your doctor or rheumatology team if:

• Your joints are more swollen or painful than usual
• You develop new symptoms (shortness of breath, eye pain, skin ulcers)
• You have signs of infection (fever, feeling unwell)
• You have neck pain with numbness or weakness in arms/legs (urgent)