Rheumatoid arthritis

Rheumatoid arthritis is a chronic autoimmune disorder resulting in a symmetrical deforming polyarthropathy and various extra-articular features.

Risk factors

• Female gender
• Age 30-50
• Genetic factors
• Smoking

Clinical features

• Polyarthritis
• Morning stiffness
• Tender, erythematous inflamed joints
• Usually symmetrical
• Any synovial joint can be affected
  • Mostly small joints (hands, feet, cervical spine)
  • MCP joints most commonly affected; DIP joints rarely affected
  • Cervical spine – odontoid peg erosion can result in fracture and atlanto-axial subluxation
• Joint deformities
  • Loss of knuckle guttering
  • Swan neck deformity (PIP joint hyperextension + DIP joint flexion)
  • Boutonnière deformity (PIP joint flexion + DIP joint hyperextension)
  • Z-shaped thumb (IP joint hyperextension + MCP joint flexion)
  • Ulnar deviation
  • Palmar subluxation of MCP joints
• Others, e.g. palmar erythema, small muscle wasting, reduced range of movement, carpal tunnel syndrome signs

Extra-articular features

Investigations

• Bloods 
  • Raised inflammatory markers (ESR, CRP) 
  • Rheumatoid factor (autoantibody to Fc portion of IgG)
  • Anti-cyclic citrullinated peptide (CCP) – more specific
• X-Rays

Management

• NSAIDs: for symptomatic relief with PPI cover
• Steroids: short course prednisolone at diagnosis to induce remission
• Conventional Disease Modifying Anti-Rheumatic Drugs (DMARDs) (e.g. methotrexate, leflunomide, sulfasalazine, hydroxychloroquine): commenced early – monotherapy initially, with additional DMARD added if uncontrolled
• Biological DMARDs (anti-TNFα, e.g. adalimumab, etanercept, infliximab; or anti-IL6, e.g. sarilumab): can halt or even reverse disease process; offered to patients with severe disease who have not responded to combination DMARDs
• Other therapies
  • Surgery: can improve mobility and reduce pain in patients with deformities
  • Physiotherapy
  • Occupational therapy

Reference: NICE ‘NG100 Rheumatoid arthritis in adults: management’ 2020

Questions

What are the classical features of rheumatoid arthritis on a radiograph?

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Which HLA genes are associated with inherited susceptibility to rheumatoid arthritis?

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Try some stations

1. Hand and wrist exam
2. Rheumatoid hand exam
3. Rheumatoid arthritis viva
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