Table of Contents
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
- Genetics: HLA-DR4 and HLA-DR1
- 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
- Steroids: short course prednisolone at diagnosis to induce remission
- Disease Modifying Anti-Rheumatic Drug (DMARD) therapy (e.g. methotrexate, leflunomide, sulfasalazine, hydroxychloroquine): commenced early to prevent long-term progression – monotherapy initially, with additional DMARD added if uncontrolled
- Biologics (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
