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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
  • 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:
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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
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Questions

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