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

Questions