Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic systemic autoimmune inflammatory disease characterized by persistent synovial inflammation leading to progressive joint destruction, deformity, and disability. The immune system mistakenly attacks the synovial membrane, causing pannus formation, cartilage erosion, and bone damage.

RA primarily affects small joints first (hands and feet) and later large joints.

Epidemiology

• Prevalence: ~0.5–1% of adults worldwide

• Female : Male ratio ≈ 3 : 1

• Peak onset: 30–60 years

• Can occur at any age

• Higher risk in smokers

• Genetic association: HLA-DR4

Etiology & Risk Factors

The exact cause is unknown, but RA results from interaction between genetic predisposition and environmental triggers.

Genetic factors

• HLA-DRB1 gene

• Family history

Environmental triggers

• Smoking (strongest known risk factor)

• Periodontal disease

• Viral infections

• Hormonal influences

Pathophysiology

1. Autoimmune activation

2. Synovial inflammation

3. Pannus formation

4. Cartilage destruction

5. Bone erosion

6. Joint deformity

Key inflammatory mediators:

• TNF-α

• IL-1

• IL-6

Autoantibodies involved:

• Rheumatoid factor

• Anti-CCP antibodies

Joints Commonly Affected

• Metacarpophalangeal joints (MCP)

• Proximal interphalangeal joints (PIP)

• Wrists

• Metatarsophalangeal joints (MTP)

• Knees (late)

• Shoulders (late)

Distal interphalangeal joints usually spared.

Signs and Symptoms

Early symptoms

• Fatigue

• Low-grade fever

• Malaise

• Weight loss

Articular symptoms

• Symmetrical joint pain

• Morning stiffness > 60 minutes

• Swelling

• Warmth

• Reduced range of motion

Progressive deformities

• Ulnar deviation

• Swan-neck deformity

• Boutonnière deformity

• Z-thumb deformity

Extra-Articular Manifestations

• Rheumatoid nodules

• Interstitial lung disease

• Pleural effusion

• Vasculitis

• Anemia of chronic disease

• Peripheral neuropathy

• Felty syndrome (RA + splenomegaly + neutropenia)

Diagnostic Criteria

Typical features:

• Insidious onset

• Symmetrical polyarthritis

• Persistent morning stiffness

• Progressive joint damage

Investigations

Blood tests

• Rheumatoid factor (positive in ~30–70%)

• Anti-CCP antibody (more specific)

• ESR ↑

• CRP ↑

• Normocytic anemia

Imaging

• X-ray: joint space narrowing, erosions

• Ultrasound: synovitis

• MRI: early erosions

Differential Diagnosis

• Osteoarthritis

• Systemic lupus erythematosus

• Psoriatic arthritis

• Gout

• Reactive arthritis

Treatment

Treatment aims to:

• Control inflammation

• Prevent joint damage

• Maintain function

• Improve quality of life

Pharmacological Treatment

Symptomatic relief (as provided)

Acetylsalicylic acid 1.2 g PO every 6 hours with food

OR

Ibuprofen 400–800 mg PO every 8 hours

(Continue as long as necessary)

Recommended Standard Therapy (Modern Practice)

Disease-modifying antirheumatic drugs (DMARDs)

First-line:

• Methotrexate (gold standard)

Alternatives:

• Sulfasalazine

• Hydroxychloroquine

• Leflunomide

Biologic therapy (specialist center)

• Anti-TNF agents

• IL-6 inhibitors

• JAK inhibitors

Non-Pharmacological Management

• Physiotherapy

• Occupational therapy

• Joint protection techniques

• Splints during active inflammation

• Regular exercise

• Smoking cessation

• Weight control

Complications

• Joint deformity

• Disability

• Cervical spine instability

• Osteoporosis

• Cardiovascular disease

• Chronic pain syndrome

Prognosis

Without treatment → progressive disabilityWith early treatment → remission possible

Poor prognostic factors:

• High antibody levels

• Early erosions

• Many joints involved

• Extra-articular disease

Prevention

There is no absolute prevention, but risk reduction includes:

• Stop smoking

• Early treatment of periodontal disease

• Early diagnosis and therapy

• Regular monitoring

Patient Education

Patients should be advised:

Seek medical care if experiencing:

• Persistent morning stiffness > 6 weeks

• Symmetrical joint swelling

• Difficulty using hands

Early treatment prevents permanent disability.