11/14/24, 10\:45 AM Rheumatoid Arthritis

Rheumatoid Arthritis

Table of contents
Key points ⚡
Succinct notes to superpower your revision
Rheumatoid arthritis (RA)\: chronic systemic in
extra-articular features.
Peak onset\: 30-50 years, a
Aetiology\: unknown; involves genetic (e.g. HLA genes), environmental (e.g. smoking), and hormonal factors. Autoimmune
disease with anti-CCP and rheumatoid factor (RF) antibodies.
Risk factors\: smoking, obesity, HLA-DR4 and DR1 genes, female sex (3x higher pre-menopausal).
Symptoms\: insidious symmetrical joint pain, swelling, sti
grade fever. Palindromic features (episodic joint pain 24-48 hrs).
Typical joint involvement\: PIP, MCP, wrist, knee, ankle, MTP, cervical spine. Deformities\: swan neck, boutonnière's, Z
deformities, ulnar deviation, piano key wrist.
Extra-articular manifestations\: dry eyes, scleritis, rashes, pericarditis, pulmonary nodules/
rheumatoid nodules, anaemia, hepatomegaly, muscle wasting, peripheral neuropathy, Raynaud’s, depression.
Felty's syndrome\: triad of RA, splenomegaly, neutropenia.
Investigations\: FBC (normocytic anaemia), ESR/CRP, LFTs (raised ALP/GGT), RF (60-70%), anti-CCP (speci
acid/synovial
Diagnosis\: ACR-EULAR criteria (≥6 for RA diagnosis). DAS28 for disease activity monitoring.
Management\: early diagnosis and DMARDs essential. Non-pharmacological\: MDT approach. DMARDs\: methotrexate,
le
Corticosteroids\: for
Complications\: deformities, depression, vasculitis, pulmonary
neuropathy, osteoporosis, accelerated cardiovascular disease. Increased infection risk from immunosuppressants.
Prognosis\: worse with high ESR/CRP, early erosions, high joint counts, positive anti-CCP or RF.
Article 🔍
A comprehensive topic overview

Introduction

Rheumatoid arthritis (RA) is a chronic, systemic in
with a predilection for the small joints in the hands. It has a variety of extra-articular features.
The peak age of onset for both genders is 30-50 years and a

Aetiology

The cause of RA remains unknown but is thought to arise due to a combination of genetic (e.g. HLA genes), environmental
(e.g. smoking, gut microbiome) and hormonal factors.
RA is an autoimmune disease, with circulating antibodies damaging previously healthy tissue.
https\://app.geekymedics.com/notebook/2744/ 1/811/14/24, 10\:45 AM Rheumatoid Arthritis
These antibodies include cyclic citrullinated peptide (anti-CCP), which is highly sensitive and speci
rheumatoid factor (RF), an autoantibody targeting the Fc portion of the patient’s IgG antibody. RF lacks speci
and is often seen in other diseases such as Sjogren’s syndrome.

Risk factors

Associations between genetic susceptibility and environmental factors are important risk factors for rheumatoid arthritis.
Risk factors include\:
Smoking (strong association and may a
Obesity
HLA DR4 and DR1 (genes often present in patients with rheumatoid arthritis)
Female sex (risk three times greater in pre-menopausal, suggesting oestrogen may have some in

Clinical features

History

RA most commonly presents with insidious joint pain, swelling and sti
present acutely with severe joint pain and systemic features such as fever.
A small number of patients present with palindromic features associated with episodic joint pain that typically lasts 24-48
hours and then completely resolves. This may evolve into more persistent arthritis.
Typical symptoms of rheumatoid arthritis include\:
Symmetrical joint pain and swelling
Multiple joints a
metacarpophalangeal (MCP) joint, wrist, knee, ankle, metatarsophalangeal (MTP) joint, and cervical spine
Associated systemic symptoms may include\:
Fatigue
Low-grade fever
For more information, see the Geeky Medics OSCE guide to rheumatological history taking.
Rheumatoid arthritis vs osteoarthritis
There are important clinical features used to distinguish between in
arthritis) and non-inosteoarthritis)
Table 1. Rheumatoid arthritis vs osteoarthritis
Rheumatoid arthritis Osteoarthritis
Onset Insidious Gradual
Morning sti
Worst time of the day Morning As day progresses
E
symptoms
Lessen with activity Worsen with activity
Systemic symptoms
Prominent, including
fatigue
Unusual

Clinical examination

Patients presenting with joint pain or swelling should undergo a thorough musculoskeletal examination.
https\://app.geekymedics.com/notebook/2744/ 2/811/14/24, 10\:45 AM Rheumatoid Arthritis
The typical clinical presentation of RA is a symmetrical small joint polyarthropathy, with prominent hand and foot
involvement. Other a
The spine is generally una
subluxation due to damage to the ligaments.
Rheumatoid arthritis deformities
Typical deformities associated with RA may include\:
Swan neck deformity\: hyperextension of the proximal interphalangeal joint (PIP) and
joint (DIP)
Boutonnière's deformity\: proximal interphalangeal joint (PIP) is
hyperextended
Z deformities of thumbs
Ulnar deviation
Piano key deformity of the wrist
Figure 1. In
Figure 2. Abnormal hand posture secondary to chronic rheumatoid arthritis
https\://app.geekymedics.com/notebook/2744/ 3/811/14/24, 10\:45 AM Rheumatoid Arthritis
Figure 3. Swan neck deformity
Extra-articular manifestations
Rheumatoid arthritis can also present with systemic and extra-articular manifestations including\:
Eyes\: dry eyes, scleritis, episcleritis, uveitis
Skin\: leg ulcers, rashes (pyoderma gangrenosum and cutaneous vasculitis)
Heart\: pericarditis
Lungs (Caplan's syndrome)\: pulmonary nodules, pulmonary
Kidneys\: amyloidosis (rare)
Rheumatoid nodules\: commonly found on the extensor surface of the forearm and dorsum of the foot
Anaemia\: usually normocytic or iron de
Liver\: hepatomegaly
Muscle wasting and tendon rupture
Nerves\: peripheral nerve entrapment, polyneuropathy
Raynaud’s phenomenon
Depression
Felty's syndrome
Felty's syndrome is a rare extra-articular manifestation of rheumatoid arthritis characterised by the triad of\:
Rheumatoid arthritis
Splenomegaly
Neutropenia

Di

Di
Viral arthritis (e.g. parvovirus, rubella, hepatitis B)
Reactive arthritis (secondary to gastrointestinal infection or sexually transmitted infection)
Seronegative inpsoriatic arthritis, ankylosing spondylitis and enteropathic arthritis)
Polyarticular gout
https\://app.geekymedics.com/notebook/2744/ 4/811/14/24, 10\:45 AM Rheumatoid Arthritis
Pseudogout
Osteoarthritis
Polymyalgia rheumatica (10% of PMR may progress to RA over time)
Connective-tissue disease (e.g. systemic lupus erythematosus, scleroderma, Sjogren's syndrome)

Investigations

Laboratory investigations

Relevant laboratory investigations include\:
Full blood count\: normochromic, normocytic anaemia
In
Liver function tests\: raised ALP and GGT (acute phase reactants)
Rheumatoid factor (RF)\: usually positive in 60-70% of patients but non-speci
Anti-cyclic citrullinated peptide (anti-CCP)\: more speci
Antinuclear antibody (ANA)\: raised in up to 30% of cases (only check if other signs or symptoms could suggest lupus or
another connective tissue disease)
Uric acid/synovial
Urinalysis\: microscopic haematuria/proteinuria may suggest connective tissue disease
Patients with either RF or anti-CCP antibodies are referred to as “seropositive”
.

Imaging

Relevant imaging investigations include\:
X-ray (
erosions and can help di
Musculoskeletal ultrasound\: can demonstrate joint in
established erosive damage
MRI\: can be useful if X-ray and ultrasound are inconclusive
Figure 4. X-ray of right fourth proximal
interphalangeal (PIP) joint with bone
erosions from rheumatoid arthritis.
Radiological signs of rheumatoid arthritis\: SPADES
SPADES is a mnemonic used to recall rheumatoid arthritis changes which may be seen on X-ray\:
Soft tissue swelling
Peri-articular osteoporosis
Absent osteophytes
Deformity
Erosions (late feature)
Subluxation (late feature)
https\://app.geekymedics.com/notebook/2744/ 5/811/14/24, 10\:45 AM Rheumatoid Arthritis

Diagnosis

The 2020 ACR-EULAR rheumatoid arthritis classi are commonly employed to aid diagnosis, with a score of
six or more required for the diagnosis of rheumatoid arthritis.

Disease monitoring

The DAS28 is an important tool for monitoring disease activity and response to treatment. The DAS28 score comprises
the number of tender or swollen joints involved (total out of 28), ESR or CRP, and the patients ‘assessment of global health’
(0-100).

Management

The early diagnosis of rheumatoid arthritis and prompt treatment with disease-modifying antirheumatic drugs (DMARDs)
is essential in reducing joint pain, swelling, sti
disability.

Non-pharmacological management

NICE guidelines recommend patients with rheumatoid arthritis should be managed by a multidisciplinary team (MDT),
which can include a rheumatologist, general practitioner, nurse specialist, physiotherapist, occupational therapist, dietician,
podiatrist, pharmacist and social worker.

Medical management

Disease-modifying antirheumatic drugs (DMARDs)
Medical management involves one or more DMARDs, with rapid titration of doses to clinical e
reviews to escalate therapy as required and monitor for side e
Common DMARDs include\:
Methotrexate (up to 25mg PO weekly)
Le
Sulfasalazine (1g PO twice daily)
Hydroxychloroquine (200-400mg daily)
All DMARDs except hydroxychloroquine require regular blood monitoring (usually in primary care as per shared care
arrangements). Patients should be counselled on the side e
rheumatology team.
Biologic drugs
If patients do not respond to DMARDs or are intolerant, and have active disease (DAS28 score >5.1) they are eligible for
biologic drugs. These may include\:
Anti-TNF (adalimumab, etanercept, certolizumab, golimumab, in
Anti-CD20 (rituximab)
Anti-IL6 (tocilizumab)
CD80/86\:CD28 co-stimulatory blockage (abatacept)
JAK-inhibitors (baracitinib, tofacitinib, updacitinib)
Corticosteroids
Corticosteroids can be used at diagnosis or during a disease
Short courses of oral prednisolone or intramuscular depo-medrone can be used. The complications of long-term steroid
use should always be considered (e.g. osteoporosis, diabetes, hypertension, cataracts, gastric ulceration and weight gain).
Corticosteroids should be used for the shortest period possible and at the lowest dose necessary.
Non-steroidal anti-in
NSAIDs (e.g. ibuprofen and naproxen) can also be used for analgesic bene
process.
https\://app.geekymedics.com/notebook/2744/ 6/811/14/24, 10\:45 AM Rheumatoid Arthritis
NSAIDs should be used cautiously in older patients and those with hypertension or chronic kidney disease. A proton pump
inhibitor such as omeprazole is usually advisable whilst taking steroids or NSAIDs to reduce the risk of gastric ulceration
and bleeding.

Surgical management

Surgical management of rheumatoid arthritis by an orthopaedic surgeon should be considered if joint symptoms such as
worsening pain and function have not responded to medical management.

Complications

Complications of rheumatoid arthritis include\:
Articular deformities and functional impairment
Depression (common)
Vasculitis
Pulmonary
Pericarditis or myocarditis
Lymphadenopathy
Dry eye syndrome
Neuropathy
Articular deformities and functional impairment
Osteoporosis (secondary to active RA or therapies such as corticosteroids)
Accelerated cardiovascular disease
DMARDS, corticosteroids and biological therapies may also make patients more susceptible to infection. Patients should
be advised to seek advice early if they develop infective symptoms. They are advised to attend for COVID-19, in
and pneumococcal vaccinations.

Prognostic factors

The following features are associated with a worse prognosis\:
High ESR/CRP
Early erosions on X-rays
High tender or swollen joint counts
Positive anti-CCP or rheumatoid factor

References

NICE. Rheumatoid arthritis in adults\: management. Published in 2020. Available from\: [LINK]
BMJ Best Practice. Rheumatoid Arthritis. Published in 2021. Available from\: [LINK]
Cojocaru, M., Cojocaru, I.M., Silosi, I., Vrabie, C.D. and Tanasescu, R., 2010. Extra-articular manifestations in rheumatoid
arthritis. M a e d i c a , 5 (4), p.286.
Šenolt, L., Grassi, W. and Szodoray, P., 2014. Laboratory biomarkers or imaging in the diagnostics of rheumatoid
arthritis?. B M C m e d i c i n e , 1 2 (1), pp.1-6.
Radiopaedia. Rheumatoid arthritis (musculoskeletal manifestations). Published in 2022. Available from\: [LINK]
Pratt, A.G. and Isaacs, J.D., 2014. Seronegative rheumatoid arthritis\: pathogenetic and therapeutic aspects. B e s t p r a c t i c e &
r e s e a r c h C l i n i c a l r h e u m a t o l o g y , 2 8 (4), pp.651-659.
Kay, J. and Upchurch, K.S., 2012. ACR/EULAR 2010 rheumatoid arthritis classi
pp.vi5-vi9.

Image references

Figure 1. David Jones. Adapted by Geeky Medics. Rheumatoid arthritis. Licence\: [CC BY 2.0]
Figure 2. James Heilman, MD. Adapted by Geeky Medics. Rheumatoid arthritis chronic changes. Licence\: [CC BY-SA]
https\://app.geekymedics.com/notebook/2744/ 7/811/14/24, 10\:45 AM Rheumatoid Arthritis
Figure 3. Phoenix119. Adapted by Geeky Medics. Swan neck deformity. Licence\: [CC BY-SA]
Figure 4. Haruko Ideguchi, Shigeru Ohno, Hideaki Hattori, Akiko Senuma and Yoshiaki Ishigatsubo. X-ray of right fourth PIP
joint with bone erosions by rheumatoid arthritis. License\: [CC BY]

Reviewer

Dr Stephen McDonald
Consultant Rheumatologist

Related notes

Behcet’s Disease
Juvenile Idiopathic Arthritis
Osteoporosis
Polymyalgia Rheumatica
Psoriatic Arthritis

Test yourself

Contents

Introduction
Aetiology
Risk factors
Clinical features
Source\: geekymedics.com
https\://app.geekymedics.com/notebook/2744/ 8/8