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Rheumatoid Arthritis

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🔥 Rheumatoid Arthritis (RA) is a chronic, autoimmune, symmetrical polyarthritis. It causes persistent synovitis, progressive joint deformities, and systemic complications. Symptoms should last >6 weeks before diagnosis. 🧪 Anti-CCP antibodies are highly specific and appear early in disease.

⚡ Managing an Acute RA Flare
⬆️ Increased joint pain, swelling, stiffness, fatigue. Triggers: infection, surgery, medication withdrawal, stress. Conservative: Bed rest, splints, pacing, gentle ROM exercises. Medications: Analgesics + NSAIDs for pain. Adjust DMARDs; intra-articular steroid injections for persistent synovitis. Systemic steroids (Prednisolone 15–20 mg, taper over 2 wks) if infection excluded.

⚡ Managing an Acute RA Flare

⬆️ Increased joint pain, swelling, stiffness, fatigue.
Triggers: infection, surgery, medication withdrawal, stress.
Conservative: Bed rest, splints, pacing, gentle ROM exercises.
Medications:
- Analgesics + NSAIDs for pain.
- Adjust DMARDs; intra-articular steroid injections for persistent synovitis.
- Systemic steroids (Prednisolone 15–20 mg, taper over 2 wks) if infection excluded.

📊 About

Prevalence ~1% of UK population 🇬🇧; female:male = 3:1.
Hallmark: ⏰ Early morning stiffness >60 minutes.
Typical: Symmetrical involvement of MCP + PIP joints (spares DIP).

🧬 Aetiology

Genetic: HLA-DR4, PTPN22, STAT4, PADI-4.
Environmental: 🚬 Smoking increases seropositive RA risk.
Hormonal: Incidence rises postpartum and during breastfeeding.
RF + Anti-CCP = worse prognosis.

🔬 Pathology

Chronic synovitis → pannus formation → cartilage + bone erosion 🦴.
Rheumatoid nodules: granulomas with fibrinoid necrosis.

🫁 Rheumatoid Lung: pulmonary nodules + interstitial fibrosis.

🩺 Clinical Features (>6 weeks)

Systemic: Fatigue, fever, weight loss, anaemia.
Skin/Eyes 👁️: Keratoconjunctivitis sicca, episcleritis, scleritis.
Joints 🦴:
- Wrists, MCPs, PIPs, knees, shoulders.
- Hand deformities: ulnar deviation, swan-neck, Boutonnière.
- Feet: MTP subluxation, flat feet.
Cardio/Respiratory ❤️🫁: Pericarditis, pleural effusion, ILD, ↑ CV risk.
Vasculitis: Ulcers, neuropathy, gangrene.
Neuro 🧠: Atlantoaxial subluxation, carpal tunnel.
Renal: Amyloidosis, NSAID nephropathy.

🔎 Comparing Osteoarthritis (OA) vs Rheumatoid Arthritis (RA)
🦴 Osteoarthritis	🤲 Rheumatoid Arthritis
Degenerative “wear & tear” disease	Autoimmune, systemic inflammatory disease
Cartilage loss and osteophyte formation	Inflamed synovium → pannus formation
Morning stiffness < 30 minutes	Morning stiffness > 60 minutes
Often asymmetrical	Typically symmetrical
Joint-only disease	Joints + extra-articular (nodules, lung, vasculitis, eyes, etc.)
Age onset usually > 50	Age onset often 20–40 (any age possible)
No systemic features	Systemic: fatigue, low-grade fever, malaise, rheumatoid nodules, Sjögren’s, Felty’s syndrome
Movement worsens pain	Movement can improve stiffness/pain
DIP + PIP + large weight-bearing joints (knees, hips, spine)	PIP + MCP, wrists; large joints can also be involved
RF negative	Often RF positive, ↑ CRP/ESR, ANA may be positive, anti-CCP highly specific
Onset slow over years	Onset subacute (weeks to months)
Joints enlarged, cool, hard on palpation	Joints swollen, red, warm, tender, soft synovium
Crepitus, reduced ROM, malalignment	Persistent synovitis → joint destruction
X-ray: osteophytes, joint-space narrowing, subchondral sclerosis	X-ray: erosions, juxta-articular osteopenia, loss of joint space

🧪 Investigations

Bloods:
- FBC: Anaemia of chronic disease, thrombocytosis, Felty’s (neutropenia + splenomegaly).
- ESR/CRP raised with disease activity.
- RF + Anti-CCP: Anti-CCP more specific.
Joint aspiration: exclude infection, shows neutrophilia.
Imaging:
- X-ray: early soft tissue swelling → erosions, osteopenia.
- MRI: detects early erosions, synovitis.
- Cervical spine X-rays → rule out atlantoaxial instability pre-op.

💊 Management

DMARDs (first-line): Methotrexate (anchor drug), Sulfasalazine, Leflunomide, Hydroxychloroquine.
Biologics: TNF-α blockers (etanercept, infliximab), IL-6 inhibitors (tocilizumab), Rituximab, Abatacept.
NSAIDs: Symptomatic relief only.
Steroids: Oral/IA for flares – use lowest dose possible.
Non-medical: Physio, OT, splints, joint protection.
Surgery: Synovectomy, joint replacement in advanced disease.

📉 Prognosis & Monitoring

Poor prognosis: High RF/anti-CCP, systemic features, early erosions, HLA-DR4, many joints involved.
Monitoring: Regular FBC/LFTs, imaging, disease activity scores (DAS28).

📚 References

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