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Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a long-term autoimmune disorder that primarily affects joints, resulting in warm, swollen, and painful joints. Pain and stiffness often worsen following rest, and the disease typically affects the wrist and hands symmetrically.

RA can also affect other parts of the body, including the skin, eyes, lungs, heart, nerves, and blood, leading to complications such as low red blood cell count, inflammation around the lungs and heart, fever, and low energy. The exact cause of RA is unknown, but it is believed to involve a combination of genetic and environmental factors.

A hand severely affected by rheumatoid arthritis
A hand severely affected by rheumatoid arthritis. This degree of swelling and deformation does not typically occur with current treatment.

Signs and Symptoms

RA primarily targets joints, causing inflammation of the synovial membrane. This inflammation results in swollen, tender, and warm joints, with stiffness that limits movement.

Typically, the small joints of the hands, feet, and cervical spine are affected first, but larger joints like the shoulder and knee can also be involved. Symptoms often include morning stiffness lasting more than an hour, and the condition progresses to cause tendon tethering, erosion, and joint surface destruction, leading to deformity and loss of function.

A diagram showing how rheumatoid arthritis affects a joint
A diagram showing how rheumatoid arthritis affects a joint

RA can also lead to extra-articular symptoms, affecting the skin, lungs, heart, blood vessels, and eyes. Rheumatoid nodules, skin ulcers, and vasculitis are common skin manifestations.

Lung complications include fibrosis and exudative pleural effusions. Cardiovascular risks are heightened, with increased susceptibility to atherosclerosis, myocardial infarction, and stroke.

Blood abnormalities such as anaemia and thrombocytosis are common, and other issues like peripheral neuropathy and renal amyloidosis may occur.

Diagnosis

Diagnosis of RA is based on clinical symptoms, medical imaging, and blood tests. X-rays of hands and feet are commonly performed to assess joint damage, which may include osteopenia, soft tissue swelling, and joint space narrowing.

Advanced imaging techniques like MRI and ultrasound can detect early synovitis and predict future joint damage.

X-ray of the hand in rheumatoid arthritis
X-ray of the hand in rheumatoid arthritis

Blood tests for rheumatoid factor (RF) and anti-citrullinated protein antibodies (ACPA) are very important. Although RF is positive in about two-thirds of cases, it is not specific to RA.

ACPA has higher specificity for RA. Additional tests like ESR, CRP, and full blood counts help in assessing inflammation and ruling out other conditions.

The 2010 ACR/EULAR criteria aid in early diagnosis and classification of RA.

Treatment

The primary goals of RA treatment are to reduce pain, decrease inflammation, and improve overall function. A combination of medication, lifestyle changes, and sometimes surgery is used.

Medications

Disease-modifying antirheumatic drugs (DMARDs) are the cornerstone of RA treatment, with methotrexate being the most commonly used. Other DMARDs include sulfasalazine, leflunomide, and hydroxychloroquine.

Biological DMARDs like TNF inhibitors are used when conventional DMARDs are ineffective. Corticosteroids and NSAIDs are used for symptom relief but do not alter the disease course.

Lifestyle and Surgery

Regular exercise, physical therapy, and occupational therapy are beneficial for maintaining joint function and reducing symptoms. In severe cases, surgical interventions like synovectomy or joint replacement may be necessary.

Appearance of synovial fluid from a joint with inflammatory arthritis
Appearance of synovial fluid from a joint with inflammatory arthritis

RA management also includes monitoring disease progression and adjusting treatment as needed. Tools like the Disease Activity Score (DAS28) help in assessing disease activity and treatment efficacy.

Prognosis and Epidemiology

RA affects 0.5-1% of adults in the developed world, with women being affected more frequently than men. The disease typically begins in middle age, but it can occur at any age.

RA reduces lifespan by an average of 3-12 years, primarily due to increased cardiovascular risk. Early and aggressive treatment can improve outcomes and reduce mortality.

Disability-adjusted life year for RA per 100,000 inhabitants in 2004
Disability-adjusted life year for RA per 100,000 inhabitants in 2004

Self-assessment MCQs (single best answer)

Which joints are most commonly affected by rheumatoid arthritis?



What is the primary goal of treatment for rheumatoid arthritis?



Which blood test is most specific for diagnosing rheumatoid arthritis?



Which medication is considered the first-line treatment for rheumatoid arthritis?



Which complication is associated with rheumatoid arthritis?



What is a common early morning symptom of rheumatoid arthritis?



Which imaging modality is most commonly used for assessing joint damage in rheumatoid arthritis?



Which of the following is NOT typically a symptom of rheumatoid arthritis?



Which of the following is a characteristic deformity seen in advanced rheumatoid arthritis?



What is the approximate prevalence of rheumatoid arthritis in the adult population in developed countries?



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