Rheumatoid arthritis

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 7 Aug 2025

Last updated: 07 Jan 2025

Rheumatoid arthritis (RA) is a chronic, erosive arthritis that requires early and aggressive treatment.

Diagnosed clinically. Laboratory and radiographic testing provide prognostic information more often than diagnostic information.

Early and aggressive treatment with disease-modifying antirheumatic drugs (DMARDs), potentially combined with a biologic agent or a targeted synthetic DMARD, is recommended.

Disease activity scores (e.g., 28-joint count version of disease activity score [DAS28], clinical disease activity index [CDAI], simplified disease activity index [SDAI], routine assessment patient index data [RAPID3]) are used routinely to provide optimum care for RA patients.

Definition

RA is a chronic inflammatory condition affecting around 1% of the population, making it the most common inflammatory arthritis seen by physicians.[1][2][3][4] It primarily affects the small joints of the hands and feet and, if not treated aggressively, can be a major cause of work loss, decreased quality of life, need for joint replacement surgery, and mortality.[5] RA is a clinical diagnosis; laboratory and radiographic tests help to confirm the diagnosis and provide useful prognostic information.

History and exam

Key diagnostic factors

active symmetric arthritis lasting >6 weeks
age 50 to 55 years
female sex
joint pain
joint swelling

Full details

Other diagnostic factors

morning stiffness
swan neck deformity
Boutonniere deformity
ulnar deviation
rheumatoid nodules
vasculitic lesions
pleuritic chest pain
scleritis and/or uveitis

Full details

Risk factors

genetic predisposition
smoking
overweight or obesity
infection

Full details

Diagnostic tests

1st tests to order

rheumatoid factor (RF)
anticyclic citrullinated peptide (anti-CCP) antibody
radiographs
ultrasonography

Full details

Tests to consider

disease activity score(s)
MRI

Full details

Treatment algorithm

ACUTE

mild disease activity at initial presentation: not pregnant or planning pregnancy

moderate-to-severe disease activity at initial presentation: not pregnant or planning pregnancy

pregnant or planning pregnancy

ONGOING

failure to reach low disease activity after 3 months of therapy: not pregnant or planning pregnancy

Contributors

Authors

Yusuf Yazici, MD

Clinical Associate Professor of Medicine

New York University School of Medicine

New York

Disclosures

YY receives research support from BMS and Amgen; he has consulted for Amgen, BMS, Hemay, Chugai, and Sanofi.

Peer reviewers

Joshua F. Baker, MD, MSCE

Associate Professor of Medicine and Epidemiology

University of Pennsylvania

Pennsylvania

Disclosures

JFB has received consulting fees from Bristol-Myers Squibb, Pfizer, Cumberland Pharma, and CorEvitas.

Peer reviewer acknowledgements

BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.

Disclosures

Peer reviewer affiliations and disclosures pertain to the time of the review.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Rheumatol. 2021 Jul;73(7):1108-23.Full text Abstract

National Institute for Health and Care Excellence. Rheumatoid arthritis in adults: management. Oct 2020 [internet publication].Full text

Smolen JS, Landewé RBM, Bergstra SA, eta al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023 Jan;82(1):3-18 Epub 2022 Nov 10.Full text Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

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Rheumatoid arthritis

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic tests

1st tests to order

Tests to consider

Treatment algorithm

mild disease activity at initial presentation: not pregnant or planning pregnancy

moderate-to-severe disease activity at initial presentation: not pregnant or planning pregnancy

pregnant or planning pregnancy

failure to reach low disease activity after 3 months of therapy: not pregnant or planning pregnancy

Contributors

Authors

Yusuf Yazici, MD

Disclosures

Peer reviewers

Joshua F. Baker, MD, MSCE

Disclosures

Peer reviewer acknowledgements

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Patient information

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice