Rheumatoid arthritis

Last reviewed: 1 Nov 2023

Last updated: 20 Apr 2023

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

Rheumatoid arthritis (RA) is a chronic inflammatory condition affecting around 1% of the population, making it the most common inflammatory arthritis seen by physicians.[1] 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.[2] RA is a clinical diagnosis; laboratory and radiographic tests help to confirm the diagnosis and provide useful prognostic information.

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History and exam

Key diagnostic factors

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

More key diagnostic factors

Other diagnostic factors

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

Other diagnostic factors

Risk factors

genetic predisposition
smoking

More risk factors

Diagnostic investigations

1st investigations to order

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

More 1st investigations to order

Investigations to consider

disease activity score(s)

More investigations to consider

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 Genentech; he has consulted for Amgen, BMS, and Sanofi.

Peer reviewers

Chris Deighton, BMedSc, MD, FRCP

Consultant Rheumatologist

Department of Rheumatology

Royal Derby Hospital

Derby

Disclosures

CD has received honoraria for talks at symposia sponsored by Wyeth and Abbott.

Raashid Luqmani, DM FRCP, FRCP(E)

Consultant Rheumatologist

Nuffield Orthopaedic Centre

Senior Lecturer in Rheumatology

Botnar Research Centre

University of Oxford

Oxford

Disclosures

RL declares that he has no competing interests.

Alan Bridges, MD

Professor of Medicine

Section of Rheumatology

University of Wisconsin

Madison

Disclosures

AB has received fees for speaking and consulting from Abbott, BMS, UCB, and Genentech.

John Kirwan, BSc, MB, BS, MD

Emeritus Professor of Rheumatic Diseases

School of Clinical Sciences

University of Bristol

Bristol

Disclosures

JK declares that he has no competing interests.

Paul Emery, MA, MD, FMedSci

Professor of Rheumatology

Arthritis Research UK

Director

Leeds Institute of Rheumatic and Musculoskeletal Medicine

University of Leeds

Director

Leeds Musculoskeletal Biomedical Research Unit

Leeds Teaching Hospitals NHS Trust

Leeds

Disclosures

Not disclosed.

Prabha Ranganathan, MD, MS

Associate Professor of Medicine

Division of Rheumatology

Washington University School of Medicine

St Louis

Disclosures

PR declares that she has no competing interests.

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Rheumatoid arthritis

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations 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

Chris Deighton, BMedSc, MD, FRCP

Disclosures

Raashid Luqmani, DM FRCP, FRCP(E)

Disclosures

Alan Bridges, MD

Disclosures

John Kirwan, BSc, MB, BS, MD

Disclosures

Paul Emery, MA, MD, FMedSci

Disclosures

Prabha Ranganathan, MD, MS

Disclosures

Differentials

Guidelines

Patient leaflets

Log in or subscribe to access all of BMJ Best Practice

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