Rheumatoid arthritis
Alerts and Notices
Synopsis
Rheumatoid arthritis (RA) is a systemic disease with a prevalence of 1% of the adult population. It can occur in adults of all ages (peak onset 50-75 years) and is 3 times more common in women than men. RA can occur in children. (See also juvenile idiopathic arthritis.) The cause of RA is unknown, but multiple genes and environmental factors contribute to genetic risk. Cigarette smoking is a prominent risk factor.Onset is usually subtle, with morning stiffness for over 30 minutes, and commonly associated with fatigue. Untreated, RA causes joint destruction with resultant disability and even increased mortality. With the development of newer medications, early and aggressive therapy can afford people with RA preserved function and improved quality of life.
RA is characterized by inflammation in the synovial membrane caused by infiltration of T cells, B cells, and monocytes, resulting in inflammation in the joint synovium. This inflammatory state leads to articular cartilage loss and bony erosion, resulting in irreversible damage and functional impairment. The onset of disease is insidious, most typically presenting with symmetric polyarthritis described as pain, swelling, and inflammation of joints leading to stiffness after a period of inactivity. Some patients present with constitutional symptoms including malaise, fatigue, and depressed mood as well as low-grade fevers and weight loss. Patients may develop anemia of chronic disease.
Classically, this symmetrically distributed polyarthritis affects the small joints of the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and metatarsophalangeal (MTP) joints early in disease. Other synovial joints may be involved, including the elbows, shoulders, ankles, and knees. Of note, the C1-C2 joints of the spine and temporomandibular, sternoclavicular, or cricoarytenoid joints may be involved. Less common initial presentations include a monarticular or oligoarticular arthritis.
RA is labeled "seropositive" when rheumatoid factor (RF) and/or anti-citrullinated protein antibodies (ACPAs) are present. Seropositive disease tends to be more severe and associated with increased risk of systemic involvement. Rheumatoid nodules occur in up to 20% of RA patients and more frequently among patients with seropositive disease.
Initial evaluation of the patient presenting with joint pain should focus on determining whether the presenting arthritis pain is inflammatory vs. noninflammatory in nature. For example, inflammatory joint symptoms include a joint stiffness that occurs after inactivity – including in the morning after waking (> 30 minutes of stiffness) – and improves with activity. Signs of inflammation such as redness, swelling, and warmth should prompt consideration of inflammatory and infectious arthritides.
Codes
ICD10CM:M06.9 – Rheumatoid arthritis, unspecified
SNOMEDCT:
69896004 – Rheumatoid arthritis
Look For
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Diagnostic Pearls
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Differential Diagnosis & Pitfalls
- Osteoarthritis
- Systemic lupus erythematosus / connective tissue disease
- Psoriatic arthritis – Look for the presence of psoriasis on the scalp, posterior auricular regions, intertriginous areas, and intergluteal cleft as well as nail changes to help make this diagnosis.
- Polymyalgia rheumatica (PMR) – Initial symptoms of PMR may be confused with RA.
- Fibromyalgia / pain syndrome
- Crystal disease (pseudogout, gout)
- Adult-onset Still disease
- Septic arthritis
- Lyme arthritis (see Lyme disease)
- Acute viral arthritis (parvovirus B19, hepatitis B, hepatitis C, HIV, chikungunya fever, rubella)
- Mononucleosis
- Inflammatory bowel disease (ulcerative colitis, Crohn disease) – Associated arthritis.
- Reactive arthritis
- Seronegative spondyloarthritis (ankylosing spondylitis, etc)
- Paraneoplastic disease (hypertrophic osteoarthropathy, myelodysplasia)
- Sarcoid arthropathy (see sarcoidosis)
- Multicentric reticulohistiocytosis – Rare.
- Whipple disease – Rare.
Best Tests
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Management Pearls
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Therapy
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Drug Reaction Data
Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.Subscription Required
References
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Last Reviewed:07/29/2021
Last Updated:03/08/2023
Last Updated:03/08/2023
Patient Information for Rheumatoid arthritis Overview
Rheumatoid arthritis is a chronic inflammatory disorder that occurs when your immune system attacks your body's own tissues. Rheumatoid arthritis causes painful swelling in your joints and can eventually lead to bone erosion and joint deformity. Rheumatoid arthritis typically affects the smaller joints first in your hands and toes. As the disease progresses, the symptoms spread to the knees, wrists, ankles, hips, elbows, and shoulders. The symptoms typically appear simultaneously on both sides of the body.Who’s At Risk
Any adult is at risk for developing rheumatoid arthritis, with 50-75 being the most common age of developing the disease. It is 3 times more common in women than men. Tobacco smoking and obesity both increase your risk of rheumatoid arthritis. Also, if a member of your family has rheumatoid arthritis, then your risk is increased.Joint stiffness after inactivity, including the morning (stiffness lasts longer than 30 minutes and improves with activity).
Signs & Symptoms
Rheumatoid arthritis has the following symptoms:- Swollen joints
- Joint stiffness
- Fatigue
- Fever
- Weight loss
- Up to 20% of patients develop rheumatoid nodules in areas of high pressure such as the sacrum of the lower back. These typically have no symptoms so removal is only for cosmetic purposes. Rheumatoid nodules are also signs that your arthritis is severe.
Self-Care Guidelines
To help manage symptoms of rheumatoid arthritis, exercise regularly and apply heat or cold to your joints. Over-the-counter drugs such as ibuprofen (Advil) can relieve pain and reduce inflammation.When to Seek Medical Care
Seek medical care if you have swelling and discomfort in your joints. It is important to diagnose this early so you can prevent it from getting worse.Treatments
Your health care provider may suggest medications such as:- NSAIDs are nonsteroidal anti-inflammatory drugs that can reduce inflammation and relieve pain (Advil and Motrin). Stronger NSAIDs may be prescribed by your health care provider
- Corticosteroid medications (prednisone) can help reduce pain, inflammation, and joint damage
- Disease-modifying antirheumatic drugs can help slow the progression of rheumatoid arthritis
Rheumatoid arthritis