Rheumatoid arthritis

Rheumatoid arthritis — autoimmune joint disease

Rheumatoid arthritis (RA) is a chronic autoimmune disease where the immune system attacks joint lining (synovium), causing inflammation, pain, swelling, and progressive damage. Unlike osteoarthritis (wear-and-tear), RA is systemic — it can affect lungs, heart, eyes, and increase cardiovascular risk.

Affects roughly 400,000 people in the UK — women twice as often as men. Early treatment within 3 months of symptom onset prevents irreversible joint erosions.

Symptoms

Joint features:

• painful, swollen, warm joints
• symmetrical pattern — both hands, both wrists, both feet
• morning stiffness lasting >30 minutes — key inflammatory clue
• small joints — MCP, PIP finger joints, wrists, MTP toes
• spares DIP joints (end finger joints) — unlike osteoarthritis

Systemic:

• fatigue — often disproportionate
• low-grade fever, weight loss
• rheumatoid nodules — firm lumps under skin (advanced)

Variable course: flares and remissions — without treatment, progressive deformity.

Extra-articular manifestations

RA can affect:

• eyes — scleritis, dry eyes
• lungs — interstitial lung disease, nodules
• heart — increased MI and stroke risk
• blood — anaemia of chronic disease
• ** nerves** — cervical spine instability (rare, atlanto-axial)

Diagnosis

GP suspects RA from history and examination. Refer urgently to rheumatology if:

• ≥3 swollen joints
• positive RF or anti-CCP antibodies
• elevated CRP/ESR with typical pattern

Blood tests:

• ** rheumatoid factor (RF)** — not specific alone
• anti-CCP antibodies — more specific for RA
• CRP, ESR — inflammation markers
• FBC — anaemia common

Imaging:

• X-rays — erosions in established disease
• ultrasound/MRI — early synovitis — rheumatology

Treatment — treat-to-target

Goal: clinical remission or low disease activity — prevents damage.

First-line DMARDs

Methotrexate — anchor drug:

• weekly oral or subcutaneous injection
• folic acid supplementation
• blood monitoring — FBC, LFTs every 1 to 3 months initially
• contraception — teratogenic; stop before pregnancy with specialist plan

Alternatives/additions:

• hydroxychloroquine
• sulfasalazine
• leflunomide

Often combination DMARDs early.

Short-term

• NSAIDs — ibuprofen, naproxen — symptom relief, not disease-modifying
• steroid injections into joints or short oral prednisolone bridge while DMARDs work

Biologics

If DMARDs insufficient — anti-TNF (adalimumab, etanercept), rituximab, tocilizumab, abatacept, JAK inhibitors (tofacitinib, baricitinib) — rheumatology specialist.

Physiotherapy and occupational therapy

Joint protection, splints, exercise — maintain function.

Lifestyle

• stop smoking — worsens RA and reduces treatment response
• cardiovascular risk management — statins, BP control — RA equals diabetes-level CV risk
• vaccinations — flu, pneumococcal; avoid live vaccines on biologics
• weight management
• ** exercise** — maintains strength without flaring joints — physiotherapy guides

RA vs other conditions

Condition	Clues
Osteoarthritis	Older, asymmetric, bony enlargement, short stiffness
Gout	Sudden monoarthritis, big toe, uric acid
Psoriatic arthritis	Psoriasis skin/nail changes, asymmetric
Viral arthritis	Self-limiting post-viral
Septic arthritis	Single hot joint, systemically unwell — emergency

Pregnancy and RA

Many DMARDs unsafe in pregnancy — preconception rheumatology planning:

• hydroxychloroquine, sulfasalazine, azathioprine — relatively safer options under specialist care
• methotrexate, leflunomide, biologics — stop before conception per guidance

RA may improve, worsen, or fluctuate in pregnancy.

Prognosis

Without treatment: progressive disability, erosions, loss of work capacity.

With early modern therapy: majority achieve low disease activity or remission — normal life expectancy approaching general population if CV risk managed.

Window of opportunity: first 3 to 6 months — do not delay specialist referral.

Rheumatoid arthritis is serious but transformed by early DMARD treatment — persistent hand/wrist swelling with long morning stiffness needs GP assessment, not paracetamol alone.

Common questions

What are the first signs of rheumatoid arthritis?

Painful, stiff, swollen joints — often small joints of hands and feet, wrists, knees. Morning stiffness lasting over 30 minutes improving with movement. Fatigue, low-grade fever, and general unwellness. Usually develops over weeks — not sudden single joint unless septic arthritis.

What is the difference between rheumatoid arthritis and osteoarthritis?

RA is autoimmune inflammation — symmetrical small joint swelling, long morning stiffness, systemic symptoms. Osteoarthritis is wear-and-tear — usually asymmetric, worse with use, short morning stiffness, larger weight-bearing joints. Blood tests and examination distinguish — GP refers if unsure.

Is rheumatoid arthritis curable?

No cure — but modern DMARDs and biologics induce remission in many people, preventing erosions and disability. Early aggressive treatment changes prognosis dramatically compared to historical outcomes.

What is methotrexate for rheumatoid arthritis?

First-line DMARD — weekly tablets or injection — suppresses immune inflammation slowing joint damage. Takes 6 to 12 weeks for full effect. Requires regular blood tests for liver and blood count. Folic acid co-prescribed. Not safe in pregnancy — contraception essential.

Can diet cure rheumatoid arthritis?

No specific diet cures RA — Mediterranean-style anti-inflammatory eating supports general health. Fish oil may modestly help symptoms. Avoid unproven restrictive diets that cause malnutrition. Weight loss reduces joint load if overweight.

Does rheumatoid arthritis run in families?

Partial genetic risk — first-degree relatives have higher incidence but most cases are sporadic. Smoking is the strongest modifiable environmental risk factor — especially in people with genetic susceptibility (shared epitope).

Sources

• NHS — Rheumatoid arthritis
• NICE — Rheumatoid arthritis management