Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic inflammatory disease that causes pain, stiffness, and swelling in the joints, usually in a symmetrical pattern (identical body part – left and right). In this type of arthritis unlike in osteoarthritis, the joint lining (synovium), which is normally smooth and shiny, becomes inflamed, painful and swollen. The disease, which usually increases and decreases (exacerbates or goes in remission) over a long period of time, can cause damage to cartilage, bone, tendons and ligaments. RA can also cause systemic involvement like inflammation in the blood vessels and the outer lining of the heart and lungs. About 3% of women and one percent of men are affected by this disorder.

Classifying Rheumatoid Arthritis:

For classification purposes, a patient is said to have RA if he or she has satisfied at least 4 of the following 7 criteria. Criteria 1 through 4 must have been present for at least 6 weeks. Patients with 2 clinical diagnoses are not excluded.

1. Morning stiffness

Morning stiffness in and around the joints, lasting at least 1 hour before maximal improvement.

2. Arthritis of 3 or more joint areas

At least 3 joint areas simultaneously have had soft tissue swelling or fluid (not bony overgrowth alone) observed by a physician; the 14 possible joint areas are right or left proximal interphalangeal (PIP) joints, metacarpophalangeal (MCP) joints, wrist, elbow, knee, ankle, and metatarsophalangeal (MTP) joints.

3. Arthritis of hand joints

At least 1 area swollen (as defined above) in a wrist, MCP or PIP joint.

4. Symmetric arthritis

Simultaneous involvement of the same joint areas (see 2 above) on both sides of the body (bilateral involvement of PIPs, MCPs, or MTPs is acceptable without absolute symmetry).

5. Rheumatoid nodules

Subcutaneous nodules, over bony prominences, or extensor surfaces, or in juxta-articular regions, observed by a physician.

6. Serum rheumatoid factor

Demonstration of abnormal amounts of serum rheumatoid factor by any method for which the result has been positive in <5% of normal control subjects.

7. Radiographic changes

Radiographic changes typical of RA on posteroanterior hand and wrist radiographs, which must include erosions or unequivocal bony decalcification localized to or most marked adjacent to the involved joints (osteoarthritis changes alone do not qualify).

The changes that occur at molecular level in osteoarthritis are

1. Increased water content (in contrast to decreased water content in normal ageing) leading to weakening of type 2 collagen network.

2. Shorter chains and shifts in the concentration of proteoglycans. The chondroitin/keratin ratio is increased (opp. to ageing).

3. Disruption is caused by an increase in collagenase and proteoglycan-degrading enzyme (stromelysin & plasmin) concentration.

4. Rate of synthesis of DNA, collagen, and proteoglycans are increased

5. Increased levels of:

• Matrix Metalloproteinases (MMPs) (collagenase, gelatinase, and stromelysin).

• Cathepsins B and D

• IL1 - enhances enzyme synthesis & has a catabolic effect.

• IL6

• TNFa

• TGF beta

• GAGs and polysulfuric acid

Common sites for RA include:

• Hands

• Wrists

• Elbows

• Shoulders

• Neck

• Hips

• Knees

Cause of Rheumatoid Arthritis:

RA is an autoimmune disease, which means our own immune system starts to attack some of your tissues. It is not exactly known what causes this autoimmune attack, but the most accepted hypothesis is that in a genetically susceptible individual, an environmental trigger (drugs, allergens, chemical or infection) causes an autoimmune attack.

Symptoms of Rheumatoid arthritis:

Rheumatoid arthritis has predominant involvement of different joints – in a characteristic exacerbating and remitting pattern. It has three phases – stage of synovitis, stage of destruction, and stage of deformity. The most common symptoms of RA are pain, swelling and stiffness in one or more joints. The pain may be similar to a headache or toothache. In some people, the joints can feel hot. Occasionally lumps of tissue known as rheumatoid nodules develop near the affected joint, usually near the elbow joint.

There may be involvement of organs other than other joint also known as systematic involvement. These include:

1. Nodules - in 20% of RA - skin, synovium, tendons, sclera, viscera

2. Lymphadenopathy (enlargement of the lymph glands)

3. Splenomegaly (enlargement of spleen)

4. Vasculitis (involvement of the vessels)

5. Myopathy ( Muscle involvement)

6. Sensory changes - neuropathy, or direct compression from synovitis

7. Visceral

• pericarditis (inflammation of the lining of heart)

• pulmonary fibrosis, nodules, pleurisy

The combination of certain systemic involvement and Rheumatoid arthritis have been known as syndrome complexes, some of which are-

1. Felty's Syndrome - splenomegaly + leukopaenia

2. Still's Disease - fever, rash + splenomegaly

3. Sjorgen Syndrome - decreased salivary & lacrimal gland secretion & lymphoid proliferation

Lab Tests: Following lab tests may become abnormal-

1. Incr. ESR

2. Incr. CRP

Potential Complications:

1. Fixed Deformities

2. Joint Rupture

3. Infection

4. Spinal cord compression

5. Peripheral nerve compression

6. Vasculitis

7. Amyloidosis - proteinuria & progressive renal failure


The main goals in treating RA are to relieve pain, reduce swelling, slow down the damage to the joints, and improve the person's ability to function.

1) Stop the Synovitis

a) Rest

b) Drugs: While there is no cure for rheumatoid arthritis, some drugs can help control the disease. A rheumatologist will often suggest:

Nonsteroidal anti-inflammatories can be used and include:

o Acetylsalicylic acid (aspirin)

o Ibuprofen

o Indomethacin

o Naproxen

o Tolmetin

Corticosteroids can also help ease pain and swelling and help slow the damage to the joints. Drugs that are corticosteroids include prednisone and cortisone.

There are also a group of drugs know as disease modifying antirheumatic drugs. These are also called DMARDs and they take much longer to act than the NSAIDs. Sometimes it can take weeks or months to begin to notice a change. But, the DMARDs may help slow the progress of the arthritis, too. There are more side effects to these drugs though and you will need to check with your doctor often. DMARDs include:

• Antimalarial drugs

• Gold compounds

• Penicillamine

• Sulfasalazine

c) Synovectomy - chemical, irradiation, surgical.

2) Prevent Deformity

a) Splintage

b) Physiotherapy

c) Tendon repairs & joint stabilisation

3) Reconstruct: Surgery, such as joint replacement, may be an option for some people

a) Arthroplasty or joint replacement.

b) Arthrodesis

c) Osteotomy

4) Rehabilitate

o Occupational therapists - aids, support

o Physiotherapy

Alternative Medicine:

Some form of medicines like Ayurveda and homeopathy have also been tried but with limited success.


• 10% improve after first attack of synovitis

• 60% have remissions & exacerbations

• 20% have severe joint erosions requiring multiple operations

• 10% become completely disabled

Poor prognostic signs:

1. Very high Rheumatoid Factor.

2. Peri-articular erosions on X rays.

3. Nodules

4. Muscle wasting

5. Joint contractures

6. Vasculitis or vessel involvement.

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