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Rheumatoid arthritis 

Rheumatoid arthritis
Rheumatoid arthritis

Kenneth F. Baker

, and John D. Isaacs

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date: 25 February 2021

Rheumatoid arthritis is a common autoimmune disease characterized by both synovial and systemic inflammation. Synovitis classically presents as a symmetrical destructive polyarthritis affecting the hands and feet typified by episodic pain, stiffness, and swelling. Systemic inflammation leads to a range of extra-articular manifestations including organ involvement (e.g. interstitial lung disease, scleritis), constitutional features (e.g. fatigue, depression) and other complications (e.g. accelerated atherosclerosis, nerve and spinal cord compression). Rheumatoid arthritis is a clinical diagnosis based largely upon history and examination, supported by a limited range of investigation findings including elevated acute-phase reactants, autoantibodies (rheumatoid factor and anti-citrullinated peptide antibody), and imaging (e.g. musculoskeletal ultrasound). If left untreated, patients can rapidly develop irreversible joint damage leading to chronic pain, deformity, disability, and premature mortality. However, with early initiation of disease-modifying anti-rheumatic drugs (DMARDs) in treat-to-target strategies, disease remission is now achievable for many patients. Conventional synthetic DMARDs are the anchor of rheumatoid arthritis therapy, with methotrexate the recommended first choice. Biological DMARDs (monoclonal antibodies and soluble receptors) and targeted synthetic DMARDs (Janus kinase inhibitors) are reserved as second-line agents. Glucocorticoids are helpful as bridging therapy, though their considerable side effect profile prohibits their use as maintenance therapy. Non-steroidal anti-inflammatory drugs (NSAIDs) are effective in relieving arthritis pain, but long-term use is limited by their potential cardiovascular, renal, and gastrointestinal toxicities. With optimal care from a multidisciplinary team, many patients achieve and retain disease remission with maintenance of employment and quality of life.

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