About Rheumatoid Arthritis (RA)

Rheumatoid arthritis is an inflammatory, autoimmune disease primarily impacting the joints.

  • F:M = 3:1
  • Onset: 20-30s and a second spike in early 60s
  • Interplay of environment and genetics: smoking, oral bacteria, shared epitope: HLA-DR1 or DR4

Disease Overview & Clinical Presentation

  • Low grade fever can occur
  • 5th MTP erosion pathognomonic for RA
  • C1/C2 subluxation is a complication
  • Spares DIPs, thoracic and lumbar spine

Diagnostic Workup & Differential Diagnosis

  • RF sensitive: if low-positive and low suspicion of RA, check hepatitis serologies
  • CCP: specific and predictive
  • Early x-rays: marginal erosions, osteopenia
    Late xrays: subluxuation, osteoporosis

Treatment

  • Glucocorticoids: weak DMARDs if NSAIDs didn’t modify disease
  • Methotrexate is gold standard, first line
  • Insidious usually >= 6 weeks
  • Symmetric, polyarthritis
    • Usually small joints
    • >1 hour morning stiffness
    • Improves with activity
  • Involving: wrists, MCPs, PIPs. MTPs (5th MTP), knees, ankles, C1/C2 subluxation
  • Associated with fatigue and low grade fever
  • Extra-articular

Lab workup

  • Rheumatoid factor (RF): high sensitivity (can be positive in hepatitis, etc.)
  • Citrullinated cyclic peptide (CCP): very specific, predictive
  • C-reactive protein ESR both very sensitive
  • Anemia of chronic disease

Synovial fluid

  • 5k-50k/mL neutrophilic

Imaging

  • Hand and feet x-rays
  • 3-views: marginal erosions (view image), late RA, subluxation
  • Other rheum disease
    • Lupus
    • Seronegative spondy
    • Crystal arthritis
      Gout
      Psueudogout
  • Viral arthritis
    Parvovirus B19
    Hepatitis B, C
  • Sarcoidosis
  • Endocrinopathy
    • Thyroid disease
    • Hemochromatosis (MCP 2/3)

Acute treatment

  • NSAIDs: doesn’t modify disease
  • Glucocorticoids: can slow/modify disease

Chronic treatment with disease modifying anti-rheumatic drugs (DMARDs)

Oral DMARDs
  • Methotrexate with folic acid, Teratogenic,CMP monitoring
  • Hydroxychloroquine, retinal toxicity, QTc prolonging
  • Sulfasalazine – Check G6PD prior
  • Leflunomide
Biologic DMARDs
  • TNF- alpha inhibitor
  • IL6R inhibitor
  • B-cell depletion
  • Abatacept
  • Targeted oral: JAKi
View ACR RA Treatment Guidelines
  • Goal of early inflammation suppression
    • Prevent joint damage (damage is irreversible)
    • Lower CV risk
  • Complications
    • Inflammatory lung disease (view image)
    • Vasculitis
    • AA amyloid