1. Rheumatoid arthritis
Chronic inflammatory
B/L symmetrical polyarthritis,
involving small joints of hands & feet

2. RA
 Common in middle-aged, females
 Epidemiological association with EBV & HHV-6
 Chronic- x >6 weeks
 Inflammatory- pain, swelling, morning stiffness
 Joints involved- B/L symmetrical PIP, MCP, MTP,
wrist; DIP spared
 Spine- C1-C2 joint involved, rest rarely;
atlanto-axial dislocation can cause quadriparesis
 Long-standing disease causes joint deformities

3. RA- X-ray

4. Extra-articular manifestation
 Rheumatoid nodules- firm, non-tender, subcutaneous
nodules on extensor surface of forearms
 Small vessel vasculitis- digital infarct,
livedo reticularis, mononeuritis multiplex
 Pericarditis
 Accelerated atherosclerosis
 Lung- pleural effusion, rheumatoid nodules, interstitial
fibrosis
 Nerve entrapment syndromes
 Felty syndrome- RA, splenomegaly, neutropenia

5. Investigation
 Anemia-normocytic, normochromic
 Raised ESR- helpful in follow-up
 X-ray of hands- juxta-articular osteopenia,
reduced joint space, bony erosions,
 Rheumatoid factor- autoAb against Fc portion
of IgG- +ve in ~50-70%
 Anti-CCP Ab- +ve in ~70%, more specific
 Synovial fluid- inflammatory

6. Differential diagnosis
 Actually none
 Ankylosing spondylitis- males, axial joints affected
 Psoriatic arthritis- skin lesions, nail changes,
DIP joint involvement
 Gout- large joints involved, asymmetricalsymmetrical
 Osteoarthritis- weight bearing joints, DIP
joints involved, X-ray suggestive
 SLE- other system involved, ds-DNA Ab +ve
 Acute rheumatic fever- asymmetric, migratory, large joints
involved, e/o antecedent streptococcal infection

7. Treatment
 No cure, except SCT
 Goals of treatment-
 Alleviate symptoms- steroids as bridge therapy
 Prevent future joint destruction & deformity- DMARDs
 Sequence of DMARDs-
 Methotrexate
 + HCQS
 + any biological TNF antagonist/Sulfasalazine
 Rituximab

8. DMARDs- start early
 Non-biological-
 Methotrexate- 5-25 mg/week; monitor CBC, LFT, RFT
 Hydroxychloroquine- 200-400 mg/day; retinal toxicity
 Sulfasalazine- 1-3 gm/day; monitor WBC
 Leflunomide- 10-20 mg/day; watch for diarrhea, monitor LFT
 Biological- costly
 Etanercept- recombinant TNF receptor, given SC
 Infliximab- chimeric monoclonal Ab against TNF, given IV
 Adalimumab- human monoclonal Ab against TNF, given SC
 Rituximab- chimeric Ab against CD20 on B-cells, given IV

9. Prognosis
 Disability-
 After 5 years- ~1/3rd
won’t be working
 After 10 years- ~half
 Poor prognostic factors
 Early erosive disease
 Rheumatoid nodules
 +ve RF/anti-CCP Ab
 Increased clinical severity
 Mortality- lifespan reduced by ~5-10 yrs.

10. Prognosis
 Disability-
 After 5 years- ~1/3rd
won’t be working
 After 10 years- ~half
 Poor prognostic factors
 Early erosive disease
 Rheumatoid nodules
 +ve RF/anti-CCP Ab
 Increased clinical severity
 Mortality- lifespan reduced by ~5-10 yrs.