Rheumatoid arthritis is a chronic inflammatory disease that causes swelling and stiffness in the joints. It is the most common form of inflammatory arthritis. It can affect other parts of the body as well as the joints, causing extra-articular manifestations like fatigue, lung involvement, and vasculitis. The disease typically affects women between 25-55 years of age and causes symptoms like morning joint stiffness lasting over an hour that improves with activity. Treatment involves medications like NSAIDs for pain relief, DMARDs like methotrexate to slow disease progression, and corticosteroids or biologics for more severe cases. Early treatment can help prevent long-term joint damage and deformities.

1. Rheumatoid Arthritis
By Dr. Kiran Bikkad

2. • A chronic inflammatory disease of unknown
etiology marked by a symmetric, peripheral
polyarthritis.
• Most common form of chronic inflammatory
arthritis

3. • A systemic Disease
• Extraarticular manifestations :
1. Fatigue
2. subcutaneous nodules
3. lung involvement
4. pericarditis
5. peripheral neuropathy
6. Vasculitis
7. hematologic abnormalities

4. CLINICAL FEATURES
• Incidence : between 25-55 years of age.
• The presenting symptoms result from
inflammation of the joints, tendons, and
bursae.
• Eearly morning joint stiffness lasting more
than 1 h that eases with physical activity.

5. CLINICAL FEATURES
• Earliest involved joints - small joints of the
hands & feet.
• May be monoarticular, oligoarticular (≤4
joints), or polyarticular (>5 joints).
• RA have a higher number of tender and
swollen joints, test positive for serum
rheumatoid factor (RF) or anti-CCP antibodies,
and have higher scores for physical disability

6. CLINICAL FEATURES
• Wrists, MCP & PIP joints stand  most
frequently involved joints
• DIP joint-- rarely involved & denotes
coexistent osteoarthritis.
• Flexor tendon tenosynovitis  a hallmark of
RA

7. CLINICAL FEATURES
• Progressive destruction of joints and soft
tissues L/T chronic, irreversible deformities.
• Subluxation of the MCP joints  Ulnar
deviation
• Hyperextension of PIP & flexion of DIP joint 
swanneck Deformity
• Flexion of the PIP & hyperextension of DIP
joint  boutonniere deformity

8. MCP & PIP joint swelling in RA

9. CLINICAL FEATURES
• Subluxation of 1st MCP joint & hyperextension
of the first interphalangeal joint L/T Z-
deformity
• Large joints involved  knees & shoulders
• Spine usually spaired except cervical spine,
which may cause compressive myelopathy &
neurologic dysfunction.

10. Extraarticular Manifestations
• May develop even prior to the onset of
arthritis.
• Risk Factors:-
1. History of smoking,
2. Early onset disability
3. Test positive RF.

11. Extraarticular Manifestations
• M/C :-
1. Subcutaneous nodules
2. Secondary Sjögren’s syndrome
3. Pulmonary Nodules
4. Anemia

12. Extraarticular Manifestations
CONSTITUTIONAL 
• weight loss, fever(101°F), fatigue, malaise,
depression, cachexia
• reflect a high degree of inflammation.

13. Extraarticular Manifestations
NODULES 
• 30–40%
• Firm; non tender; adherent to periosteum,
• tendons
• Develop in areas of repeated trauma
• E.g. : forearm, sacral prominences, Achilles
tendon.
• Also in lungs, pleura, pericardium & peritoneum.

14. Extraarticular Manifestations
SJOGREN’S SYNDROME 
• defined by the presence of either
keratoconjunctivitis sicca (dry eyes) or
xerostomia (dry mouth) in association with
another connective tissue disease, such as RA.

15. Extraarticular Manifestations
PULMONARY 
• Pleuritis most common pulmonary
manifestation of RA.
• Pleural effusions exudative, increased
monocytes & neutrophils.
• Interstitial lung disease (ILD)Diagnosed by HRCT.
• Caplan’s syndrome characterized by nodules &
pneumoconiosis following silica exposure.
• bronchiolitis and bronchiectasis.

16. Extraarticular Manifestations
CARDIAC 
• The most frequent site  pericardium.
• Cardiomyopathy, result from necrotizing or
granulomatous myocarditis
• MR is M/C valvular abnormality in RA

17. Extraarticular Manifestations
VASCULITIS 
• In patients with
– long-standing disease
– a positive serum RF
– Hypo-complementemia.
• The cutaneous signs include
• petechiae, purpura, digital infarcts, gangrene,
livedo reticularis
• Vasculitic ulcers, treated with
immunosuppressive agents & skin grafting.

18. Extraarticular Manifestations
HEMATOLOGIC 
• A normochromic, normocytic anemia
• Degree of anemia denotes degree of
inflammation, correlating with CRP & ESR
levels.
• Platelet elevated in RA as acute-phase
reactant.

19. Extraarticular Manifestations

20. Pathophysiology

21. Diagnosis
• signs and symptoms of chronic inflammatory
arthritis
• with laboratory & radiographic results
• American College of Rheumatology (ACR)
classification criteria for RA, a score of 0–10,
with a score of ≥ 6 fulfil the requirements for
definite RA.

22. Classification Criteria for Rheumatoid
Arthritis

23. LABORATORY FEATURES
1. Elevated nonspecific inflammatory markers E.g.
ESR, CRP
2. Detection of serum RF and anti-CCP antibodies
3. Serum IgM RF found in 75–80% of patients
• diagnostic
• anti-CCP antibody : specificity 95%, so a positive
test , with early inflammatory arthritis, helps
distinguishing RA from other arthritis.

24. • SYNOVIAL FLUID ANALYSIS
• Reflects an inflammatory State.
• Synovial fluid WBC -- 5000 and 50,000 WBC/μL
• (compared to <2000 WBC/μL for osteoarthritis)
• M/C Cell in the synovial fluid  neutrophil.
• Most useful for confirming inflammatory arthritis
(as compared to osteoarthritis) & excluding
infection or crystal induced arthritis e.g. gout or
pseudo-gout.

25. • JOINT IMAGING
• for diagnosing RA
• for tracking progression of joint damage.
1. Plain x-ray (M/C)-
– Peri-articular osteopenia, soft tissue swelling, symmetric
joint space loss, subchondral erosions.
– signs of severe destruction :- joint subluxation and collapse
2. MRI
3. Ultrasound techniques
• Detect changes in soft tissues
• E.g. synovitis, tenosynovitis, effusions & bony
abnormalities

26. X-ray progression of erosions PIP joint

27. ‘Swan neck’ deformity of the fingers.

28. Ulnar deviation of the fingers with wasting of the small muscles of the hands and synovial
swelling at the wrists, the extensor tendon sheaths, the metacarpophalangeal and proximal
interphalangeal joints.

30. Rheumatoid nodules and olecranon bursitis. Nodules
were palpable within as well as outside the bursa.

31. Marginal erosions at metatarsal heads

32. MANAGEMENT
• Primary Objectives
– Target is low disease activity or remission
– Reduction of inflammation and pain
– Preservation of function
– Prevention of deformity
DRUGS USED
– NSAIDs
– CORTICOSTEROIDS
– DMARDs
• SYNTETIC
• BIOLOGICAL

33. General Measures
The general aims of management are to:
• Educate the patient
• Control pain
• Optimise function
• Modify the disease process where this is
possible
• Identify and treat related comorbidity

34. NSAIDs
• Symptomatic relief in RA
• Do not prevent erosions/alter disease
progression.
• Not appropriate for monotherapy
• Used in conjunction with DMARDs

35. Corticosteroids
• Prompt anti-inflammatory effect in RA & slow
rate of erosion.
• Multiple side effects limit their long term use.
• Low-dose corticosteroids – as a bridge to reduce
disease activity until the slower acting DMARDs
take effect
• Use : as Adjunctive therapy for active disease that
persists despite treatment with DMARDs.
• 10 mg of prednisone or equivalent per day is
appropriate for articular disease.

36. Corticosteroids
• Higher doses use : to manage extra-articular
manifestations
– eg: pericarditis, necrotizing scleritis.
• Intra-articular corticosteroids
– if one or two joints are highly inflaimed.
– Triamcinolone, 10–40 mg depending on the size of
the joint
– Not more than four times a year.

37. Synthetic DMARDs
• Methotrexate is the initial synthetic DMARD
of choice.
• Effect in 2–6 weeks.
• The usual initial dose is 7.5 mg of
methotrexate orally once weekly.
• Gastric irritation, stomatitis, cytopenias, and
hepatotoxicity
• Daily folate suplimentation

39. Biological DMARDs

40. Which Drugs and When???
• Early RA - RA disease duration <6 months
• Established RA - RA disease duration >6 months or meeting
the classification criteria
• Disease activity - low, moderate and high
• Poor prognosis - Presence of 1 or more of the following
features:
– functional limitation
– extraarticular disease (e.g. presence of rheumatoid
nodules, RA vasculitis, Felty’s syndrome)
– positive rheumatoid factor or anti–cyclic citrullinated
peptide antibodies
– bony erosions by radiograph

41. ACR and EULAR update

43. Pregnancy
1. Prednisone
2. Hydroxychloroquine
3. Sulfasalazine
are the safest DMARDs
• Methotrexate & leflunomide are
contraindicated

44. Other Treatments2
Surgery
• Synovectomy of wrist or finger tendon sheaths
for pain relief or to prevent tendon rupture
when medical interventions have failed.
• Osteotomy
• Arthrodesis
• Athroplasty