Rheumatoid arthritis

Rheumatoid arthritis (RA) is the most common inflammatory arthritis in adults, characterised by progressive joint destruction and deformity, usually of peripheral joints

• presentation is typically as an insidious polyarthritis characterised by inflammatory changes in the synovial membranes and articular structures leading to deformity and ankylosis.
• systemic features, leading to extra-articular manifestations (EAM), usually develop as the disease progresses(1,2,3)

Rheumatoid arthritis (RA) is an inflammatory disease largely affecting synovial joints (4):

• typically affects the small joints of the hands and the feet, and usually both sides equally and symmetrically, although any synovial joint can be affected
• a systemic disease and so can affect the whole body, including the heart, lungs and eyes
• incidence of the condition is low, with around 1.5 men and 3.6 women developing RA per 10,000 people per year
• overall occurrence of RA is 2 to 4 times greater in women than men. The peak age of incidence in the UK for both men and women is the 70s, but people of all ages can develop the disease
• approximately one-third of people stop work because of the disease within 2 years of onset, and this increases thereafter

The cause is unknown, but an autoimmune mechanism involving viral infection has been postulated.

Treat-to-target strategy (4)

• treat active RA in adults with the aim of achieving a target of remission or low disease activity if remission cannot be achieved (treat-to-target)
  • achieving the target may involve trying multiple conventional disease-modifying anti-rheumatic drugs (cDMARDs) and biological DMARDs with different mechanisms of action, one after the other
• consider making the target remission rather than low disease activity for people with an increased risk of radiological progression (presence of anti-CCP antibodies or erosions on X-ray at baseline assessment)
• in adults with active RA, measure C-reactive protein (CRP) and disease activity (using a composite score such as DAS28) monthly in specialist care until the target of remission or low disease activity is achieved.

Reference:

1. Singh JA et al. 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Rheumatol. 2016;68(1):1-26.
2. Amaya-Amaya J, Rojas-Villarraga A, Mantilla RD, et al. Rheumatoid arthritis. In: Anaya JM, Shoenfeld Y, Rojas-Villarraga A, et al., editors. Autoimmunity: From Bench to Bedside [Internet]. Bogota (Colombia): El Rosario University Press; 2013 Jul 18. Chapter 24.
3. Harnden K, Pease C, Jackson A. Rheumatoid arthritis. BMJ. 2016;352:i387.
4. National Institute for Health and Care Excellence (NICE) - updated November 2020. Rheumatoid arthritis in adults: management