Rheumatoid arthritis

Rheumatoid arthritis
James Heilman, MD · CC BY-SA 3.0 · source
Name	Rheumatoid arthritis
Field	Rheumatology
Symptoms	Joint pain, swelling, stiffness
Complications	Joint deformity, cardiovascular disease

Rheumatoid arthritis is a chronic inflammatory autoimmune condition primarily affecting synovial joints and systemic tissues. It causes persistent synovitis that can lead to joint destruction, functional disability, and reduced life expectancy; management involves immunomodulation, symptomatic care, and multidisciplinary rehabilitation. Major centers and organizations involved in research and care include Johns Hopkins Hospital, Mayo Clinic, Cleveland Clinic, National Institutes of Health, and the World Health Organization.

Signs and symptoms

Patients typically present with symmetric polyarthritis affecting small joints of the hands and feet, with morning stiffness lasting over 30 minutes and improvement with activity. Clinical examination often reveals synovial swelling, tenderness, ulnar deviation, and subluxation; joints commonly involved include the metacarpophalangeal and proximal interphalangeal joints, while the distal interphalangeal joints are usually spared. Extra-articular manifestations include rheumatoid nodules, pulmonary involvement such as interstitial lung disease, ocular disease like scleritis, and systemic features such as fatigue and low-grade fever; care pathways may involve referrals to Mayo Clinic, Cleveland Clinic, University College London Hospitals NHS Foundation Trust, and specialty clinics at Massachusetts General Hospital.

Causes and pathophysiology

The etiology is multifactorial, combining genetic predisposition (notably HLA-DRB1 shared epitope alleles) with environmental triggers such as smoking and periodontal infection with Porphyromonas gingivalis. Autoimmune responses include autoantibodies like rheumatoid factor and anti-citrullinated protein antibodies that form immune complexes, activate complement, and recruit inflammatory cells to the synovium, leading to pannus formation and cartilage erosion mediated by cytokines including tumor necrosis factor-alpha and interleukin-6. Synovial angiogenesis and fibroblast-like synoviocyte aggression contribute to bone erosion; molecular pathways under study at institutions like Harvard Medical School, Stanford University School of Medicine, and University of Oxford have motivated targeted therapies developed by pharmaceutical companies such as Roche, Pfizer, and AbbVie.

Diagnosis

Diagnosis integrates clinical criteria, serology, and imaging. Classification criteria developed by organizations such as the American College of Rheumatology and the European League Against Rheumatism combine joint involvement, serology (rheumatoid factor, anti-CCP), acute-phase reactants (ESR, CRP), and symptom duration. Radiography, ultrasound, and magnetic resonance imaging performed at centers like Mount Sinai Hospital and Karolinska Institutet detect erosions and synovitis earlier than plain films. Differential diagnosis may involve exclusion of conditions evaluated by consultants from institutions such as Cleveland Clinic and Johns Hopkins Hospital to distinguish from psoriatic arthritis, osteoarthritis, systemic lupus erythematosus, and infectious arthritis.

Treatment

Management follows a treat-to-target strategy aiming for remission or low disease activity, guided by outcome measures endorsed by the American College of Rheumatology and European League Against Rheumatism. First-line disease-modifying antirheumatic drugs include methotrexate often combined with folic acid, with adjuncts such as sulfasalazine and hydroxychloroquine; biologic agents targeting TNF, IL-6, or B cells (e.g., agents developed by AbbVie, Johnson & Johnson, Celltrion) and small-molecule JAK inhibitors produced by Pfizer and Incyte are used for inadequate response. Short courses of glucocorticoids and nonsteroidal anti-inflammatory drugs provide symptomatic relief; non-pharmacologic interventions involve physical therapy programs offered at Spaulding Rehabilitation Hospital and occupational therapy from services at Mayo Clinic. Surgical options, including synovectomy and joint replacement, are performed in centers like Royal National Orthopaedic Hospital and Hospital for Special Surgery for advanced joint destruction.

Prognosis and complications

Prognosis varies with disease severity, seropositivity, and treatment timeliness; chronic inflammation increases risk for comorbidities such as ischemic heart disease, interstitial lung disease, and osteoporosis. Complications include joint deformities (swan neck, boutonnière), tendon rupture, and increased susceptibility to infections, particularly with immunosuppressive therapies monitored by specialists at Johns Hopkins Hospital and Cleveland Clinic. Long-term outcomes have improved with earlier aggressive therapy and biologic agents developed following research at institutions including Broad Institute and Imperial College London.

Epidemiology and risk factors

Prevalence estimates vary globally, with higher reported rates in populations studied by Framingham Heart Study collaborators and national cohorts from Sweden and United Kingdom. Incidence rises with age and is more common in women, with a typical onset between middle age and older adulthood; risk factors include family history, HLA-DRB1 alleles, smoking, and periodontal disease linked to Porphyromonas gingivalis infection. Large-scale epidemiologic studies have been conducted by Centers for Disease Control and Prevention, World Health Organization, and regional registries such as the Swedish Rheumatology Quality Register and the British Society for Rheumatology databases.

Category:Autoimmune diseases