Rheumatoid arthritis

1. Introduction

  • Definition: Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by systemic inflammation and synovial joint involvement, leading to pain, swelling, and eventual joint deformity.
  • Epidemiology: Affects approximately 1% of the global population, with higher prevalence in women (3:1 ratio) and peak onset between ages 30–60 years.
  • Significance: RA is a leading cause of disability and requires early diagnosis and treatment to prevent joint damage and systemic complications.

2. Causes and Risk Factors

  • Causes:
    • Autoimmune dysfunction triggered by genetic and environmental factors.
  • Risk Factors:
    • Genetic predisposition (e.g., HLA-DR4).
    • Female gender and hormonal influences.
    • Smoking and environmental triggers (e.g., infections).
    • Obesity and poor oral health (e.g., periodontal disease).

3. Pathophysiology

  • Immune system activation causes chronic inflammation in the synovium, leading to synovial hyperplasia (pannus formation), cartilage destruction, and bone erosion.

4. Symptoms and Features

  • Common Symptoms:
    • Symmetrical joint pain and swelling (commonly small joints of hands, wrists, and feet).
    • Morning stiffness lasting >1 hour.
    • Fatigue, low-grade fever, and malaise.
  • Advanced Features:
    • Joint deformities (e.g., ulnar deviation, boutonnière deformity).
    • Rheumatoid nodules on extensor surfaces.

5. Complications

  • Joint destruction and deformities.
  • Increased risk of cardiovascular disease and infections.
  • Pulmonary complications (e.g., interstitial lung disease).
  • Psychological effects such as depression and anxiety.

6. Diagnosis

  • Clinical Features: Symmetrical arthritis, joint tenderness/swelling, and systemic symptoms.
  • Laboratory Tests:
    • Rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) antibodies (high specificity).
    • Elevated ESR and CRP indicating inflammation.
  • Imaging:
    • X-rays: Joint space narrowing, erosions.
    • Ultrasound or MRI for early synovitis detection.

7. Management Overview

  • Goals: Achieve disease remission or low disease activity, prevent joint damage, and improve quality of life.
  • Approach: Early, aggressive treatment with disease-modifying antirheumatic drugs (DMARDs).

8. Treatment Options with Cost (USD)

  • DMARDs:
    • Methotrexate: ~$30–$60/month.
    • Sulfasalazine: ~$20–$50/month.
  • Biologic DMARDs:
    • Adalimumab: ~$2,000–$3,500/month.
    • Etanercept: ~$2,500–$3,500/month.
  • Supportive Therapies:
    • Physical therapy: ~$50–$150/session.

9. Advanced Treatment Options with Cost (USD)

  • Janus Kinase (JAK) Inhibitors:
    • Tofacitinib: ~$5,000–$10,000/month.
  • Surgical Interventions:
    • Joint replacement: ~$15,000–$30,000 per joint.

10. Pharmacological Treatment

  • First-line: Methotrexate as monotherapy or combined with other DMARDs.
  • Second-line: Biologics (e.g., TNF inhibitors, IL-6 inhibitors) for refractory cases.
  • Supportive: NSAIDs and corticosteroids for symptom control during flares.

11. Medication Tables

Table 1: Doses and Side Effects

DrugIndicationDoseCommon Side Effects
MethotrexateFirst-line DMARD7.5–25 mg weeklyNausea, liver toxicity, mouth sores
SulfasalazineAlternative DMARD1–3 g dailyGI upset, rash, leukopenia
AdalimumabTNF inhibitor40 mg subcutaneously every 2 weeksInjection site reactions, infections
TofacitinibJAK inhibitor5–10 mg twice dailyIncreased cholesterol, infections
PrednisoneFlares/symptom control5–15 mg dailyWeight gain, osteoporosis, hyperglycemia

Table 2: Brand Names and Approximate Costs (USD)

DrugBrand NamesApprox. Cost
MethotrexateRheumatrex, Trexall$30–$60 per month
SulfasalazineAzulfidine$20–$50 per month
AdalimumabHumira$2,000–$3,500 per month
TofacitinibXeljanz$5,000–$10,000 per month
PrednisoneDeltasone$10–$30 per month

12. Lifestyle Interventions

  • Regular low-impact exercise (e.g., walking, swimming) to maintain joint function.
  • Anti-inflammatory diet rich in omega-3 fatty acids, fruits, and vegetables.
  • Smoking cessation to reduce disease activity.

13. Monitoring Parameters

  • Regular monitoring of disease activity (e.g., DAS28 score).
  • Routine blood tests (e.g., CBC, liver function) for methotrexate toxicity.
  • Imaging to assess disease progression or treatment response.

14. Patient Counseling Points

  • Emphasize the importance of early and consistent treatment to prevent joint damage.
  • Educate on the potential side effects of medications and the need for regular follow-ups.
  • Encourage self-management strategies, including physical activity and stress reduction.
  • Discuss the emotional impact of RA and provide resources for support groups.

15. Special Populations

  • In Children: Juvenile idiopathic arthritis (JIA) is the pediatric equivalent; treatment is similar with adjusted dosing.
  • In Pregnancy: Avoid teratogenic drugs like methotrexate; use safer alternatives like sulfasalazine or biologics.
  • In Elderly: Increased risk of medication side effects; monitor closely for infections or organ toxicity.

16. Prevention

  • There is no definitive prevention, but lifestyle modifications such as smoking cessation and maintaining a healthy weight can reduce risk factors and disease severity.

17. FAQs

  1. What is rheumatoid arthritis?
    Answer: An autoimmune disease causing chronic joint inflammation and systemic effects.
  2. What causes RA?
    Answer: A combination of genetic and environmental factors.
  3. How is RA diagnosed?
    Answer: Based on clinical features, blood tests (e.g., RF, anti-CCP), and imaging.
  4. Is RA curable?
    Answer: No, but it can be managed effectively with treatment.
  5. What are DMARDs?
    Answer: Medications that slow disease progression, such as methotrexate.
  6. How does methotrexate work?
    Answer: It reduces inflammation by suppressing the immune response.
  7. What are biologics?
    Answer: Targeted therapies that block specific inflammatory pathways, like TNF inhibitors.
  8. Can RA affect other organs?
    Answer: Yes, including the lungs, heart, and eyes.
  9. What is the role of lifestyle in managing RA?
    Answer: Regular exercise and a healthy diet help reduce symptoms and improve quality of life.
  10. How is RA different from osteoarthritis?
    Answer: RA is autoimmune, while osteoarthritis is a degenerative joint disease.
  11. Are there surgical options for RA?
    Answer: Yes, joint replacement or synovectomy may be needed for advanced cases.
  12. Can RA go into remission?
    Answer: Yes, with early and effective treatment.
  13. What foods help reduce RA inflammation?
    Answer: Fatty fish, leafy greens, and berries.
  14. Are there risks with long-term steroid use?
    Answer: Yes, including osteoporosis, diabetes, and weight gain.
  15. When should I see a rheumatologist?
    Answer: If you experience persistent joint pain, swelling, and stiffness