II. Epidemiology
- Prevalence: 0.5 to 1% in U.S. and 0.3% worldwide
- Women affected 2-3x more often (account for more than three-quarters of patients)
- Twin concordance: 30 to 50%
- Peak Incidence ages 30 to 50 years (mean age of onset 48 years old)
- Associated with HLA-DR4 and HLA-DR1 haplotypes
- Associated with STAT4 gene and CD40 locus
III. Pathophysiology: Order of changes
- Immune response
- Autoantibodies to citrulline-containing endogenous Proteins (response to genetic and environmental factors)
- Synovial Macrophage and fibroblast activation
- Cytokine production and release (Interleukin-6, Tumor Necrosis Factor or TNF) results in fever, Anemia
- Lymphoctes infiltrate perivascular areas
- Musculoskeletal and vascular effects
- Synovial thickening (Pannus formation and spread)
- Neovascularization
- Local micro-Vasculitis
- Chondrocyte, Osteoclast, CD4+ Helper activity
- Endothelial proliferation
- Joint space narrowing
IV. Risk Factors
- Increased risk
- Female gender
- Family History of Rheumatoid Arthritis
- Tobacco Abuse (most significant environmental trigger)
- Relative Risk: 2.2 for more than 40 pack year smokers
- Also associated with more severe joint disease and extraarticular disease (e.g. Vasculitis, pulmonary fibrosis)
- More than 3 cups coffee daily (esp. decaffeinated)
- Decreased risk
- Women who've delivered children
- Breastfeeding
- Diets rich in fish
- References
V. Findings
VI. Course
- Self-limited (5-20%)
- Minimally progressive (5-20%)
- Progressive (60-90%)
- Early damage
- Two Years from onset:
- Joint space narrowing and erosions in 50%
- Ten years from onset:
- Young working patients are disabled: 50%
- Two Years from onset:
- Early death by multiple causes
- Women's Life Expectancy reduced by 10 years
- Men's Life Expectancy reduced by 4 years
- Early damage
VII. Diagnosis
VIII. Differential Diagnosis
- See Rheumatoid Arthritis Prediction Rule for Undifferentiated Arthritis
- See Polyarthritis
- Arthropathy of Inflammatory Bowel Disease
- Hemochromatosis
- Hepatitis B
- Hypothyroidism
- Fibromyalgia
- Gonococcal Arthritis
- Gouty Arthritis (Polyarticular)
- Lyme Disease
- Parvovirus
- Polymyalgia Rheumatica
- Psoriatic Arthritis
- Reiter's Syndrome
- Sarcoidosis
- Scleroderma
- Septic Arthritis
- Still's Disease
- Subacute Bacterial Endocarditis
- Systemic Lupus Erythematosus
IX. Labs (ARA recommended, but do not exclude diagnosis)
- Initial Labs
- Complete Blood Count with differential
- Rheumatoid Factor (Initially positive in 70%)
- Sedimentation Rate (ESR) or C-Reactive Protein (C-RP)
- Consider Anticyclic Citrullinated Peptide Antibody
- Consider Antinuclear Antibody (especially in juvenile forms as has prognostic value)
- Additional labs in preparation for rheumatic agents
- Labs needed before Steroids, TNF Inhibitors or DMARDs
- PPD with candida controls
- HBsAg
- Hepatitis C Antibody
- Markers of disease course
X. Imaging
- Obtain baseline hand and feet XRays
- May demonstrate periarticular erosive changes
- May define more aggressive disease
- See Rheumatoid Arthritis Related XRay Changes
- Chest XRay (erosions define moderate to severe disease)
XI. Management
XII. Associated Conditions
- See Rheumatoid Arthritis Extra-articular Signs
- Atlanto-axial instability
- Exercise caution with intubation
- Risk of C-Spine Fracture with Trauma
- Lymphoma (and other lymphoproliferative disorders)
- Insulin Resistance (50-60%)
-
Coronary Artery Disease
- See Cardiac Risk Management
- Rheumatoid Arthritis is now considered a coronary equivalent (similar to diabetes mellitus Cardiovascular Risk)
- Methotrexate is associated with reduced Cardiovascular Risk
- Overall Increased Mortality
- Related to cardiovascular disease, higher infection rates, Chronic Kidney Disease
- Mortality is increased as much as 1.5 to 2 fold in Rheumatoid Arthritis patients
XIII. Prognosis: Predictors of prolonged Remission (achieved in 10-50% of patients)
- Males
- Non-smokers
- Age under 40 years old
- Onset after age 65 years
- Shorter duration of Rheumatoid Arthritis
- Milder Rheumatoid Arthritis disease course
- Acute phase reactants not elevated (e.g. C-RP)
- Rheumatoid Factor negative
- Anti-Citrullinated Protein Antibody negative
XIV. Prognosis: Poor Prognostic Signs
- Hyper-acute onset (overnight onset)
- Multiple joint involvement (especially >20 joints)
- High titer Rheumatoid Factor (RF)
- HLA-DRBI 0404
- Low dose Corticosteroid resistance
- Early loss of function or young age of onset
- Higher Erythrocyte Sedimentation Rate
- Rheumatoid Arthritis Extra-articular Signs
Images: Related links to external sites (from Bing)
Related Studies
| Definition (MEDLINEPLUS) |
Rheumatoid arthritis (RA) is a form of arthritis that causes pain, swelling, stiffness and loss of function in your joints. It can affect any joint but is common in the wrist and fingers. More women than men get rheumatoid arthritis. It often starts in middle age and is most common in older people. But children and young adults can also get it. You might have the disease for only a short time, or symptoms might come and go. The severe form can last a lifetime. Rheumatoid arthritis is different from osteoarthritis, the common arthritis that often comes with older age. RA can affect body parts besides joints, such as your eyes, mouth and lungs. RA is an autoimmune disease, which means the arthritis results from your immune system attacking your body's own tissues. No one knows what causes rheumatoid arthritis. Genes, environment and hormones might contribute. Treatments include medicine, lifestyle changes and surgery. These can slow or stop joint damage and reduce pain and swelling. NIH: National Institute of Arthritis and Musculoskeletal and Skin Diseases |
| Definition (NCI_NCI-GLOSS) | An autoimmune disease that causes pain, swelling, and stiffness in the joints, and may cause severe joint damage, loss of function, and disability. The disease may last from months to a lifetime, and symptoms may improve and worsen over time. |
| Definition (NCI) | A chronic systemic disease, primarily of the joints, marked by inflammatory changes in the synovial membranes and articular structures, widespread fibrinoid degeneration of the collagen fibers in mesenchymal tissues, and by atrophy and rarefaction of bony structures. Etiology is unknown, but autoimmune mechanisms have been implicated. |
| Definition (MSH) | A chronic systemic disease, primarily of the joints, marked by inflammatory changes in the synovial membranes and articular structures, widespread fibrinoid degeneration of the collagen fibers in mesenchymal tissues, and by atrophy and rarefaction of bony structures. Etiology is unknown, but autoimmune mechanisms have been implicated. |
| Definition (CSP) | chronic systemic disease, primarily of the joints, marked by inflammatory changes in the synovial membranes and articular structures, widespread fibrinoid degeneration of the collagen fibers in mesenchymal tissues, and by atrophy and rarefaction of bony structures; etiology is unknown, but autoimmune mechanisms have been implicated. |
| Concepts | Disease or Syndrome (T047) |
| MSH | D001172 |
| ICD9 | 714.0 |
| ICD10 | M06.9 , M06.99 |
| SnomedCT | 156471009, 287010008, 156481008, 69896004 |
| LNC | LP30644-6, LA15161-5 |
| English | Arthritis, Rheumatoid, ARTHRITIS RHEUMATOID, Rheumatoid Arthritis, Rheumatoid arthritis, unspecified, RHEUMATOID ARTHRITIS, RHEUMATOID ARTHRITIS, SUSCEPTIBILITY TO, Rheumatoid arthritis NOS, rheumatoid arthritis, RA (rheumatoid arthritis), rheumatoid arthritis (diagnosis), R arthritis, Rh arthritis, Arthritis rheumatoid, Systemic rheumatoid arthritis, RA, Arthritis, Rheumatoid [Disease/Finding], Rheumatoid arthritis, unspecified, site unspecified, rheumatoid arthritis systemic, gout rheumatic, proliferative arthritis, atrophic arthritis, Rheumatoid arthritis NOS (disorder), ARTHRITIS, RHEUMATOID, Rheumatoid arthritis, Atrophic arthritis, Chronic rheumatic arthritis, Rheumatic gout, RA - Rheumatoid arthritis, RhA - Rheumatoid arthritis, Rheumatoid disease, Rheumatoid arthritis (disorder), atrophic; arthritis, rheumatoid; arthritis, arthritis; atrophic, arthritis; rheumatoid, Atrophic Arthritis, Arthritis or polyarthritis, atrophic, Arthritis or polyarthritis, rheumatic |
| Portuguese | ARTRITE REUMATOIDE, Artrite reactiva reumatóide, Artrite atrófica, Artrite reumatóide sistémica, Artrite Reumatoide, Artrite reumatóide |
| Spanish | ARTRITIS REUMATOIDE, Artritis reumatoide sistémica, Artritis R, Artritis Re, Artritis atrófica, AR, Artritis Reumatoidea, artritis reumatoide, SAI, Rheumatoid arthritis NOS, artritis reumatoide, SAI (trastorno), artritis atrófica, artritis reumatoide (trastorno), artritis reumatoide, artritis reumática crónica, gota reumática, Artritis reumatoide, Artritis Reumatoide |
| Dutch | systemische reumatoïde artritis, atrofische artritis, RA, reumatische artritis, artritis; atrofisch, artritis; reumatoïd, atrofisch; artritis, reumatoïd; artritis, Reumatoïde artritis, niet gespecificeerd, reumatoïde artritis, Artritis, reumatoïde, Reumatoïde artritis |
| French | Arthrite d, Arthrite rhumatoïde systémique, AR, Polyarthrite rh, ARTHRITE RHUMATOIDE, Polyarthrite rhumatismale, PCE (Polyarthrite Chronique Évolutive), Polyarthrite chronique évolutive, Polyarthrite rhumatoïde, PR (Polyarthrite Rhumatoïde) |
| German | systemische rheumatische Arthritis, atrophische Arthritis, Rh Arthritis, RA, R Arthritis, ARTHRITIS RHEUMATOID, Chronische Polyarthritis, nicht naeher bezeichnet, rheumatoide Arthritis, Arthritis, rheumatoide, Rheumatoide Arthritis, PcP (Primär-chronische Polyarthritis), Polyarthritis, primär chronische, Primär-chronische Polyarthritis |
| Italian | Artrite reumatoide sistemica, AR, Artrite atrofica, Artrite reumatoide |
| Japanese | 全身性関節リウマチ, ｲｼｭｸｾｲｶﾝｾﾂｴﾝ, ｾﾞﾝｼﾝｾｲｶﾝｾﾂﾘｳﾏﾁ, ｶﾝｾﾂﾘｳﾏﾁ, 関節リウマチ, 萎縮性関節炎, リウマチ様関節炎, 慢性関節リウマチ, 関節リウマチ-慢性, 関節炎-リウマチ様 |
| Swedish | Ledgångsreumatism |
| Czech | polyartritida progresivní, Systémová revmatoidní artritida, Revmatoidní artritida, Atrofická artritida, artritida revmatoidní, revmatoidní artritida |
| Finnish | Nivelreuma |
| Russian | ARTRIT REVMATOIDNYI, ARTRIT INFEKTSIONNYI NESPETSIFICHESKII, POLIARTRIT REVMATOIDNYI, АРТРИТ ИНФЕКЦИОННЫЙ НЕСПЕЦИФИЧЕСКИЙ, АРТРИТ РЕВМАТОИДНЫЙ, ПОЛИАРТРИТ РЕВМАТОИДНЫЙ |
| Korean | 상세불명의 류마티스 관절염 |
| Croatian | ARTRITIS, REUMATOIDNI |
| Polish | Zapalenie stawów reumatoidalne, Gościec przewlekły postępujący, RZS, Reumatoidalne zapalenie stawów, Gościec pierwotnie przewlekły, Zapalenie gośćcowe |
| Hungarian | RA (rheumatoid arthritis), Rheumatoid arthritis, Atrophiás arthritis, R arthritis, Rh arthritis, Systemás rheumatoid arthritis |
| Norwegian | Artritt, revmatoid, Leddgikt, Revmatoid artritt |
