Rheumatology
Rheumatoid Arthritis
류마티스관절염
Chronic autoimmune synovitis causing symmetric polyarthritis
- How common
- 1% of population (3:1 female)
- Typical age
- Onset 30s–50s
What is it?
Genetic susceptibility (HLA-DR4 shared epitope) and environmental triggers (smoking, periodontitis) drive autoimmunity to citrullinated antigens; synovial infiltration and pannus erode cartilage and bone.
Commonly affected: Bilateral MCP, PIP, wrists, MTP (symmetric)
How it develops
- Citrullination & autoantibodiesPAD enzymes citrullinate proteins, generating anti-CCP and RF
- Synovial infiltrationT cells, B cells, macrophages infiltrate synovium, releasing TNF and IL-6
- Pannus formationHyperplastic synovium forms pannus invading cartilage
- Cartilage/bone erosionMMPs and RANKL drive cartilage destruction and bone erosion
Symptoms
- Symmetric polyarthritisSymmetric MCP/PIP/wrist swelling
- Joint deformitySwan neck, boutonnière, ulnar deviation
- Morning stiffness >1hStiffness improving with activity
- Rheumatoid nodulesSubcutaneous nodules over extensor surfaces
- FatigueLow-grade fever, weight loss, fatigue
How it is examined
- ACR/EULAR 2010 criteriaScore joints, serology, APR, duration (≥6 points)
- SerologyRF, anti-CCP, ESR, CRP
- DAS28 activity28-joint score for disease activity
Imaging
Hand/foot X-ray shows juxta-articular osteopenia, erosions, joint space narrowing.
- Soft tissue swelling
- Bone erosions
- Joint space narrowing
- Ulnar deviation
MRI/US detects early synovitis and bone marrow edema (more sensitive than X-ray).
- Synovial hypertrophy
- Bone marrow edema
- Micro-erosions
Non-surgical care
- Methotrexate (anchor DMARD)Weekly oral 7.5–25mg with folic acid
- HydroxychloroquineMild disease/combo, requires retinal monitoring
- SulfasalazineMild–moderate or pregnancy use
- Low-dose corticosteroidsShort-term bridging (prednisolone ≤10mg)
- NSAIDs (symptomatic)Pain/stiffness relief; do not modify disease
Conservative options are generally tried first. Medications listed here can have side effects — discuss them with your prescriber.
When surgery is considered
Biologics if DMARDs fail; surgery for end-stage joint damage
Procedures that may be discussed
- TNF inhibitors (etanercept, adalimumab, infliximab)
- IL-6 inhibitor (tocilizumab)
- JAK inhibitors (tofacitinib, baricitinib)
- Rituximab (anti-CD20)
- Synovectomy/arthroplasty
Outlook
Early diagnosis with treat-to-target enables remission. Untreated progresses to deformity and increased CV mortality.