Treatment Guideline Chart

Rheumatoid arthritis is a chronic inflammatory arthritis of unknown etiology.
It is the most common autoimmune inflammatory arthritis in adults.
Patient usually complains of joint pain and/or swelling with morning stiffness that lasts for more than an hour.

Goals of treatment are clinical and radiological remission of disease and to reduce functional limitations and permanent joint damage.

Rheumatoid%20arthritis Signs and Symptoms


  • Rheumatoid arthritis (RA) is a chronic inflammatory arthritis of unknown etiology
    • Most common autoimmune inflammatory arthritis in adults
    • Persistent synovitis leads to progressive joint destruction and deformity
  • Believed to result from the interaction between genetic and environmental factors


  • Prevalence worldwide is approximately 0.24% 
  • Least common in East/Southeast Asians than with Western European and North American ethnic groups 
  • More prevalent in women than men with risk increasing with older age   


  • A possible autoimmune or infectious triggering incident causes the proliferation of fibroblasts and synovial macrophages
    • Perivascular regions are infiltrated by lymphocytes and endothelial cells proliferate followed by growth of new blood vessels which become occluded with inflammatory cells or small clots
    • An irregular growth of inflamed synovial tissue develops over time with invasive pannus tissue formation
    • The cartilage and bone are then destroyed by the pannus invasion, with bone erosion resulting from generation of osteoclasts by fibroblasts and inflammatory cells
    • Further joint destruction and systemic complication development occur with the release of several cytokines, interleukins (IL), growth factors and proteinases   
  • Anti-citrullinated protein antibody (ACPA), present in patients with rheumatoid arthritis, binds citrullinated residues on self-proteins (eg fibrinogen, type 2 collagen) resulting in complement activation 
    • Antibody presence in rheumatoid arthritis is called seropositive rheumatoid arthritis 
  • Repeated activation of the patient’s innate immunity is also thought to be the mechanism responsible for environment-triggered rheumatoid arthritis  

Risk Factors

  • Include female sex, older age, familial (1st-degree relative) and genetic (eg human leukocyte antigen [HLA]-DRB1 gene) factors, high-calorie low-fiber diet, physical inactivity, obesity, low socioeconomic status and level of education, stress   
  • Environmental risk factors include cigarette smoking, inhalant exposure (eg silica, chemical fertilizers), chronic mucosal or periodontal disease (microbial dybiosis), and bacterial and viral infections  
    • Cigarette smoking increases incidence for developing rheumatoid arthritis in ACPA-positive patients  
    • Bacteria (eg Escherichia coli, Helicobacter pylori, Proteus mirabilis, Mycobacteria, Mycoplasma, Streptococcus), viruses (eg Epstein-Barr virus, rubella, parvovirus B19) and periodontal disease (Porphyromonas gingivalis) are strongly associated with the occurrence of rheumatoid arthritis

Signs and Symptoms


  • Joint pain and/or swelling
  • Morning stiffness lasting ≥1 hour
  • Myalgia, fatigue, weight loss, low-grade fever, depression
  • Typically involves the joints of the fingers, wrists, toes
    • Upper and lower extremity joints are also affected (eg shoulders, elbows, knees and ankles)
  • Syndrome of polymyalgia rheumatica may occasionally be present

Early Rheumatoid Arthritis

  • Duration of occurrence of rheumatoid arthritis signs and symptoms is <6 months and meets the classification criteria of rheumatoid arthritis

Established Rheumatoid Arthritis

  • Duration of occurrence of rheumatoid arthritis signs and symptoms is ≥6 months and meets the classification criteria of rheumatoid arthritis

Palindromic Rheumatism

  • Follows an episodic pattern
    • Joints may be affected for hours to days followed by symptom-free periods lasting for days to months

Undifferentiated Arthritis

  • May indicate onset of a polyarticular disease
    • Interval between monoarthritis and polyarthritis may extend from days to weeks in patients with progressive disease
  • Large joints are frequently affected (eg shoulder, wrist, hip, knee, ankles)
  • History of joint trauma may be the initiating event

Extra-articular Involvement

  • Anemia, fatigue, pleuropericarditis, interstitial lung disease, neuropathy, scleritis, Sjogren’s syndrome, vasculitis
  • Subcutaneous rheumatoid nodules on extensor surfaces of elbows and over Achilles tendons
  • Splenomegaly
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