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Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease of indefinite etiology. The disease primarily affects synovial joints eventually progressing to ongoing inflammation, and destruction of both cartilaginous and bony elements of the joint, with resultant pain and disability. It commonly involves multiple joints of both hands with morning stiffness that may last for several hours. Globally the prevalence of RA is 0.5% to 1%. Rheumatoid arthritis (RA) occurs in about 5 per 1000 people and can lead to severe joint damage and disability. It occurs more commonly in women than in men.

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Symptoms

RA may be insidious in onset with some cases showing the acute onset of symptoms whereas some cases may have a chronic clinical course. The symptoms often begin with fatigue or weakness, fever, malaise, and arthralgia before progressing to joint inflammation, pain, and swelling. The key symptoms are early morning stiffness of the joints, pain, limitation of motion, tenderness, redness, joint swelling affecting more than two to three joints, and difficulty performing activities of daily living. The symptoms lead to disability followed by emotional, social, and economic challenges in the patients with RA. The affected joint is painful if pressure is applied to the joint or on movement with or without joint swelling. Synovial thickening with a "boggy" feel on palpation is noted. Joint erythema and warmth are usually absent, and wrist involvement may present with typical signs and symptoms of carpal tunnel syndrome. With multiple joint involvements, reduced grip strength can be seen on physical testing.

Diagnosis

The diagnosis of RA is based on a detailed patient’s clinical history, followed by a thorough physical examination, imaging modalities, and laboratory investigations. The clinician should elicit the patient’s history with a detailed assessment of various signs and symptoms and an evaluation of the clinical manifestations of the patient. A detailed physical examination should be performed to evaluate upper extremities (metacarpo phalangeal joints, wrists, elbows, and shoulders), lower extremities (ankles, feet, knees, hips), and cervical spine. Various imaging modalities are beneficial to evaluate the progression of the disease. It includes conventional radiographs (mainly for hands, wrists, knees, feet, elbows, shoulders, hips, cervical spine, and other joints as indicated), ultrasonography of the joints (for the joints, as well as tendon sheaths, changes, and degree of vascularization of the synovial membrane, and even erosions), and magnetic resonance imaging (primarily for cervical spine).  The preferred and useful laboratory investigations that aid in the diagnosis of RA and help to assess the progression of the disease include the complete blood count, erythrocyte sedimentation rate, C- reactive protein level, rheumatoid factor assay, anti-nuclear antibody assay, and anti−cyclic citrullinated peptide and anti−mutated citrullinated vimentin assays.

Treatment

The management of RA is very challenging. The management approach has been established based on the guidelines and international recommendations by the American College of Rheumatology (ACR), European League Against Rheumatism (EULAR), and Asia Pacific League of Associations for Rheumatology. The treatment paradigm has shown a dramatic shift in the last two decades. The current strategy has been changed from “treat to relief” to “treat to target”. This aims to normalize, sustain or maximize physical functionality via retardation or arrest of joint damage. Hence, the current approaches are concerned with early aggressive intervention with conventional/ traditional disease-modifying anti-rheumatic drugs (DMARDs) or biologics (BMARDs) either as monotherapy or combination therapy in addition to symptomatic anti-inflammatory therapy which includes non-steroidal anti-inflammatory drugs (NSAIDs, prednisolone). However, a substantial proportion of patients with RA still cannot achieve remission with pharmacological therapies alone. As a consequence, several non-pharmacological adjuvant therapies are currently being explored, to complement the standard treatment of RA which include patient education, exercise therapy, other physical modalities, assistive devices, and dietary interventions. Thus, the aim of the therapy should be to reduce discomfort and improve the quality of life of these patients. However, the optimal use of disease-modifying anti-rheumatic drugs (DMARDs) and the advent of biologic therapies have dramatically enhanced the success of RA management, improving the quality of life and decreasing the mortality of RA patients.

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