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Rheumatoid Arthritis

William S. Wilke, MD

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Definition

Rheumatoid arthritis (RA) is the most common form of chronic inflammatory arthritis. Although most readily recognized by its articular manifestations, RA can affect any organ system. The presentation and disease course are distinct for any individual patient, making diagnosis and management a thoughtful, complex, and dynamic process. The diagnostic criteria for RA (Box 1)(1) may be used to classify disease in patients in the appropriate clinical setting, but in early disease the criteria may be less helpful in establishing the diagnosis. Whether disease expression is confined to mild articular manifestations or manifests as severe, multisystem disease, our current understanding demands that patients receive early and aggressive therapy. Achieving prompt control of local and systemic inflammatory processes minimizes damage of articular structures, preserves function, and reduces early mortality.


Box 1: Criteria for the Classification of Rheumatoid Arthritis

For classification purposes, a patient has rheumatoid arthritis if he or she has satisfied at least four of these seven criteria. Criteria 1 through 4 must have been present for at least 6 weeks. Patients with two clinical diagnoses are not excluded. Designation as classic, definite, or probable rheumatoid arthritis is not to be made.

Morning stiffness
Morning stiffness in and around the joints
Lasting at least 1 hour before maximal improvement

Arthritis of three or more joint areas
At least three joint areas simultaneously have had soft tissue swelling or fluid (not bony overgrowth alone) observed by a physician
The 14 possible areas are right or left PIP, MCP, wrist, elbow, knee, ankle, and MTP joints.

Arthritis of hand joints
At least one area swollen (as defined in 2) in a wrist or in an MCP or PIP joint

Symmetrical arthritis
Simultaneous involvement of the same joint areas (as defined in 2) on both sides of the body
Bilateral involvement of PIPs, MCPs, or MTPs is acceptable without absolute symmetry

Rheumatoid nodules
Subcutaneous nodules over bony prominences, or extensor surfaces, or in juxta-articular regions, observed by a physician

Serum rheumatoid factor
Demonstration of abnormal amounts of serum rheumatoid factor by any method for which the result has been positive in <5% of normal control subjects

Radiographic changes
Radiographic changes typical of rheumatoid arthritis on posteroanterior hand and wrist radiographs, which must include erosions or unequivocal bony decalcification localized in, or most marked adjacent to, the involved joints
Osteoarthritis changes alone do not qualify

MCP, metacarpophalangeal; MTP, metatarsophalangeal; PIP, proximal interphalangeal.
Adapted with permission from Kirkham BW, Lassere MN, Edmonds JP, et al: Synovial membrane cytokine expression is predictive of joint damage progression in rheumatoid arthritis: a two-year prospective study (the DAMAGE study cohort). Arthritis Rheum 2006;54:1122-1131.

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