Education And Debate

ABC of Rheumatology: RHEUMATOID ARTHRITIS—I: CLINICAL FEATURES AND DIAGNOSIS

BMJ 1995; 310 doi: https://doi.org/10.1136/bmj.310.6979.587 (Published 04 March 1995) Cite this as: BMJ 1995;310:587
  1. M Akil,
  2. R S Amos
  1. M Akil is registrar in rheumatology and R S Amos is consultant rheumatologist at Sheffield Centre for Rheumatic Diseases, Neither Edge Hospital, Sheffield.
  2. The ABC of Rheumatology is edited by Michael L Snaith, senior lecturer in rheumatology at Nether Edge Hospital, Sheffield.

    Rheumatoid arthritis is the commonest disorder of connective tissues and is an important cause of disability, morbidity, and mortality. Life expectancy is reduced by four years in men and by 10 years in women, though this reduction is accounted for by a minority of patients with more severe disease. Nevertheless, patients with this condition may be offered life insurance only on the basis of loaded premiums.

    Rheumatoid arthritis occurs worldwide with variable incidence and severity. In Western countries, it affects up to 1-3% of the population, although many are not severely affected and may not seek medical advice at all. Overall, there is a 3:1 female preponderance, but this excess is greater in young people and the age related incidence is approximately equal in elderly people.

    Factors associated with poorer prognosis in rheumatoid arthritis

    • Insidious polyarticular onset

    • Male patients

    • Extra-articular manifestations

    • Functional disability at one year after start of disease

    • Substantially raised concentration of rheumatoid factors

    • Presence of HLA-DR4

    • Radiographic evidence of erosions within three years of start of disease

    The aetiology of rheumatoid arthritis remains unclear, but there is evidence of genetic predisposition to the disease. The presence of HLA-DR4 is significantly commoner among sufferers of rheumatoid arthritis who are white. Rheumatoid arthritis is associated with only certain subtypes of HLA-DR4 (HLA-Dw4 and HLA-Dw14); susceptibility is related to a shared epitope on the HLA molecule.

    Rheumatoid arthritis in women

    • Higher incidence of disease in women of child bearing age

    • Disease tends to go into remission during pregnancy and to flare after giving birth

    • Use of contraceptive pill or high gravidity adds some protection against later development of disease

    Clinical features Joint damage

    The start of the disease is usually insidious but can be episodic or acute. Rheumatoid arthritis usually presents as a polyarthritis affecting small joints or small and large joints. Early disease is characterised by pain …

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