The map

Rheumatoid arthritis (RA) is a common chronic disorder of disturbed immunity that affects about 1% of adults in the United Kingdom. It typically develops in middle or late life and is three times more common in women than it is in men. It is characterised by joint pain, swelling, and stiffness, particularly of the small joints of the hands and feet. Its onset varies between gradual and acute. The classic pathological features include inflammation in the synovial lining joints and tendon sheaths. Patients feel sore, especially in the morning. Its natural course is variable, with disease severity changing over time, although in many patients there is increasing joint damage and functional disability. From the perspective of patients, pain, reduced mobility, fatigue, and psychological effects, such as depression, are the dominant concerns. In contrast, clinicians generally focus on measurable disease activity, along with radiographically identifiable progressive joint damage. They aim to achieve remission of the synovitis and to delay or limit functional disability, to minimise the effect on work participation and dependency on family, carers, and the health service.

Optimal treatment is now seen to be care provided by a multidisciplinary team and includes education, advice, exercise, drug treatment, and joint surgery in late disease. Treatment options comprise analgesics, non-steroidal inflammatory drugs, disease modifying drugs such as methotrexate, steroids, and the new biologicals (for example, anti-tumour necrosis factor agents). Despite these various treatments, the key features of rheumatoid arthritis are the unpredictability of both the acute flare-ups and of how patients respond to the drugs. This means that control over the illness is often difficult and requires patients and professionals to continuously adapt to the disease state.

The good news

Over recent years the emergence of the new biological drugs, with their palliative effect on patients' symptoms of pain, limited mobility, and fatigue, has …