Practice Easily Missed?

Rheumatoid arthritis

BMJ 2016; 352 doi: https://doi.org/10.1136/bmj.i387 (Published 23 March 2016) Cite this as: BMJ 2016;352:i387
  1. Kate Harnden, foundation year 1 doctor1,
  2. Colin Pease, consultant rheumatologist2,
  3. Andrew Jackson, general practitioner3
  1. 1St James’ University Hospital, Leeds LS9 7TF, UK
  2. 2Rheumatology, Chapel Allerton Hospital, Leeds LS7 4SA, UK
  3. 3Bingley Medical Practice, Canalside Health Care Centre, Bingley BD16 4RP, UK
  1. Correspondence to: K Harnden kateharnden{at}doctors.org.uk

What you need to know

  • Consider rheumatoid arthritis in any patient presenting with joint pain, swelling, and morning stiffness of over 30 minutes

  • Refer within two weeks if symptoms affect small joints of the hands or feet, or more than one joint, or have been present for at least three months

  • Starting treatment with combination disease-modifying antirheumatic drugs (including methotrexate), especially within three months of symptom onset, can slow disease progression and improve symptoms, function, and quality of life

  • When rheumatoid arthritis is suspected, x ray symptomatic joints and measure rheumatoid factor, erythrocyte sedimentation rate, and C reactive protein without delaying referral, as negative results do not exclude the diagnosis

A 43 year old woman with six weeks of bilateral wrist pain is diagnosed with repetitive strain injury. Five weeks later, she returns with worsening pain. On further questioning, she reports increasing fatigue and two hours of morning stiffness in her hands. Examination reveals bilateral wrist and metacarpophalangeal joint swelling. She is referred to a rheumatologist, who diagnoses rheumatoid arthritis and initiates treatment.

What is rheumatoid arthritis?

Rheumatoid arthritis is an autoimmune, polyarticular arthritis characterised by progressive joint destruction and deformity, usually of peripheral joints (box 1). Its cause is unknown, and extra-articular organ involvement such as interstitial lung disease and Sjögrens syndrome may occur. Appropriate early therapy improves symptoms, function, and mortality, and may reduce comorbidities.

Box 1: How common is rheumatoid arthritis?

  • In a 2010 systematic review, estimated prevalence in North …

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