Rheumatoid Arthritis

Rheumatoid arthritis is a chronic inflammatory autoimmune disease. It commonly affects the small joints of the hands and feet, although larger joints can also be involved. Pain and swelling are often accompanied by prolonged stiffness after waking or resting, and fatigue can be a major part of the illness.

Unlike osteoarthritis, the primary problem is not gradual wear of the articular cartilage. In rheumatoid arthritis, inflammation begins in the synovium and, if it remains active, can damage cartilage, bone and the tissues supporting the joint. The disease can also affect other parts of the body.

Inside the rheumatoid joint

A synovial joint is enclosed by a capsule lined with a thin synovial membrane. The ends of the bones are covered by articular cartilage, and a small amount of synovial fluid lubricates the joint as it moves.

In rheumatoid arthritis, immune cells accumulate in the synovium and release inflammatory mediators, including tumour necrosis factor (TNF) and interleukin-6 (IL-6). The synovium becomes inflamed, thickened and more vascular. Fluid and inflammatory cells contribute to the soft, sometimes warm swelling felt around an active joint.

As synovitis persists, abnormal synovial tissue can extend over the cartilage as pannus. Inflammatory mediators contribute to cartilage breakdown, while increased osteoclast activity causes bone resorption at the joint margins. These marginal erosions are characteristic of established rheumatoid arthritis. Tendons, tendon sheaths, ligaments and bursae can also be affected.

Joint damage develops over time rather than appearing at the onset of every case. Early treatment is therefore aimed at suppressing inflammation before irreversible structural damage and loss of function develop.

How rheumatoid arthritis presents

The metacarpophalangeal joints across the knuckles, proximal interphalangeal joints of the fingers, wrists and metatarsophalangeal joints of the feet are commonly affected. The distal interphalangeal joints nearest the fingertips are usually spared. Several joints are often involved, frequently in a broadly symmetrical pattern.

Morning stiffness is common and may last well beyond the first few minutes after getting up. Stiffness can also return after sitting still for a while. During active disease, joints may be swollen, tender and warm, and movement can become painful or restricted.

The effect on function may appear before dramatic deformity is present. Hand disease can make turning a key, opening packaging, fastening clothes or holding cutlery difficult. Forefoot involvement can make standing and walking painful. Established disease can produce deformities such as ulnar deviation at the metacarpophalangeal joints, although modern disease-modifying treatment aims to prevent progression to this stage.

Symptoms often vary over time. Periods of increased disease activity are usually described as flares. A new hot, acutely painful joint should still be assessed rather than automatically attributed to rheumatoid arthritis, particularly when the patient is febrile or systemically unwell. Septic arthritis is an important differential and requires urgent medical assessment.

Rheumatoid arthritis beyond the joints

Fatigue is common and may be severe even when the visible joint findings seem modest. Pain, poor sleep and systemic inflammation can all contribute. During active disease, some people also experience reduced appetite, weight loss or a general feeling of being unwell.

Extra-articular disease can involve several organs. Rheumatoid nodules may occur, particularly in seropositive disease. Pulmonary involvement includes interstitial lung disease and pleural disease. Ocular complications include episcleritis and scleritis. Chronic inflammation is also associated with increased cardiovascular risk, while osteoporosis may be influenced by inflammation, reduced mobility and glucocorticoid exposure.

NICE recommends annual review for people with rheumatoid arthritis. Alongside disease activity and function, this includes checking for comorbidities and complications, including symptoms affecting the cervical spine, lungs and eyes, and discussing how the condition is affecting everyday life.

Investigating suspected rheumatoid arthritis

Rheumatoid arthritis is a clinical diagnosis supported by investigations. No individual blood test can confirm it on its own, and normal blood results do not exclude active inflammatory arthritis.

When persistent synovitis has no clear cause, NICE recommends referral for specialist rheumatology assessment. Referral should be urgent when the small joints of the hands or feet are affected, more than one joint is involved, or three months or more have passed between the onset of symptoms and the person seeking medical advice. Investigations in primary care should not delay referral.

C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) may be raised when inflammation is active, but normal inflammatory markers do not rule out rheumatoid arthritis. A full blood count may identify anaemia and provides useful baseline information before some treatments are started.

Rheumatoid factor (RF) is an autoantibody found in many people with rheumatoid arthritis, but it is not specific to the disease. Anti-cyclic citrullinated peptide (anti-CCP) antibodies are more specific and can also provide information about the likelihood of erosive disease. Some patients have neither antibody and are described as having seronegative rheumatoid arthritis.

Plain X-rays of the hands and feet are used to look for erosions and provide a record against which later structural change can be compared. Ultrasound can demonstrate synovial thickening, effusions and increased blood flow associated with active synovitis. Magnetic resonance imaging can identify synovitis and erosive change in greater detail when required.

Controlling the inflammation

The main treatment is disease-modifying therapy. Analgesics may reduce pain and non-steroidal anti-inflammatory drugs can reduce pain and stiffness in selected patients, but neither prevents the underlying inflammatory disease from damaging the joint.

Disease-modifying antirheumatic drugs (DMARDs) suppress disease activity. NICE recommends starting conventional DMARD treatment as soon as possible after diagnosis, ideally within three months of persistent symptoms. Methotrexate, leflunomide and sulfasalazine are among the conventional DMARDs used, while hydroxychloroquine may be appropriate for milder disease. Treatment is managed towards remission or low disease activity, with regular assessment and adjustment when the target has not been reached.

Short courses of glucocorticoids may be used when rapid control of inflammation is needed, including while a newly prescribed DMARD begins to work or during some flares. Long-term glucocorticoid treatment is avoided where possible because prolonged exposure increases the risk of complications such as osteoporosis, diabetes, infection and adrenal suppression.

If disease remains active despite conventional DMARDs, specialist treatment can progress to biological DMARDs or targeted synthetic DMARDs. These include medicines acting on specific inflammatory pathways, such as TNF inhibitors and Janus kinase inhibitors. Their use depends on disease activity, previous treatment, contraindications and the relevant NICE technology appraisal.

Physiotherapy and occupational therapy are often part of treatment. Maintaining movement and muscle strength can support function, while practical adaptations can reduce the difficulty caused by painful or restricted joints. Podiatry may be particularly useful when the feet are affected. Severe established joint damage occasionally requires orthopaedic surgery.

Nursing assessment and medicines

Joint pain needs some context. Ask about morning stiffness, swelling, fatigue and recent changes in mobility or dexterity. A patient who reports moderate pain may nevertheless be struggling to dress, prepare meals or manage stairs. Looking at function alongside symptoms gives a better picture of what the disease is doing to everyday life.

When examining an affected area, note swelling, warmth, tenderness and movement. Compare with the patient's usual pattern where possible. Fever, marked systemic illness, rapidly increasing pain or a single acutely inflamed joint warrants further assessment rather than being recorded simply as a flare.

DMARDs require ongoing safety monitoring. The exact blood tests and frequency depend on the medicine and stage of treatment, but monitoring commonly includes the full blood count, liver function and renal function. Results need to be considered alongside new symptoms and any changes in treatment.

Methotrexate prescribed for rheumatoid arthritis is taken once weekly. Accidental daily dosing can cause severe toxicity. When taking a medication history, check the prescribed dose, the day it is taken and whether the patient is taking folic acid as prescribed. New mouth ulcers, unexplained bruising or bleeding, severe sore throat, fever, breathlessness or other concerning symptoms require appropriate assessment.

Many treatments alter immune function, so infection cannot be treated as an incidental issue. Ask about current infection symptoms and follow the relevant medicine-specific and local advice if infection develops. Vaccination is also considered as part of long-term care, particularly before or during immunosuppressive treatment.

Living with rheumatoid arthritis

Good disease control has changed what rheumatoid arthritis can look like over a lifetime. Severe deformity is still seen, but it should not be presented to patients as inevitable. Early recognition, prompt specialist assessment and effective DMARD treatment can limit joint damage and preserve function.

There are still periods when living with the disease is difficult. Pain and fatigue can interfere with work, study, caring responsibilities, sleep and social life. Hand or foot symptoms can turn ordinary activities into slow and frustrating tasks. Asking what the patient is finding difficult often tells you more than asking for a pain score alone.

Patients should know how to contact their rheumatology service when symptoms worsen, how their medicines are monitored and which symptoms need medical assessment. Treatment may continue when symptoms are well controlled because remission does not mean that rheumatoid arthritis has disappeared. Decisions about reducing disease-modifying treatment are made with the rheumatology team rather than by stopping medication when the joints feel better.

References

National Institute for Health and Care Excellence (NICE) (2018, updated 2024) Rheumatoid arthritis in adults: management. NG100. London: NICE.

NHS (2023) Rheumatoid arthritis.

NHS (2023) Rheumatoid arthritis: diagnosis.

NHS (2023) Rheumatoid arthritis: treatment.

Educational note: Bleepbook supports learning and clinical reasoning. It does not replace university teaching, current national guidance, local policy, clinical supervision or professional judgement.