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Rheumatoid arthritis (RA)
RA is a symmetric arthritis of the small joints of the hands (MCP, PIP, wrist) with prolonged morning stiffness, and methotrexate is started as early as possible with a target of remission (treat-to-target) — every delay adds irreversible joint damage.
Why it matters in the exam
Exam questions present a middle-aged woman with symmetric pain and swelling of the finger joints and wrists, morning stiffness of more than an hour and fatigue. The candidate must separate RA from osteoarthritis (DIP joints, short stiffness, Heberden nodes), psoriatic arthritis (DIP, "sausage" digit) and lupus (arthritis without joint destruction). The specific antibody is anti-CCP; RF is less specific and also occurs in healthy older people and in hepatitis C. On the film, periarticular erosions and osteopenia are typical.
Treatment questions focus on methotrexate: the first drug, with folic acid, and monitoring of the blood count and liver tests; it is contraindicated in pregnancy and can cause pneumonitis. If the target is not reached within 3–6 months, a biologic (for example anti-TNF) or a JAK inhibitor is added — after screening for latent tuberculosis and hepatitis B. Steroids are given only as a short "bridge". Extra-articular disease is also tested: ILD, subcutaneous nodules, Felty syndrome (enlarged spleen and neutropenia), pleural effusion with very low glucose, and atlanto-axial subluxation — which requires assessment of the cervical spine before intubation.
Key points
- RA: symmetric, MCP, PIP and wrist, morning stiffness over an hour.
- Anti-CCP specific; RF less specific.
- Early methotrexate with folic acid; steroids only as a bridge.
- Target not reached at 3–6 months → biologic or JAK inhibitor after screening for tuberculosis and hepatitis B.
- Outside the joints: ILD, Felty, effusion with low glucose, C1–C2 subluxation.
Summary table
| Topic | RA | Distinguish from | Exam note |
|---|---|---|---|
| Joints | MCP, PIP, wrist, symmetric; spares DIP | OA: DIP, Heberden nodes; psoriatic: DIP, sausage digit | Morning stiffness over an hour |
| Serology | Anti-CCP specific; RF less specific | Lupus: ANA, anti-dsDNA | RF also positive in hepatitis C and older people |
| Film | Periarticular erosions, osteopenia | OA: joint-space narrowing, osteophytes | Erosions = active disease that must be controlled |
| First treatment | Early methotrexate + folic acid | Steroids only as a short bridge | Treat-to-target: review every 1–3 months |
| Target not reached at 3–6 months | Add a biologic (anti-TNF) or JAK inhibitor | — | Before: latent tuberculosis and hepatitis B |
| Outside the joints | ILD, nodules, Felty, effusion with low glucose | — | C1–C2 subluxation before intubation |
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Sources
- EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs, 2022 — Treat-to-target strategy and drug sequence
- ACR/EULAR Rheumatoid Arthritis Classification Criteria, 2010 — Classification criteria
- Harrison's Principles of Internal Medicine, 21st edition (2022) — Rheumatoid Arthritis
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.