Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a systemic autoimmune disease in which the immune system mistakenly attacks the synovial lining of joints, leading to chronic inflammation, pain, swelling and, if untreated, progressive joint damage. It affects approximately 1% of the UK population and is around three times more common in women than men, though it can occur at any age.

Unlike osteoarthritis, which is primarily a wear-and-tear condition, RA is driven by immune dysregulation. Inflammation can affect multiple joints simultaneously — most commonly the small joints of the hands, wrists and feet — and may also involve other organs including the lungs, eyes and cardiovascular system. The systemic nature of the disease means that fatigue and general unwellness are common alongside joint symptoms.

The outlook for RA has been transformed over the past two decades. A treat-to-target approach — aiming for clinical remission or low disease activity — combined with a rapidly expanding therapeutic arsenal means that most patients, when diagnosed and treated promptly, can live full and active lives with minimal joint damage.

Treatment is guided by a treat-to-target strategy, with the aim of achieving remission or low disease activity as assessed by validated scoring tools. The first-line disease-modifying antirheumatic drug (DMARD) is usually methotrexate, often combined with short courses of corticosteroids to bridge the gap while the medication takes effect. Hydroxychloroquine, sulfasalazine and leflunomide are also used, sometimes in combination.

For patients who do not respond adequately to conventional DMARDs, biologic therapies offer highly effective alternatives. These include TNF inhibitors (such as adalimumab, etanercept and certolizumab), IL-6 inhibitors (tocilizumab, sarilumab), abatacept, and the B-cell depleting agent rituximab. Targeted synthetic DMARDs — JAK inhibitors including tofacitinib, baricitinib and upadacitinib — provide additional oral options, particularly for patients who prefer to avoid injections or have not responded to biologics.

Lifestyle measures including regular, appropriate exercise, joint protection techniques and smoking cessation are important adjuncts. Physiotherapy and occupational therapy input can substantially improve function and quality of life. Cardiovascular risk management is an integral part of holistic RA care, given the increased cardiovascular risk associated with chronic inflammation.