Rheumatoid Arthritis (RA)
• Autoantibodies:
o Rheumatoid Factor (RF): 70–80% sensitivity; low specificity
o Anti-CCP: ~98% specificity; predicts erosive disease
• Clinical features:
o Symmetrical small joint polyarthritis: MCP, PIP, wrists
o Morning stiffness >1 hr
o Spares DIPs
• Extra-articular features:
o Rheumatoid nodules (extensor surfaces)
o Episcleritis, scleritis
o Interstitial lung disease (NSIP > UIP pattern)
o Vasculitis: mononeuritis multiplex, skin ulcers
o Felty’s syndrome: RA + splenomegaly + neutropenia
• Investigations:
o Bloods: RF, anti-CCP, CRP/ESR, normocytic anaemia
o Imaging:
X-ray hands/feet: joint space narrowing, marginal erosions, periarticular osteopenia, subluxation
Ultrasound/MRI: detects early synovitis/erosions
• Diagnosis: clinical + supported by 2010 ACR/EULAR classification criteria
• Management:
o NSAIDs: symptom relief only
o Steroids: short-term (e.g. flares or bridging)
o DMARDs:
First-line: methotrexate (monitor FBC, LFTs, U&E)
Others: sulfasalazine, hydroxychloroquine, leflunomide
o Biologics:
Indicated if inadequate response to ≥2 DMARDs
Anti-TNF (e.g. etanercept, adalimumab)
Screen for TB and hepatitis B/C before starting
• Complications:
o Cervical spine instability (atlantoaxial subluxation)
o Osteoporosis (disease + steroid use)
o Cardiovascular risk ↑
o Amyloidosis (rare)
• Recurrent, brief episodes of mono- or oligoarthritis (resolves spontaneously)
• No joint damage between episodes
• ~30–40% are anti-CCP positive
• ~50% develop full-blown RA
• Treatment: often NSAIDs ± hydroxychloroquine
• Clinical picture of RA but RF and anti-CCP negative
• May have milder disease or slower progression
• Still classified as RA if ACR/EULAR criteria met
• Management similar to seropositive RA
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Author & Educational Disclaimer
Author:
Dr Phillip Cockrell BM FRCP DipClinEd
Dr Phillip Cockrell is a UK Consultant Physician in Internal Medicine, currently working at Queen Alexandra Hospital, Portsmouth University Hospitals NHS Trust. He has previously worked as a registrar across Intensive Care Medicine, Gastroenterology, Cardiology, Stroke Medicine, Acute Medicine, and Respiratory Medicine.
He has held senior leadership roles including Associate Clinical Director of the Acute Medical Unit, Clinical Director of Internal Medicine, and Chief of Medicine. Dr Cockrell has over 15 years’ experience in postgraduate medical education, having lectured extensively across the MRCP syllabus and contributed to MRCP revision teaching and course development.
Dr Cockrell holds a Bachelor of Medicine (BM), Fellowship of the Royal College of Physicians (FRCP), and a Diploma in Clinical Education (DipClinEd). His teaching approach is based on structured consolidation of complex medical topics to support efficient and effective revision for postgraduate examinations.
Purpose of this content:
The material on this page is intended solely for educational purposes to support revision for the MRCP (UK) Part 1 examination. It reflects examination-relevant principles of internal medicine and is designed to aid learning and pattern recognition.
Medical disclaimer:
This content is designed for postgraduate medical examination revision and does not constitute medical advice, diagnosis, or treatment guidance and must not be used as a substitute for professional clinical judgement, local guidelines, or specialist consultation. Clinical decisions should always be made in the context of individual patient circumstances and current national guidance.
