Rheumatoid Arthritis
An autoimmune disease causing symmetrical joint inflammation and joint damage if untreated.
Overview
Rheumatoid arthritis typically affects small joints of the hands and feet symmetrically, with morning stiffness lasting more than an hour. Early disease-modifying anti-rheumatic drugs (DMARDs) prevent joint damage.
Symptoms
- • Symmetrical joint pain and swelling
- • Prolonged morning stiffness >1 hour
- • Fatigue
- • Low-grade fever
- • Rheumatoid nodules
Risk factors
- • Female sex
- • Family history
- • Smoking
- • Age 30–60
Causes
- • Autoimmune (anti-CCP and rheumatoid factor often positive)
- • Genetic and environmental triggers
🚨 Red flags — seek urgent care
- • Hot single joint — exclude septic arthritis
- • New shortness of breath (pulmonary involvement)
- • Cervical spine instability symptoms
When to seek care
- • Persistent joint swelling >6 weeks
- • Suspected flare
- • Side effects from DMARDs
Diagnosis
- • Symmetrical polyarthritis (small joints of hands/feet) with morning stiffness ≥30 min
- • ACR/EULAR 2010 criteria using joint count, serology (RF, anti-CCP), acute phase reactants and duration
- • Urgent rheumatology referral for any persistent synovitis (do not wait for serology)
- • X-ray and ultrasound to detect erosions and active synovitis
Treatment
- • Treat-to-target with early DMARD: methotrexate first-line, escalate dose to 20–25 mg/week within weeks
- • Combination conventional DMARDs (methotrexate + sulfasalazine + hydroxychloroquine) if monotherapy fails
- • Biologic / targeted DMARD (anti-TNF, IL-6, JAK inhibitors) for inadequate response
- • Short-course oral or IM corticosteroid as bridge therapy
- • Pre-treatment screening (TB, hepatitis, vaccinations), MTX folate co-prescription, contraception counselling
Prevention
- • No primary prevention proven
- • Smoking cessation reduces severity and improves drug response
- • Healthy weight and Mediterranean diet may slow progression
- • Maintain physical activity
Complications
- • Joint destruction and disability
- • Cardiovascular disease (excess mortality)
- • Interstitial lung disease
- • Osteoporosis (disease + steroids)
- • Infections (disease + immunosuppression), lymphoma
Education & self-care
This guidance is reviewed by Dr. Handel Emery, MD, FRCP (UK) and last updated 2026-06-08. It is educational and not a substitute for professional medical advice.
Frequently asked questions
Will I need methotrexate forever?
Many patients continue DMARDs long-term; some achieve remission and can taper under specialist supervision.
Why start treatment so early?
Early aggressive treatment within 12 weeks of symptom onset prevents joint damage and disability. Methotrexate plus targeted biologic or JAK inhibitor therapy can produce sustained remission.
Will I always need methotrexate?
Many people stay on methotrexate or another DMARD long-term to maintain remission. Some achieve drug-free remission, but treatment is rarely stopped abruptly because relapses are common.
Does diet affect rheumatoid arthritis?
A Mediterranean-style diet, oily fish and limited alcohol are associated with milder disease activity. Stopping smoking is one of the strongest modifiable factors and improves treatment response.