RHEUMATOID ARTHRITIS (RA)

Definition of Rheumatoid Arthritis

• Rheumatoid arthritis is a chronic, systemic, autoimmune inflammatory disease.
• It mainly affects synovial joints and leads to progressive joint destruction and deformity.

Etiopathology of Rheumatoid Arthritis

Autoimmune Mechanism

• RA is an autoimmune disorder.
• Immune system attacks synovial membrane of joints.
• Formation of autoantibodies:
  • Rheumatoid factor (RF)
  • Anti-citrullinated protein antibodies (anti-CCP)

Pathogenic Process

• Activation of T cells and B cells.
• Release of pro-inflammatory cytokines:
  • TNF-α
  • IL-1
  • IL-6
• Chronic synovial inflammation.
• Progressive cartilage and bone destruction.

Risk Factors

• Genetic predisposition (HLA-DR4, HLA-DR1)
• Environmental factors:
  • Smoking
  • Infections
• Female sex
• Hormonal factors

Stages of Rheumatoid Arthritis

Stage 1: Early Synovitis

• Inflammation of synovial membrane.
• Synovial thickening.
• Increased synovial fluid.
• Joint pain and stiffness.

Stage 2: Pannus Formation

• Hyperplastic synovium forms pannus.
• Pannus spreads over cartilage.
• Begins erosion of cartilage and bone.

Stage 3: Cartilage and Bone Destruction

• Progressive joint erosion.
• Narrowing of joint space.
• Decreased joint mobility.

Stage 4: Fibrous and Bony Ankylosis

• Permanent joint damage.
• Joint deformity.
• Loss of joint function.

Clinical Features of Rheumatoid Arthritis

Articular Features

• Symmetrical joint involvement.
• Small joints affected:
  • MCP
  • PIP
  • Wrist
  • MTP
• Pain and swelling.
• Morning stiffness lasting more than 1 hour.
• Joint deformities:
  • Ulnar deviation
  • Swan neck deformity
  • Boutonnière deformity

Extra-Articular Features

• Fatigue
• Weight loss
• Low-grade fever
• Rheumatoid nodules
• Secondary osteoarthritis
• Anaemia

Diagnosis of Rheumatoid Arthritis

Clinical Assessment

• History of chronic symmetrical polyarthritis.
• Duration of symptoms more than 6 weeks.

Laboratory Investigations

• Rheumatoid factor (RF)
• Anti-CCP antibodies
• ESR – raised
• CRP – raised
• Complete blood count

Imaging

• X-ray:
  • Joint space narrowing
  • Erosions
• MRI / Ultrasound:
  • Early synovitis
  • Pannus formation

Management of Rheumatoid Arthritis

Medical Management

• NSAIDs – pain and inflammation relief.
• DMARDs:
  • Methotrexate
  • Sulfasalazine
  • Leflunomide
• Biologic agents:
  • Anti-TNF drugs
  • IL-6 inhibitors
• Corticosteroids for acute flares.

Non-Pharmacological Management

• Physiotherapy.
• Occupational therapy.
• Joint protection techniques.
• Regular exercise.
• Balanced diet.
• Smoking cessation.

Surgical Management

• Synovectomy.
• Joint replacement surgery.

Homoeopathic Therapeutics in Rheumatoid Arthritis

• Arnica montana – inflammation and soreness.
• Rhus toxicodendron – stiffness better with movement.
• Bryonia – pain worse on movement.
• Ledum palustre – small joint involvement.
• Calcarea carbonica – fatigue and weakness.
• Ruta graveolens – ligament and tendon pain.
• Hypericum – nerve pain.
• Arsenicum album – burning pain and restlessness.

Important Points

• RA is autoimmune and systemic.
• Symmetrical joint involvement is characteristic.
• Morning stiffness > 1 hour is typical.
• Anti-CCP is more specific than RF.
• Early treatment prevents deformity.