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Osteoarthritis- diagnosis

How is osteoarthritis diagnosed?

Osteoarthritis is diagnosed with a combination of medical history, physical exam, xrays, labs, and possibly other tests.


Medical history

There are several “clues” a physician looks for in differentiating osteoarthritis from other types of arthritis. For example, in osteoarthritis, the pain usually comes on over time, it is worse at night and with use of the joints, and there is minimal stiffness in the morning.

Although these clues are helpful, they may not be true in every person. For example, some people with rheumatoid arthritis may present with similar symptoms. On the other hand, some people with osteoarthritis may have only some or none of these clues.


Physical exam

Although osteoarthritic joints can be warm and swollen, there is usually less swelling in osteoarthritis than some other forms of arthritis like rheumatoid arthritis or gout.

Heberden's nodes
Heberden’s nodes- From operation-pro.de/

Osteoarthritis can lead to joint deformity. Sometimes the two bones in a joint actually fuse and the joint loses its

flexibility. As the body attempts to repair the damage joints, extra bone may form around the joint causing the joint to get larger and sometimes have “bumps”. These bumps are otherwise known as Heberden’s and Bouchard’s nodes.



Hand osteoarthritis
Hand osteoarthritis

In more advanced osteoarthritis, xrays can show narrowing of the space between two bones and even joint damage characteristic of osteoarthritis.




Although there is no blood test for osteoarthritis, labs can be done to rule out other forms of arthritis.


Joint fluid

If there is significant swelling in the joint, examination of the fluid drawn from the joint can help provide another clue. The joint fluid from an osteoarthritic joint has different characteristics from that from a joint with rheumatoid arthritis, infection, or gout.


See also:











Osteoarthritis- The most common type of arthritis

What is osteoarthritis?

Arthritis pain
Arthritis pain

Of the 100-or-so types of arthritis that can affect us, osteoarthritis (OA) is the most common type. OA is caused by “wear and tear” on the joints over time. Much like the tires on a car, the cartilage between joints, which provides cushioning to the joint, wears down over time and with use.

Osteoarthritis is like wear and tear of a tire


When the cushioning between the joints is worn off, the bones rub against each other. This causes pain, stiffness, and swelling in the joint.


Who gets osteoarthritis?

Basically, everyone. As we get older the chance of developing OA increases. Risk factors for developing OA sooner and more severe include obesity, previous joint injury, weak thigh muscles, and genetics (do your mom and grandmother have osteoarthritis?).


What exactly happens in osteoarthritis?

There is usually a rubbery material between the two bones that form a joint called cartilage. Cartilage acts as a cushion between the two bones.  As the bones slide over each other (like bending a joint) or pressed against each other (like walking), cartilage absorbs the impact and prevents bone damage and pain. As cartilage wears off over time, the two bones get closer to each other and eventually start rubbing against each other.

Components of a normal joint
Components of a normal joint

The joints we use the most often- the joints of the hands, knees, hips, and spine- are most likely to be affected by osteoarthritis. However, almost any joint may be affected.


Osteoarthritis symptoms

Symptoms of OA may include:

  • Joint pain
  • Join stiffness
  • Joint deformity
  • Swelling in the joint
  • Grinding noise with movement
  • Decreased range of motion of the joint


See also:






Safety of Biologic Drugs In Rheumatology

Safety of biologic drugs

Biologic drugs have recently revolutionized the treatment of many rheumatologic conditions such as rheumatoid arthritis, lupus, and psoriatic arthritis, to name a few. These powerful agents function by targeting a specific component of the immune system thought to be crucial in causing inflammation.

Specifically, TNF inhibitors (Humira, Enbrel, Remicade, Cimzia and Simponi) block activation of tumor-necrosis factor-α, Orencia inhibits the stimulation of T cells by the B cells, Rituxan inactivates certain B cells, Actemra blocks the activity of interleukin-6, and Xeljanz interferes with the JAK-STAT signaling pathway.

Biologic drugs have helped us achieve remission in many conditions that previously led to disability. For example, whereas rheumatoid arthritis used to lead to joint deformity and disability in a great number of the affected people in the past, nowadays the majority of people with this disease can enjoy a normal and pain-free life. Life threatening conditions, like kidney, lung or heart failure are also now treated successfully with these drugs.

However, safety of biologic drugs has been an issue, and at times, a topic of debate. Keep in mind that all medications, including Aspirin, Tylenol, or even vitamins, can have side effect. It is therefore important that biologic drugs are prescribed and managed by physicians who are well aware of potential side effects and well-equipped to recognize and treat them if necessary.

The majority of the data on the safety of biologic drugs come from people with rheumatoid arthritis. In this article I will summarize the major risks in this group. While it is possible that the risks are similar in other conditions, since the data is limited, little conclusion can be drawn.



Since biologic drugs target the immune system, it is not surprising that infection is a potential risk.

Bacterial infection:

An increased risk of bacterial infections, like pneumonia and skin infection, has been reported with all biologic drugs.

What this means for you: If you have a serious infection requiring antibiotics, hold your biologic drug until the infection has cleared. This allows your immune system to fight the infection.



If you were exposed to tuberculosis in the past, the organism may live in your body for years without causing disease. Once the immune system is lowered, tuberculosis can be reactivated. In severe cases it can affect not just the lungs, but potentially the entire body.

What this means for you: You will need a PPD (TB test) before starting most biologic drugs to make sure you have not been exposed to tuberculosis.


Viral infections:

Hepatitis B and C- Biologic drugs are used with caution in people with hepatitis.

JC virus- This is an infection affecting the brain. A very small risk has been observed (4 cases in rheumatoid arthritis patients, or 1 in 20,000 patients treated with Rituxan).

Herpes Simplex

Other infections

What this means for you: Get your vaccines before and while on biologic drugs. This includes Shingles, pneumonia vaccine and flu vaccine.



An early study suggested there may be a very small but increased risk of malignancy (specially lymphoma and nonmelanotic skin cancer) in people treated with TNF-inhibitors Remicade, Enbrel and Humira. However subsequent larger studies and reviews have not confirmed this risk. The data is not sufficient on the risk with Orencia, Actemra, or Xeljanz. Malignancy does not seem to be increased with Rituxan.

What this means for you: If you have a personal or family history of malignancy, alert your rheumatologist. This does not mean that you are not a candidate, but caution may be advised.



Cases of multiple sclerosis, optic neuritis, and Guillain-Barre syndrome have been reported with the use of TNF inhibitors.

What this means for you: If you have one of these conditions you may not be a good candidate for TNF inhibitor biologics.


Heart failure:

TNF inhibitors as well as Rituxan may exacerbate moderate to severe heart failure.

What this means for you: If you have moderate to severe heart failure (NYHA class III or IV) you may not be a candidate for some of the biologic drugs.


High cholesterol:

Actemra and Xeljanz may cause elevation of the bad cholesterol.

What this means for you: Your rheumatologist will periodically monitor your cholesterol level while on these drugs.


Drug-induced lupus:

New onset of lupus-like symptoms have been reported in people using TNF inhibitors. Symptoms usually resolve once the drug is discontinued.

What this means for you: Let your rheumatologist know if you develop new symptoms- including rashes, new joint pain, sores in the mouth, chest pain, etc.- while you are using these medications.


The bottom line:

Like any other medication, biologic drugs can be associated with a variety of potential side effects. And like with all other medications, their benefits should be balanced against their risks and individually assessed for every patient. When used correctly and safely, these drugs can save people’s lives.



What is arthritis? What is the difference between osteoarthritis and rheumatoid arthritis?

In this video Dr. Firooz discusses the basics of arthritis.



Living with rheumatoid arthritis- the 7 golden rules

Now that we have effective medications to treat this disease, living with rheumatoid arthritis is not as scary as once it may have been. You may still want to make a couple of adjustments in your lifestyle to help control the symptoms and prevent worsening of the disease. These are the 7 golden rules to help you live easier with rheumatoid arthritis:


1) Rest as needed

Inflammation associated with rheumatoid arthritis can cause significant fatigue. If your disease is active, you may need intermittent periods of rest during your day.


2) Exercise!

Staying active is an essential components of living with rhuematoid arthritis. With prolonged inactivity, joints will stiffen and muscles will become weak. This can actually exacerbate the pain in rheumatoid arthritis. Therefore it is a good idea to exercise your joints and muscles. If your arthritis is active, you may engage in milder forms of exercise until your disease is under better control. Many people with arthritis find it easier to exercise in the pool- swimming, aqua-aerobics, etc. Walking and biking are other, generally well tolerated forms of exercise. If you find that a particular exercise causes pain and swelling in your joints, opt for a different type of exercise instead.

3) Eat a healthy diet

Although there is no specific diet for rheumatoid arthritis, eating healthy, well balanced meals can be beneficial. A diet low in saturated fat and high in greens will help keep your heart healthy. While a healthy diet is important for everyone, it is especially crucial in people with rheumatoid arthritis, who are at higher risk for developing heart disease. If you are overweight, losing weight will lessen the load on your joints and help ease some of the pain.


4) Protect your joints

You may find that wrapping a joint with splints or braces can provide more stability to the joint and ease your pain. If you have arthritis
in your hip or knee, using a cane or a walker can help unload some of the weight. Nowadays, many assistive devices make living with rheumatoid arthritis easier. Some examples include:

  • Electrical appliances (can openers, power tools)Arthritis gadgets
  • Use of velcro instead of zippers or buttons
  • Padded handles for pots/pans, toothbrush, pen, keys, for easy grip
  • Elevated seats or chair legs
  • Larger door/cabinet/drawer handles
  • Many more


These devices may be available in pharmacies, surgical supply stores, or online. Here are just a few examples of places you can look:

4) Consider Supplements

While herbal supplements and vitamins do not play a major role in rheumatoid arthritis, data suggests some benefits for several supplements:
People with rheumatoid arthritis are at risk for developing osteoporosis; therefore vitamin D supplements may help prevent this. Fish oil is rich in omega-3 and may have anti-inflammatory properties Borage seed oil and Turmeric also have mild anti-inflammatory effects.


5) Keep your followup appointments

Rheumatoid arthritis is a chronic disease. You will most likely need regular visits with your rheumatologist or primary care physician to adjust your medications, monitor your disease, and prevent complications from rheumatoid arthritis.


6) Get your vaccines in order

Like in many chronic conditions, people with rheumatoid arthritis are encouraged to have yearly flu shots. Pneumonia vaccine is also recommended. If you are on medications that can lower your immune system, you should also get vaccinated for shingles.


7) Stop smoking!

We now have sufficient data that shows smoking is not only a risk for developing rheumatoid arthritis, it also can exacerbate the disease and interfere with the medications that are used to treat it.


Do Rheumatoid Arthritis treatments increase cancer risk?

Whether or not biologic drugs increase the risk of cancer in people with rheumatoid arthritis has been the subject of much research and concern in the past few years.

Biologic drugs work by targeting and disabling a specific component of the immune system. Since rheumatoid arthritis is an autoimmune disease, targeting the immune system has been a very effective way of treating the disease. But the question has been, what exactly is the role of the immune system in controlling and fighting cancer? And what happens if we interfere with this function?

We do know that patients with rheumatoid arthritis in general are at higher risk of getting certain malignancies than the general population. Specifically, they are at higher risk of developing lymphoma, leukemia, lung cancer, and skin cancer. Non-Hodgkin lymphoma is the most common malignancy in rheumatoid arthritis patients. This risk is directly related to the degree and duration of inflammation. In other words, the worse the disease, the higher risk of malignancy.

We first started using biologic drugs for treatment of rheumatoid arthritis in 1996. A class of biologic drugs named TNF-inhibitors was the first to be used, and it is still first line biologic treatment for treatment of rheumatoid arthritis. The results have been dramatic, with miraculous improvements in pain, swelling, and prevention of joint deformity.  But in 2003 the FDA noted 6 cases of lymphoma in over 6000 patients that were treated with TNF-alpha inhibitors. The TNF inhibitors available at that time were Enbrel, Humira, and Remicade. So the concern was born:


Do biologic drugs increase risk of cancer in patients with rheumatoid arthritis?

In trying to answer this question, we have learned a few things. First, that almost all the cancers reported in 2003 seemed to have happened in the first year of the TNF inhibitor use. In fact, if one looks at cancer risk over several years, the overall incidence seems to be the same in people who used biologics and those who did not. This can suggest that the drug did not actually cause the cancer, but unmasked the growth of one that was already there, too small to be detected at the time of starting the drug.

Second, if cancer risk is greater in patients with worse rheumatoid arthritis, and these patients were the ones who needed the stronger TNF inhibitor drugs to treat their disease, it is not surprising that they developed the malignancy while those patients with milder disease who did not need the stronger drugs did not.

Finally, the risk of cancer is still very low- both in general population and in patient with RA. This has made investigating the difference between the two groups even more difficult, since most studies of these drugs do not have enough patients developing cancer to power the statistics. So, we have relied on observational studies and metanalyses to answer this question. In fact, there have been multiple such studies in the past few years. And the answer? These studies showed that there is a higher rate of malignancy in patients with rheumatoid arthritis than in the general population; however the risk is the same in patients receiving biologic therapies as those who are not.


The 2012 American College of Rheumatology conclusions on this subject are:

  1. RA patients are at increased risk of lymphoma and lung and skin cancer
  2. Biologic-treated RA patients have similar rates cancer as do non-biologic treated RA patients
  3. RA patients on biologics with a prior history of most cancers are not risk of cancer recurrence





Treatment of rheumatoid arthritis

Rheumatoid arthritis treatment

There is no cure for rheumatoid arthritis (RA). However, in the recent decades, groundbreaking advances in the treatment of rheumatoid

Rheumatoid arthritis can cause joint space narrowing and bone erosions
Rheumatoid arthritis can cause joint space narrowing and bone erosions

arthritis have made treatment of this disease a lot more successful. While a great number of people with RA needed to be on disability just a few decades ago, nowadays most people with rheumatoid arthritis can expect a relatively normal life. In fact, the current goal in rheumatoid arthritis treatment is remission. If remission is not possible, the goal is to reduce inflammation and pain and prevent joint damage.

Recent research in rheumatoid arthritis has shown that the earlier this disease is treated, the more likely it is to achieve remission. There seems to be a “window of opportunity” during which achieving remission and preventing future joint damage is most probable. This seems to be during the first year after onset of symptoms. As a result, experts recommend early aggressive treatment EARLY, with hopes to reduce treatment once remission is achieved.


Choice of treatment

Lifestyle changes

Some lifestyle changes can help improve symptoms and quality of life in people with rheumatoid arthritis. These lifestyle changes are used in conjunction with- not in place of- medications used to treat RA. Most people with RA do require medical therapy while the disease is active to prevent joint damage.


  • Exercise– despite fatigue, joint pain and stiffness experienced by people with RA, regular exercise is not only safe, but also necessary to prevent loss of muscle strength and deconditioning. The intensity of exercise can be increased as symptoms improve.


  • Quit smoking– Smoking is a risk factor for developing rheumatoid arthritis. It also interferes with, and lessons the effects of, medications used to treat RA.


  • Diet– some dietary supplements, like fish oil, turmeric and borage seed oil, may have anti-inflammatory properties and may have a modest effect on the symptoms of RA. Please note that these supplements will not cure arthritis. They should be used as supplements to- not replacement of- medical treatment for rheumatoid arthritis.


  • Preventative measures– people with rheumatoid arthritis are at an increased risk for heart disease and osteoporosis. Management of traditional risk factors for heart disease- including control of blood pressure, cholesterol, blood sugar, and quitting smoking- is important to lessen the risk of heart disease. Vitamin D supplementation (if deficient in vitamin D) and physical activity can help reduce the risk of osteoporosis.


Medical treatment

Choice of medications in rheumatoid arthritis treatment is usually individualized, depending on the person’s risk factors, comorbid conditions, and potential side effects. Several classes of medications can be used to treat rheumatoid arthritis, and medications from two or more classes may be combined to achieve the desired outcome.


  • Nonsteroidal anti-inflammatory drugs (NSAIDS)- examples of this class include ibuprofen (Advil, Motrin), Naproxen (Aleve), Meloxicam (Mobic), Celebrex, Diclofenac (Voltaren), etc. NSAIDs can be used to decrease pain and inflammation. They are rarely used as monotherapy in RA since most patients need stronger medications to decrease the inflammatory burden and to prevent joint damage.


  • Disease-modifying anti-rheumatic drugs (DMARDs)

These medications are usually the first ones used for treatment of RA. They are stronger than NSAIDs and, in the long run, safer than steroids. They can take several weeks to take effect so sometimes in severe RA steroids are started at the same time and tapered as DMARDs take effect.


  • Methotrexate– this medication has become the first-line medication for rheumatoid arthritis treatment, as it has proven to be very effective at treating symptoms, improving quality of life, and preventing joint damage. It can take 4-6 weeks to see improvement with methotrexate. Although at very high doses, Methotrexate can be used to treat cancer, at the low doses used for rheumatoid arthritis it is NOT chemotherapy. The most common side effects are nausea and abdominal upset. It is contraindicated in pregnancy as it is teratogenic and can cause birth defects. It can affect liver enzymes so alcohol consumption is not recommended. Laboratory monitoring is done periodically; every 1-3 months.


  • Sulfasalazine– Sulfasalazine is used in combination with methotrexate or in place of it in those who are intolerant or have contraindications to methotrexate use. It can take 4-8 weeks to see improvement with sulfasalazine. Common side effects include nausea, diarrhea, and rash. Periodic laboratory monitoring every 2-3 months is recommended.


  • Leflunomide– Like sulfasalazine, leflunomide is used either in combination or in place of methotrexate in methotrexate cannot be used. It takes 6-8 weeks to see a response. The main side effects are abdominal upset, nausea, diarrhea, and hair loss. Extreme care should be taken for women not to get pregnant while taking this drug as it is teratogenic and can linger in the body for up to 18 months.


  • Plaquenil– Plaquenil is sometimes used in mild rheumatoid arthritis alone or in combination with other DMARDs. It can take up to 8-10 weeks for the levels to build up in the body. It is a relatively safe drug with rare and minor side effects including fatigue, body aches or rashes. Deposition of Plaquenil in the retina of the eye causing loss of peripheral vision is a feared potential side effect that is extremely rare and will take years to occur. Yearly eye exams will be able to detect this process early and prevent any vision loss.


  • Cyclosporine– is used rarely in rheumatoid arthritis.
  • Gold injections– were used in the past and have faded in favor of other more effective treatments like methotrexate.


  • Corticosteroids- Examples: Prednisone (oral), solumedrol (IV)

Steroids work quickly and are strong anti-inflammatory agents. Because of potential side effects in the long term use (elevated blood sugar, weight gain, cataracts, osteoporosis, bruising) they are usually used short term when a quick response is required. Low dose steroids (ie. 5mg prednisone or less per day) is fairly safe when used long term.


Biologic drugs

These potent medications have truly revolutionized the treatment of rheumatoid arthritis in the recent decades. These drugs each target a specific component of the immune system, thus “cooling down” an otherwise angry immune system. Infection is a potential, though infrequent, side effect of these drugs. A tuberculosis test is usually required before starting most biologic drugs to rule out dormant or active tuberculosis that can activate once the immune system is lowered. These drugs are usually used in people who have had inadequate response to DMARDs. They are often combined with DMARDs like methotrexate. Several classes of biologics are currently in the market:


  • TNF-alpha inhibitors (tumor-necrosis-factor inhibitors)- work by blocking the effect of TNF-alpha, an important component of the immune system which causes inflammation and ultimately leads to joint destruction. Recall that people with rheumatoid arthritis are at increased risk of developing lymphoma. There is some debate that TNF inhibitors may increase the risk of lymphoma in these people. Although initial studies reported a minimal increased risk, subsequent large reviews did not find a substantial risk so the issue has remained controversial. There are several members in this family:

Etanercept (Enbrel)- subcutaneous injection, weekly

Adalimumab (Humira)- subcutaneous injection, biweekly

Infliximab (Remicade)- IV infusion, every 2-8 weeks

Golimumab (Simponi)- subcutaneous injection, monthly

                     Golimumab (Simponi Aria)- IV infusion, every 8 weeks

Certulizumab (Cimzia)- subcutaneous injection, monthly


  • Abatacept (Orencia)- works by blocking the communication between the B-type and T-type lymphocytes. Orencia comes in both IV (monthly infusion) and subcutaneous (weekly injection) formulations.


  • Rituxaimab (Rituxan)- monoclonal antibodies against a subtype of B-lymphocytes (B19) that makes them ineffective. This drug is IV and is administered every 6 months. Since it is also a chemotherapy agent, it is often used in rheumatoid arthritis patients with a history of malignancy.


  • IL-6 inhibitors- these drugs work by nhibiting the function of IL-1, also an important component of the immune system which causes inflammation.

Tocilizumab (Actemra IV)- IV infusion, every 4 weeks

Tocilizumab (Actemra SubQ)- subcutaneous injection, biweekly

Sarilumab (Kevzara)- subcutaneous injection, every 2 weeks


  • Jak inhibitors- These small molecules work by inhibiting Janus Kinase 1, 2, or 3. They influence DNA transcription, ultimately reducing inflammation. They are taken orally.

Tofacitinib (Xeljanz)- Oral, 5mg twice daily or 11mg daily

Baricitinib (Olumient)- Oral, 2mg daily


See also:

What is Rheumatoid arthritis?

Rheumatoid arthritis symptoms

Rheumatoid arthritis: diagnosis




Rheumatoid arthritis: Diagnosis

How is rheumatoid arthritis diagnosed?

Rheumatoid arthritis diagnosis can be difficult; specially if it’s early in the course of the disease. There is no one test that will definitively diagnose rheumatoid arthritis (RA). For example, the blood tests may be negative in someone who has rheumatoid arthritis and positive in someone else who doesn’t. In early rheumatoid arthritis, the xrays may be completely normal. A skilled rheumatologist is able to carefully investigate all the available data and determine if someone has rheumatoid arthritis.

Besides a careful history and physical exam, several clues can help in the rheumatoid arthritis diagnosis process:

Blood tests

When rheumatoid arthritis is suspected clinically, certain laboratory tests can help confirm the diagnosis.

  • Antibodies

Rheumatoid factor (RF)– rheumatoid factor is present in about 80% of people with rheumatoid arthritis. In about 20% of people, the diagnosis established in the absence of this antibody. False positive rheumatoid factor can be seen in a minority of healthy people and can be associated with bacterial endocarditis, hepatitis C, chronic liver disease, sarcoidosis, or aging.

Anti-citrullinated peptite antibody (ACPA or anti-CCP)– these antibodies can also be seen in about 70% of people with rheumatoid arthritis. CCP is more specific than rheumatoid arthritis for diagnosis of RA.

It is possible to have rheumatoid arthritis with a negative RF and CCP. These cases are called “seronegative” RA. Presence of RF and/or CCP antibodies are associated with a more aggressive disease.


  • Other laboratory abnormalities

People with rheumatoid arthritis commonly have elevated inflammatory markers erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Anemia of chronic disease is not uncommon. They may also have a low positive anti-nuclear antibody (ANA).


Imaging studies

  • Xrays

Xrays are commonly obtained at the time of rheumatoid arthritis diagnosis. Xrays of the hands and feet are most commonly taken, since these are the areas most affected by RA. In early RA, xrays may be normal. As the disease progresses RA-specific findings may become apparent on the xrays including thinning of the bone around a joint, narrowing of the joint, subluxation and deformity of a joint, and erosions around the joint. Xrays are also used during the treatment of rheumatoid arthritis to assess response to treatment and ensure the disease is not progressing.

Rheumatoid arthritis can cause joint space narrowing and bone erosions
Rheumatoid arthritis can cause joint space narrowing and bone erosions

Eventually destruction of joints can be seen
Eventually destruction of joints can be seen

  • MRI

MRI is sometimes used in the diagnosis of rheumatoid arthritis when it is highly suspected but the antibodies are negative and xrays are normal. Presence of synovitis- inflammation of the joint- or bony erosions typical of RA help confirm the diagnosis.

  • Ultrasound

The use of ultrasound is becoming increasingly popular both in the diagnosis and followup of RA, since it is a relatively inexpensive and noninvasive procedure that can be easily performed in the office. Studies have shown that ultrasound can be as sensitive as MRI in picking up joint inflammation and erosion. The accuracy of the ultrasound findings depends on the expertise of the person performing the ultrasound.


Joint fluid

Examination of fluid from a swollen joint can be helpful to distinguish rheumatoid arthritis from osteoarthritis, gout, or infection. Unlike the fluid from an osteoarthritic joint, the RA joint fluid will show abundant inflammation. Presence of uric acid crystals in the joint fluid may indicate that gout is the correct diagnosis.


Classification criteria

Classification criteria for RA were originally designed to for research purposes, but have been used by many physicians as a means to confirm the diagnosis of rheumatoid arthritis.

The initial criteria were first established in 1987 jointly by the American College of Rheumatology (ACR) and European League Against Rheumatism (EULAR). It required presence of symptoms for at least 3 months, and at least 4 out of 7 criteria to classify as RA.

The 1987 ACR/EULAR classification criteria for rheumatoid arthritis

1. Morning stiffnessMorning stiffness in and around the joints, lasting at least 1 hour
2. Arthritis of  ≥3 jointsThe qualified areas are PIP, MCP, wrist, elbow, knee, ankle, and MTP joints
3. Arthritis of hand jointsAt least 1 area swollen in a wrist, MCP, or PIP joint
4. Symmetric arthritisSimultaneous involvement of the same joint areas on both sides of the body
5. Rheumatoid nodulesSubcutaneous nodules over bony prominences, extensor surfaces, or around joints
6. Rheumatoid factorPositive rheumatoid factor
7. Radiographic changesIncluding erosions or periarticular demineralization


As advances in diagnostic abilities allowed for earlier diagnosis of rheumatoid arthritis, the 1987 criteria was criticized for not allowing for early diagnosis of RA. For example, people with early rheumatoid arthritis may not have rheumatoid nodules or any radiographic changes.

The most recent ACR/EULAR rheumatoid arthritis classification criteria, introduced in 2010, has been useful to diagnose RA earlier than the previous criteria. A total of 6 points is required to meet the criteria.

From: Arthritis & Rheumatism; vol 62, No 6, September 2010, pp 2569-2581
From: Arthritis & Rheumatism; vol 62, No 6, September 2010, pp 2569-2581


This criteria is used most often to establish early diagnosis of RA. It is recognized that some people with longstanding RA may qualify the 1987 criteria but not the ones from 2010. Large joints refers to shoulders, elbows, hips, knees, and ankles. Small joints refers to metacarpophalangeal (MCP) joints, proximal interphalangeal (PIP) joints, 2nd-5th metatarsophalangeal joints, thumb interphalangeal joints, and wrists.

Why is it important to diagnose rheumatoid arthritis early?

The goal in management of rheuamtoid arthritis is to control the symptoms and prevent joint damage. In the past several years, studies have shown that the earlier the rheumatoid arthritis diagnosis is established, and the earlier treatment is initiated, the better the outcome of the disease. For this reason, it is important to diagnose rheumatoid arthritis as early as possible.


See also:

What is rheumatoid arthritis?

Rheumatoid arthritis symptoms

Treatment of rheumatoid arthritis




Rheumatoid arthritis symptoms

What are some of the rheumatoid arthritis symptoms?


Rheumatoid arthritis symptoms can range from mild to moderate to severe. Although joint pain and swelling is the hallmark of rheumatoid arthritis (RA), other organs may also be affected.


  • Constitutional symptoms

People with RA may note fever, fatigue, body aches, and weight loss


  • Joints

normal joint
Components of a normal joint

Rheumatoid arthritis affects the synovial joints. These are joints that are lined by a synovial membrane. The most commonly affected joints are the small joints of the hands and feet, but RA can also be seen in the shoulders, elbows, hips, knees, and cervical spine. Less commonly temporomandibular joints (TMJ) and sternoclavicular joints may be affected.

Inflammation of the synovial membrane causes pain, swelling, redness and warmth. The affected joints are usually stiff after extended periods of inactivity, especially after waking up in the morning. Synovial inflammation may eventually lead to erosion of the adjacent bone and lead to deformity.


With longstanding untreated RA, joint deformity can occur. “Swan-neck deformity” refers to flexion of the hand joint distally and extension proximally, so the finger resembles neck of a swan. In Boutonniere deformity, the distal joints are extended and the middle joint is flexed. Fingers may also deviate laterally; a finding termed “ulnar deviation”. “Z-deformity” is caused by subluxation of the thumb at the base and hyperextention distally so the thumb appears like a Z.

 RA defomity

The toes may turn upward, therefore putting more pressure on the bottom of the toes. People with RA sometimes describe this as if they are “walking on marbles”.


Extra-articular involvement in RA

Involvement of organs other than joints:

  • Skin

Rheumatoid nodules are painless lumps under the skin that develop in pressured areas like under the forearm, on the elbow, and on the tendons of the hands, among other areas.


  • Heart

RA can cause inflammation of the lining of the heart (pericarditis). This causes a sharp chest pain worse when taking a deep breath, and in severe cases can collapse the chambers of the heart.


People with RA are more prone to developing atherosclerosis (hardening of the arteries) and heart attacks.


  • Lungs

Similar to pericarditis, inflammation of the lining of the lungs (pleuritis) can cause chest pain and difficulty breathing. Rheumatoid arthritis can also cause inflammation of the lung tissue leading to interstitial lung disease. Occasionally patients with RA can have nodules (similar to rheumatoid nodules) in the lungs.


  • Kidneys

Chronic inflammation from severe, untreated RA can lead to deposits of inflammatory protein (amyloid) in the kidneys. Amyloidosis is the main cause of kidney failure in RA.


  • Blood

People with rheumatoid arthritis may be anemic. The anemia can be caused by chronic inflammation (anemia of chronic disease) or destruction of the red cells by the immune system. An enlarged spleen, which may be a late complication of rheumatoid arthritis, can cause low white blood cells (Felty’s syndrome).


  • Blood vessels

Inflammation of the blood vessels can cause a variety of symptoms, some that may be life threatening.


  • Nerves

Inflammation in the wrist can put pressure on the median nerve and cause carpal tunnel syndrome. A similar process in the ankle can cause numbness and tingling in the feet.


Erosion of the odontoid process (the part of the spine in the neck where the skull rests on) can cause instability in the neck. Slipping of the unstable vertebrae can compress the spinal cord and eventually lead to quadriplegia.


  • Eyes

Inflammation of the white part of the eye can cause pain and changes in the vision.

Some people with rheumatoid arthritis develop dry eyes and dry mouth- a syndrome called Sjogren’s syndrome which may also be seen with a variety of other autoimmune diseases.


  • Bones

Rheumatoid arthritis, as well as some of the medications used to treat it, can increase the risk for osteoporosis.


  • Lymph

Although uncommon, lymphoma risk is increased in people with RA.

See also:

What is rheumatoid arthritis?

Rheumatoid arthritis diagnosis

Treatment of rheumatoid arthritis




What is Rheumatoid Arthritis?

Rheumatoid arthritis

Rheumatoid arthritis (RA) is an autoimmune inflammatory disease mainly of the joints. The immune system is normally designed to attack foreign bodies like bacteria and viruses. In rheumatoid arthritis, the immune system abnormally attacks the joints causing inflammation and pain. Although the joints are the main targets in rheumatoid arthritis, many other tissues like the lungs or the heart may also become involved. The prevalence of rheumatoid arthritis is about 1%.


Risk factors

The cause of rheumatoid arthritis is not known. It is thought that some people are more susceptible to developing rheumatoid arthritis because of genetic factors. Certain environmental exposures may tip the susceptible person over to develop RA. The following are some of the risk factors thought to be important in development of RA:

  • Gender– women are more likely than men to develop rheumatoid arthritis
  • Genetics– several genes have been linked to development of rheumatoid arthritis. Certain HLA genes (HLA-DR4) have shown specially strong association.
  • Infection– It is thought that certain infections may trigger the immune system into developing autoimmune properties. A proposed mechanism for this is called molecular mimicry. If the infectious particles (like proteins from the bacteria or virus) are molecularly close to the proteins in our body, the immune system, triggered by these foreign particles, may later mistake our proteins as foreign and attack them as unwanted particles. Viruses like Epstein Bar virus (EBV) and Human Herpes Virus 6 (HHV-6) are candidates, but others may exist.
  • Smoking– smokers are more likely to develop rheumatoid arthritis, and once they have, they are likely to have a more severe disease than nonsmokers.
  • Stress– both physical and emotional major life events can precede the onset of rheumatoid arthritis.

How does rheumatoid arthritis develop?

Once the immune system is abnormally triggered, it produces antibodies like rheumatoid factor (RF) and cyclic citrullinated peptide (CCP). These antibodies in turn activate macrophages and cause an inflammatory reaction in the synovium, which is the lining of the joint. As the inflammation continues, excess synovial fluid is produced which can lead to visible swelling of a joint. The joint lining also can thicken, forming a fibrous tissue called pannus. The enzymes produced by the pannus can eventually lead to damage of the joint and cartilage.

Stages of rheumatoid arthritisIn longstanding active rheumatoid arthritis, persistent inflammation and pannus formation can cause destruction, deformity, and even fusion of the joint.

See also:

Rheumatoid arthritis symptoms

Rheumatoid arthritis: diagnosis

Treatment of rheumatoid arthritis