Rheumatoid arthritis: ARA Criteria and Clinical features

Rheumatoid arthritis (RA) occurs world wide in all ethnic groups and peak incidence is in the fifth decade.

CRITERIA

The following are the revised criteria of American Rheumatology Association (ARA), for diagnosing RA:

"MORNING  Always Helps to See Nature Fresh and RADIANT"

•   MORNING - Morning stiffness of >1 hour duration
•   Always - Arthritis of  atleast three areas ( PIP, MCP, MTP, WRIST etc.)
•   Helps -  Hand arthritis
•   See* - Symmetrical arthritis
•   Nature - Nodules as observed by physician
•   Fresh -  rheumatoid Factor &
•   RADIANT - Radiological changes

CLINICAL FEATURES

The word RADIANT can be used as the mnemonic for many of the clincal features of RA:

•   Respiratory maifestations - (pleurisy with effusion, pulmonary fibrosis, caplan's syndrome, alveolitis), Renal manifestations, Radiological changes
•   Anaemia, Arteritis, Amyloidosis
•   Deformities and Deviation - (Swan neck, Boutonniere, Z deformity of thumb, ulnar deviation), DMARD's** as treatment
•   Immune complex vasculitis (nail fold infarcts, chronic leg ulcers, digital gangrene)
•   Atlanto axial subluxation, Anti-CCP antibodies
•   Neurological complications (peripheral neuropathy, mononeuritis, carpal tunnel syndrome, cervical myelopathy)
•   Thrombocytopaenia (due to splenomegaly in Felty's syndrome), TNFalpha gives dramatic  improvement in symptoms and appears to halt disease progression, Triggering fingers

* The word SEE efers to ocular manifestations like scleritis, scleromalacia perforans, episcleritis & keratoconjunctivitis sicca.

** SMILE refers to the drugs- Sulphasalazin, Steroids, Methotrexate, Infliximab, Leflunomide & Etanercept

Did you know?

The presence of atleast 4 criteria is required for the diagnosis of RA. The diagnosis is based on a collection of clinical features

Poor prognostic factors are female sex, extra-articular disease, high concentration of RA Factor & HLA-DR4

Rheumatoid factor is positive in upto 80% of patients. Both the ESR and CRP are elevated in active disease and correlate with disease severity

The causes of anaemia in RA are many: a) Normochromic normocytic anaemia due to chronic disease b) Hypochromic microcytic anaemia due to NSAID's causing chronic blood loss and iron deficiency c) Macrocytic anaemia resulting from folate deficiency from Sulphasalazine or Methotrexate and d) B12 deficiency associated with Pernicious anaemia e) Haemolytic anaemia (drug induced) f) Bone marrow suppression from drugs g) Hypersplenism as in Felty's syndrome