Rheumatoid arthritis 1

Rheumatoid arthritis

Rheumatoid arthritisClassification and external resources

A hand affected by rheumatoid arthritis

ICD-10 M 05. [1]-M 06. [2]

ICD-9 714 [3]

OMIM 180300 [4]

DiseasesDB 11506 [5]

MedlinePlus 000431 [6]

eMedicine article/331715 [7] article/1266195 [8] article/305417 [9] article/401271 [10] article/335186 [11] article/808419 [12]

MeSH D001172 [13]

Rheumatoid arthritis (RA) is a chronic, systemic inflammatory disorder that may affect many tissues and organs,but principally attacks synovial joints. The process produces an inflammatory response of the synovium (synovitis)secondary to hyperplasia of synovial cells, excess synovial fluid, and the development of pannus in the synovium.The pathology of the disease process often leads to the destruction of articular cartilage and ankylosis of the joints.Rheumatoid arthritis can also produce diffuse inflammation in the lungs, pericardium, pleura, and sclera, and alsonodular lesions, most common in subcutaneous tissue. Although the cause of rheumatoid arthritis is unknown,autoimmunity plays a pivotal role in both its chronicity and progression, and RA is considered a systemicautoimmune disease.About 1% of the world's population is afflicted by rheumatoid arthritis, women three times more often than men.Onset is most frequent between the ages of 40 and 50, but people of any age can be affected. It can be a disablingand painful condition, which can lead to substantial loss of functioning and mobility if not adequately treated. It is aclinical diagnosis made on the basis of symptoms, physical exam, radiographs (X-rays) and labs; although theAmerican College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR) publishdiagnostic guidelines. Diagnosis and long-term management are typically performed by a rheumatologist, an expertin auto-immune diseases.[14]

Various treatments are available. Non-pharmacological treatment includes physical therapy, orthoses, occupational therapy and nutritional therapy but do not stop progression of joint destruction. Analgesia (painkillers) and anti-inflammatory drugs, including steroids, are used to suppress the symptoms, while disease-modifying antirheumatic drugs (DMARDs) are required to inhibit or halt the underlying immune process and prevent long-term

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damage. In recent times, the newer group of biologics has increased treatment options.[14]

The name is based on the term "rheumatic fever", an illness which includes joint pain and is derived from the Greekword ῥεύμα-rheuma (nom.), ῥεύματος-rheumatos (gen.) ("flow, current"). The suffix -oid ("resembling") gives thetranslation as joint inflammation that resembles rheumatic fever. The first recognized description of rheumatoidarthritis was made in 1800 by Dr Augustin Jacob Landré-Beauvais (1772–1840) of Paris.[15]

Signs and symptomsWhile rheumatoid arthritis primarily affects joints, problems involving other organs of the body are known to occur.Extra-articular ("outside the joints") manifestations other than anemia (which is very common) are clinically evidentin about 15–25% of individuals with rheumatoid arthritis.[16] It can be difficult to determine whether diseasemanifestations are directly caused by the rheumatoid process itself, or from side effects of the medicationscommonly used to treat it – for example, lung fibrosis from methotrexate or osteoporosis from corticosteroids.

Joints

A diagram showing how rheumatoid arthritisaffects a joint

The arthritis of joints known as synovitis is inflammation of thesynovial membrane that lines joints and tendon sheaths. Joints becomeswollen, tender and warm, and stiffness limits their movement. Withtime RA nearly always affects multiple joints (it is a polyarthritis),most commonly small joints of the hands, feet and cervical spine, butlarger joints like the shoulder and knee can also be involved. Synovitiscan lead to tethering of tissue with loss of movement and erosion of thejoint surface causing deformity and loss of function.[14]

Rheumatoid arthritis typically manifests with signs of inflammation,with the affected joints being swollen, warm, painful and stiff,particularly early in the morning on waking or following prolongedinactivity. Increased stiffness early in the morning is often a prominentfeature of the disease and typically lasts for more than an hour. Gentlemovements may relieve symptoms in early stages of the disease. Thesesigns help distinguish rheumatoid from non-inflammatory problems ofthe joints, often referred to as osteoarthritis or "wear-and-tear" arthritis.In arthritis of non-inflammatory causes, signs of inflammation andearly morning stiffness are less prominent with stiffness typically lessthan 1 hour, and movements induce pain caused by mechanicalarthritis.[17] In RA, the joints are often affected in a fairly symmetricalfashion, although this is not specific, and the initial presentation maybe asymmetrical.

As the pathology progresses the inflammatory activity leads to tendontethering and erosion and destruction of the joint surface, which impairs range of movement and leads to deformity.The fingers may suffer from almost any deformity depending on which joints are most involved. Medical studentsare taught to learn names for specific deformities, such as ulnar deviation, boutonniere deformity, swan neckdeformity and "Z-thumb," but these are of no more significance to diagnosis or disability than other variants, sincethey occur in osteoarthritis as well. "Z-thumb" or "Z-deformity" consists of hyperextension of the interphalangealjoint, fixed flexion and subluxation of the metacarpophalangeal joint and gives a "Z" appearance to the thumb.

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SkinThe rheumatoid nodule, which is often subcutaneous, is the cutaneous feature most characteristic of rheumatoidarthritis. The initial pathologic process in nodule formation is unknown but may be essentially the same as thesynovitis, since similar structural features occur in both. The nodule has a central area of fibrinoid necrosis that maybe fissured and which corresponds to the fibrin-rich necrotic material found in and around an affected synovialspace. Surrounding the necrosis is a layer of palisading macrophages and fibroblasts, corresponding to the intimallayer in synovium and a cuff of connective tissue containing clusters of lymphocytes and plasma cells, correspondingto the subintimal zone in synovitis. The typical rheumatoid nodule may be a few millimetres to a few centimetres indiameter and is usually found over bony prominences, such as the olecranon, the calcaneal tuberosity, themetacarpophalangeal joint, or other areas that sustain repeated mechanical stress. Nodules are associated with apositive RF (rheumatoid factor) titer and severe erosive arthritis. Rarely, these can occur in internal organs or atdiverse sites on the body.Several forms of vasculitis occur in rheumatoid arthritis. A benign form occurs as microinfarcts around the nailfolds.More severe forms include livedo reticularis, which is a network (reticulum) of erythematous to purplishdiscoloration of the skin caused by the presence of an obliterative cutaneous capillaropathy.Other, rather rare, skin associated symptoms include:• pyoderma gangrenosum, a necrotizing, ulcerative, noninfectious neutrophilic dermatosis.• Sweet's syndrome, a neutrophilic dermatosis usually associated with myeloproliferative disorders• drug reactions• erythema nodosum• lobular panniculitis• atrophy of digital skin• palmar erythema• diffuse thinning (rice paper skin), and skin fragility (often worsened by corticosteroid use).

LungsFibrosis of the lungs is a recognized response to rheumatoid disease. It is also a rare but well recognizedconsequence of therapy (for example with methotrexate and leflunomide). Caplan's syndrome describes lung nodulesin individuals with rheumatoid arthritis and additional exposure to coal dust. Pleural effusions are also associatedwith rheumatoid arthritis. Another complication of RA is Rheumatoid Lung Disease. It is estimated that about onequarter of Americans with RA develop Rheumatoid Lung Disease.[18]

KidneysRenal amyloidosis can occur as a consequence of chronic inflammation.[19] Rheumatoid arthritis may affect thekidney glomerulus directly through a vasculopathy or a mesangial infiltrate but this is less well documented.Treatment with Penicillamine and gold salts are recognized causes of membranous nephropathy.

Heart and blood vesselsPeople with rheumatoid arthritis are more prone to atherosclerosis, and risk of myocardial infarction (heart attack) and stroke is markedly increased.[20] [21] Other possible complications that may arise include: pericarditis, endocarditis, left ventricular failure, valvulitis and fibrosis.[22] Many people with rheumatoid arthritis do not experience the same chest pain that others feel when they have angina or myocardial infarction. To reduce cardiovascular risk, it is crucial to maintain optimal control of the inflammation caused by rheumatoid arthritis (which may be involved in causing the cardiovascular risk), and to use exercise and medications appropriately to reduce other cardiovascular risk factors such as blood lipids and blood pressure. Doctors who treat rheumatoid arthritis patients should be sensitive to cardiovascular risk when prescribing anti-inflammatory medications, and may

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want to consider prescribing routine use of low doses of aspirin if the gastrointestinal effects are tolerable.[22]

OtherOcular

The eye is directly affected in the form of episcleritis which when severe can very rarely progress toperforating scleromalacia. Rather more common is the indirect effect of keratoconjunctivitis sicca, which is adryness of eyes and mouth caused by lymphocyte infiltration of lacrimal and salivary glands. When severe,dryness of the cornea can lead to keratitis and loss of vision. Preventive treatment of severe dryness withmeasures such as nasolacrimal duct occlusion is important.

HepaticCytokine production in joints and/or hepatic Kupffer cells leads to increased activity of hepatocytes withincreased production of acute-phase proteins, such as C-reactive protein, and increased release of enzymessuch as alkaline phosphatase into the blood. In Felty's syndrome, Kuppfer cell activation is so marked that theresulting increase in hepatocyte activity is associated with nodular hyperplasia of the liver, which may bepalpably enlarged. Because Kuppfer cells are not within the liver parenchyma, there is little or no evidence ofhepatitis. Hepatic involvement in RA is essentially asymptomatic.

HematologicalAnemia is by far the most common abnormality of the blood cells. Rheumatoid arthritis may cause a warmautoimmune hemolytic anemia.[23] The red cells are of normal size and colour (normocytic andnormochromic). A low white blood cell count (neutropenia) usually only occurs in patients with Felty'ssyndrome with an enlarged liver and spleen. The mechanism of neutropenia is complex. An increased plateletcount (thrombocytosis) occurs when inflammation is uncontrolled, as does the anemia.

NeurologicalPeripheral neuropathy and mononeuritis multiplex may occur. The most common problem is carpal tunnelsyndrome caused by compression of the median nerve by swelling around the wrist. Atlanto-axial subluxationcan occur, owing to erosion of the odontoid process and or/transverse ligaments in the cervical spine'sconnection to the skull. Such an erosion (>3mm) can give rise to vertebrae slipping over one another andcompressing the spinal cord. Clumsiness is initially experienced, but without due care this can progress toquadriplegia.

Constitutional symptomsConstitutional symptoms including fatigue, low grade fever, malaise, morning stiffness, loss of appetite andloss of weight are common systemic manifestations seen in patients with active rheumatoid arthritis.

OsteoporosisLocal osteoporosis occurs in RA around inflamed joints. It is postulated to be partially caused by inflammatorycytokines. More general osteoporosis is probably contributed to by immobility, systemic cytokine effects,local cytokine release in bone marrow and corticosteroid therapy.

LymphomaThe incidence of lymphoma is increased in RA, although it is still uncommon.

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Diagnosis

Imaging

X-ray of the hand in rheumatoid arthritis.

Appearance of synovial fluid from a joint withinflammatory arthritis.

X-rays of the hands and feet are generally performed in people with apolyarthritis. In rheumatoid arthritis, there may be no changes in theearly stages of the disease, or the x-ray may demonstrate juxta-articularosteopenia, soft tissue swelling and loss of joint space. As the diseaseadvances, there may be bony erosions and subluxation. X-rays of otherjoints may be taken if symptoms of pain or swelling occur in thosejoints.

Other medical imaging techniques such as magnetic resonance imaging(MRI) and ultrasound are also used in rheumatoid arthritis.There have been technical advances in ultrasonography.High-frequency transducers (10 MHz or higher) have improved thespatial resolution of ultrasound images; these images can depict 20%more erosions than conventional radiography. Also, color Doppler andpower Doppler ultrasound, which show vascular signals of activesynovitis depending on the degree of inflammation, are useful inassessing synovial inflammation. This is important, since in the earlystages of rheumatoid arthritis, the synovium is primarily affected, andsynovitis seems to be the best predictive marker of future jointdamage.[24]

Blood tests

When RA is clinically suspected, immunological studies are required,such as testing for the presence of rheumatoid factor (RF, anon-specific antibody).[25] A negative RF does not rule out RA; rather,the arthritis is called seronegative. This is the case in about 15% ofpatients.[26] During the first year of illness, rheumatoid factor is morelikely to be negative with some individuals converting to seropositivestatus over time. RF is also seen in other illnesses, for exampleSjögren's syndrome, Hepatitis C, chronic infections and inapproximately 10% of the healthy population, therefore the test is notvery specific.

Because of this low specificity, new serological tests have beendeveloped, which test for the presence of the anti-citrullinated proteinantibodies (ACPAs) or anti-CCP. Like RF, these tests are positive inonly a proportion (67%) of all RA cases, but are rarely positive if RAis not present, giving it a specificity of around 95%.[26] As with RF,there is evidence for ACPAs being present in many cases even beforeonset of clinical disease.

The most common tests for ACPAs are the anti-CCP (cyclic citrullinated peptide) test and the Anti-MCV assay(antibodies against

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Signs of destruction and inflammation onultrasonography and magnetic resonance imaging

in the second metacarpophalangeal joint inestablished rheumatoid arthritis. Thin arrows

indicate an erosive change; thick arrows indicatesynovitis. Ultrasonography (left side of image) inthe (a) longitudinal and (b) the transverse planes

shows both signs of destruction andinflammation. Axial T1-weighted magnetic

resonance images were obtained (c) before and(d) after contrast administration, also

demonstrating synovitis. Additionally, a coronalT1-weighted magnetic resonance image (e)

before contrast administration visualizes the samebone erosion as shown in panels c and d.

mutated citrullinated Vimentin). Recently a serological point-of-caretest (POCT) for the early detection of RA has been developed. Thisassay combines the detection of rheumatoid factor and anti-MCV fordiagnosis of rheumatoid arthritis and shows a sensitivity of 72% andspecificity of 99.7%.[27] [28]

Also, several other blood tests are usually done to allow for othercauses of arthritis, such as lupus erythematosus. The erythrocytesedimentation rate (ESR), C-reactive protein, full blood count, renalfunction, liver enzymes and other immunological tests (e.g.,antinuclear antibody/ANA) are all performed at this stage. Elevatedferritin levels can reveal hemochromatosis, a mimic RA, or be a sign ofStill's disease , a seronegative, usually juvenile, variant of rheumatoid.

Criteria

In 2010 the 2010 ACR / EULAR Rheumatoid Arthritis ClassificationCriteria were introduced.[29] These new classification criteriaoverruled the "old" ACR criteria of 1987 and are adapted for early RAdiagnosis. The "new" classification criteria, jointly published by theAmerican College of Rheumatology (ACR) and the European LeagueAgainst Rheumatism (EULAR) establish a point value between 0 and10. Every patient with a point total of 6 or higher is unequivocallyclassified as an RA patient, provided he has synovitis in at least onejoint and given that there is no other diagnosis better explaining thesynovitis. Four areas are covered in the diagnosis:

• joint involvement – depending on the type and number of joints: upto 5 points

• serological parameters – including the rheumatoid factors as well asACPA – "ACPA" stands for "anti-citrullinated protein antibody":up to 3 points depending on titre level

• acute phase reactants: 1 point for elevated erythrocyte sedimentation rate, ESR, or elevated CRP value (c-reactiveprotein)

• duration of arthritis: 1 point for symptoms lasting six weeks or longerThe new criteria accommodate to the growing understanding of rheumatoid arthritis and the improvements indiagnosing RA and disease treatment. In the "new" criteria serology and autoimmune diagnostics carries majorweight, as ACPA detection is appropriate to diagnose the disease in an early state, before joints destructions occur.Destruction of the joints viewed in radiological images was a significant point of the ACR criteria from 1987.[30]

This criterion no longer is regarded to be relevant, as this is just the type of damage that treatment is meant to avoid.

The criteria are not intended for the diagnosis for routine clinical care; they were primarily intended to categorizeresearch (classification criteria). In clinical practice, the following criteria apply:• two or more swollen joints• morning stiffness lasting more than one hour for at least six weeks• the detection of rheumatoid factors or autoantibodies against ACPA such as autoantibodies to mutated

citrullinated vimentin can confirm the suspicion of rheumatoid arthritis. A negative autoantibody result does notexclude a diagnosis of RA.

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Differential diagnosesSeveral other medical conditions can resemble RA, and usually need to be distinguished from it at the time ofdiagnosis:[31] [32]

• Crystal induced arthritis (gout, and pseudogout) – usually involves particular joints and can be distinguished withaspiration of joint fluid if in doubt

• Osteoarthritis – distinguished with X-rays of the affected joints and blood tests• Systemic lupus erythematosus (SLE) – distinguished by specific clinical symptoms and blood tests (antibodies

against double-stranded DNA)• One of the several types of psoriatic arthritis resembles RA – nail changes and skin symptoms distinguish

between them• Lyme disease causes erosive arthritis and may closely resemble RA – it may be distinguished by blood test in

endemic areas• Reactive arthritis (previously Reiter's disease) – asymmetrically involves heel, sacroiliac joints, and large joints of

the leg. It is usually associated with urethritis, conjunctivitis, iritis, painless buccal ulcers, and keratodermablennorrhagica.

• Ankylosing spondylitis – this involves the spine and is usually diagnosed in males, although a RA-likesymmetrical small-joint polyarthritis may occur in the context of this condition.

• Hepatitis C – RA-like symmetrical small-joint polyarthritis may occur in the context of this condition. Hepatitis Cmay also induce Rheumatoid Factor auto-antibodies

Rarer causes that usually behave differently but may cause joint pains:[31]

• Sarcoidosis, amyloidosis, and Whipple's disease can also resemble RA.• Hemochromatosis may cause hand joint arthritis.• Acute rheumatic fever can be differentiated from RA by a migratory pattern of joint involvement and evidence of

antecedent streptococcal infection. Bacterial arthritis (such as streptococcus) is usually asymmetric, while RAusually involves both sides of the body symmetrically.

• Gonococcal arthritis (another bacterial arthritis) is also initially migratory and can involve tendons around thewrists and ankles.

Pathophysiology and causesRheumatoid arthritis is a form of autoimmunity, the causes of which are still incompletely known. It is a systemic(whole body) disorder principally affecting synovial tissues.The key pieces of evidence relating to pathogenesis are:1. A genetic link with HLA-DR4 and related allotypes of MHC Class II and the T cell-associated protein PTPN22.2. A link with cigarette smoking that appears to be causal.3. A remarkable deceleration of disease progression in many cases by blockade of the cytokine TNF (alpha).4. A similar dramatic response in many cases to depletion of B lymphocytes, but no comparable response todepletion of T lymphocytes.5. A more or less random pattern of whether and when predisposed individuals are affected.6. The presence of autoantibodies to IgGFc, known as rheumatoid factors (RF), and antibodies to citrullinatedpeptides (ACPA).These data suggest that the disease involves abnormal B cell–T cell interaction, with presentation of antigens by B cells to T cells via HLA-DR eliciting T cell help and consequent production of RF and ACPA. Inflammation is then driven either by B cell or T cell products stimulating release of TNF and other cytokines. The process may be facilitated by an effect of smoking on citrullination but the stochastic (random) epidemiology suggests that the rate

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limiting step in genesis of disease in predisposed individuals may be an inherent stochastic process within theimmune response such as immunoglobulin or T cell receptor gene recombination and mutation. (See entry underautoimmunity for general mechanisms.)If TNF release is stimulated by B cell products in the form of RF or ACPA -containing immune complexes, throughactivation of immunoglobulin Fc receptors, then RA can be seen as a form of Type III hypersensitivity.[33] [34] IfTNF release is stimulated by T cell products such as interleukin-17 it might be considered closer to type IVhypersensitivity although this terminology may be getting somewhat dated and unhelpful.[35] The debate on therelative roles of immune complexes and T cell products in inflammation in RA has continued for 30 years. There islittle doubt that both B and T cells are essential to the disease. However, there is good evidence for neither cell beingnecessary at the site of inflammation. This tends to favour immune complexes (based on antibody synthesisedelsewhere) as the initiators, even if not the sole perpetuators of inflammation. Moreover, work by Thurlings andothers in Paul-Peter Tak's group and also by Arthur Kavanagh's group suggest that if any immune cells are relevantlocally they are the plasma cells, which derive from B cells and produce in bulk the antibodies selected at the B cellstage.Although TNF appears to be the dominant, other cytokines (chemical mediators) are likely to be involved ininflammation in RA. Blockade of TNF does not benefit all patients or all tissues (lung disease and nodules may getworse). Blockade of IL-1, IL-15 and IL-6 also have beneficial effects and IL-17 may be important. Constitutionalsymptoms such as fever, malaise, loss of appetite and weight loss are also caused by cytokines released in to theblood stream.As with most autoimmune diseases, it is important to distinguish between the cause(s) that trigger the process, andthose that may permit it to persist and progress.

Possible infectious triggersIt has long been suspected that certain infections could be triggers for this disease. The "mistaken identity" theorysuggests that an infection triggers an immune response, leaving behind antibodies that should be specific to thatorganism. The antibodies are not sufficiently specific, though, and set off an immune attack against part of the host.Because the normal host molecule "looks like" a molecule on the offending organism that triggered the initialimmune reaction—this phenomenon is called molecular mimicry. Some infectious organisms suspected of triggeringrheumatoid arthritis include Mycoplasma, Erysipelothrix, parvovirus B19 and rubella, but these associations havenever been supported in epidemiological studies. Nor has convincing evidence been presented for other types oftriggers such as food allergies.Epidemiological studies have confirmed a potential association between RA and two herpesvirus infections:Epstein-Barr virus (EBV) and Human Herpes Virus 6 (HHV-6).[36] Individuals with RA are more likely to exhibit anabnormal immune response to the Epstein-Barr virus.[37] [38] The allele HLA-DRB1*0404 is associated with lowfrequencies of T cells specific for the EBV glycoprotein 110 and predisposes one to develop RA.[39]

Psychological factorsThere is no evidence that physical and emotional effects or stress could be a trigger for the disease. The manynegative findings suggest that either the trigger varies, or that it might in fact be a chance event inherent with theimmune response, as suggested by Edwards et al.[40]

Continued abnormal immune responseThe factors that allow an abnormal immune response, once initiated, to become permanent and chronic, are becoming more clearly understood. The genetic association with HLA-DR4, as well as the newly discovered associations with the gene PTPN22 and with two additional genes[41] , all implicate altered thresholds in regulation of the adaptive immune response. It has also become clear from recent studies that these genetic factors may interact

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with the most clearly defined environmental risk factor for rheumatoid arthritis, namely cigarette smoking[42] [43]

Other environmental factors also appear to modulate the risk of acquiring RA, and hormonal factors in the individualmay explain some features of the disease, such as the higher occurrence in women, the not-infrequent onset afterchild-birth, and the (slight) modulation of disease risk by hormonal medications. Exactly how altered regulatorythresholds allow the triggering of a specific autoimmune response remains uncertain. However, one possibility is thatnegative feedback mechanisms that normally maintain tolerance of self are overtaken by aberrant positive feedbackmechanisms for certain antigens such as IgG Fc (bound by RF) and citrullinated fibrinogen (bound by ACPA) (seeentry on autoimmunity).Once the abnormal immune response has become established (which may take several years before any symptomsoccur), plasma cells derived from B lymphocytes produce rheumatoid factors and ACPA of the IgG and IgM classesin large quantities. These are not deposited in the way that they are in systemic lupus. Rather, they appear to activatemacrophages through Fc receptor and perhaps complement binding. This can contribute to inflammation of thesynovium, in terms of edema, vasodilation and infiltration by activated T-cells (mainly CD4 in nodular aggregatesand CD8 in diffuse infiltrates). Synovial macrophages and dendritic cells further function as antigen presenting cellsby expressing MHC class II molecules, leading to an established local immune reaction in the tissue. The diseaseprogresses in concert with formation of granulation tissue at the edges of the synovial lining (pannus) with extensiveangiogenesis and production of enzymes that cause tissue damage. Modern pharmacological treatments of RA targetthese mediators. Once the inflammatory reaction is established, the synovium thickens, the cartilage and theunderlying bone begins to disintegrate and evidence of joint destruction accrues.

TreatmentThere is no known cure for rheumatoid arthritis, but many different types of treatment can alleviate symptoms and/ormodify the disease process. Recommendations of the American College of Rheumatology (ACR), published in 2008,followed a trend in supporting earlier, more aggressive treatment of RA, and reflected heightened expectations oftreatment effectiveness, including remission or substantial alleviation of symptoms for a rising percentage ofpatients.[44]

The goal of treatment is twofold: alleviating the current symptoms, and preventing the future destruction of the jointswith the resulting handicap if the disease is left unchecked. These two goals may not always coincide: while painrelievers may achieve the first goal, they do not have any impact on the long-term consequences. For these reasons,the ACR recommends that RA should generally be treated with at least one specific anti-rheumatic medication, alsonamed DMARD (see below), to which other medications may be added depending on how long a person has hadRA, how active the disease is, and prognostic factors (such as X-ray evidence of bone erosion; elevation of bloodfactors such as Rheumatoid factor, anti-cyclic citrullinated peptide, C-reactive protein, and erythrocyte sedimentationrate; age and gender; physical functioning; and smoking, for example).[44]

Cortisone therapy has offered relief in the past, but its long-term effects have been deemed undesirable.[45] However,cortisone injections can be valuable adjuncts to a long-term treatment plan, and using low dosages of daily cortisone(e.g., prednisone or prednisolone, 5–7.5 mg daily) can also have an important benefit if added to a proper specificanti-rheumatic treatment.Pharmacological treatment of RA can be divided into disease-modifying antirheumatic drugs (DMARDs),anti-inflammatory agents and analgesics.[46] [47] Treatment also includes rest and physical activity.

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Disease modifying anti-rheumatic drugs (DMARDs)The term Disease modifying anti-rheumatic drug (DMARD) originally meant a drug that affects biological measuressuch as ESR and haemoglobin and autoantibody levels, but is now usually used to mean a drug that reduces the rateof damage to bone and cartilage. DMARDs have been found both to produce durable symptomatic remissions and todelay or halt progression. This is important as such damage is usually irreversible. Anti-inflammatories andanalgesics improve pain and stiffness but do not prevent joint damage or slow the disease progression.There is an increasing recognition among rheumatologists that permanent damage to the joints occurs at a very earlystage in the disease. In the past it was common to start with just an anti-inflammatory drug, and assess progressionclinically and using X-rays. If there was evidence that joint damage was starting to occur then a more potentDMARD would be prescribed. Ultrasound and MRI are more sensitive methods of imaging the joints and havedemonstrated that joint damage occurs much earlier and in more sufferers than was previously thought. People withnormal X-rays will often have erosions detectable by ultrasound that X ray could not demonstrate. The aim now is totreat before damage occurs.There may be other reasons why starting DMARDs early is beneficial as well as prevention of structural jointdamage. From the earliest stages of the disease, the joints are infiltrated by cells of the immune system that signal toone another in ways that may involve a variety of positive feedback loops (it has long been observed that a singlecorticosteroid injection may abort synovitis in a particular joint for long periods). Interrupting this process as early aspossible with an effective DMARD (such as methotrexate) appears to improve the outcome from the RA for yearsafterwards. Delaying therapy for as little as a few months after the onset of symptoms can result in worse outcomesin the long term. There is therefore considerable interest in establishing the most effective therapy with earlyarthritis, when they are most responsive to therapy and have the most to gain.[48]

Disease modifying anti-rheumatic drugs have been used in the treatment of rheumatic arthritis for a long time now.Over 90% of rheumatologists now use combination therapy of multiple disease modifying drugs for rheumatoidarthritis as it has become apparent that using combination of these drugs does not increase their relative toxicityprofiles.[49] Common combinations of DMARDs include methotrexate – hydroxychloroquine, methotrexate –sulfasalazine, sulfasalazine – hydroxychloroquine, and methotrexate – hydroxychloroquine – sulfasalazine.In order to be effective, disease modifying anti-rheumatic drugs must be administered before the deformities appearor the erosive disease occurs. Usually, Rheumatologists do not wait for the fulfillment of the criteria forclassification of RA as published by the American College of Rheumatology (ACR) and start treatment with thistype of drugs if the pain and synovitis persist and the function is compromised.[50]

Traditional small molecular mass drugs

Chemically synthesised DMARDs:• azathioprine• ciclosporin (cyclosporine A)• D-penicillamine• gold salts• hydroxychloroquine• leflunomide• methotrexate (MTX)• minocycline• sulfasalazine (SSZ)Cytotoxic drugs:• Cyclophosphamide

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The most important and most common adverse events relate to liver and bone marrow toxicity (MTX, SSZ,leflunomide, azathioprine, gold compounds, D-penicillamine), renal toxicity (cyclosporine A, parenteral gold salts,D-penicillamine), pneumonitis (MTX), allergic skin reactions (gold compounds, SSZ), autoimmunity(D-penicillamine, SSZ, minocycline) and infections (azathioprine, cyclosporine A).Hydroxychloroquine may cause ocular toxicity, although this is rare, and because hydroxychloroquine does notaffect the bone marrow or liver it is often considered to be the DMARD with the least toxicity. Unfortunatelyhydroxychloroquine is not very potent, and is usually insufficient to control symptoms on its own.Methotrexate is considered by many rheumatologists to be the most important and useful DMARD, largely becauseof lower drop-out rates for reasons of toxicity. Nevertheless, methotrexate is often considered as a very 'toxic' drug.This reputation is not entirely justified, and at times can result in people being denied the most effective treatmentfor their arthritis. Although methotrexate does have the potential to suppress bone marrow or cause hepatitis, theseeffects can be monitored using regular blood tests, and the drug withdrawn at an early stage if the tests are abnormalbefore any serious harm is done (typically the blood tests return to normal after stopping the drug). In clinical trials,where one of a range of different DMARDs were used, people who were prescribed methotrexate stayed on theirmedication the longest (the others stopped because of either side-effects or failure of the drug to control the arthritis).Methotrexate is often preferred by rheumatologists because if it does not control arthritis on its own then it workswell in combination with many other drugs, especially the biological agents. Other DMARDs may not be as effectiveor as safe in combination with biological agents.Sulphasalazine : Although it appears to be a highly efficient drug in the treatment of rheumatoid arthritis,sulphasalazine may cause side effects that can range in severity from mild to serious. Mild side effects that may arisefrom treatment with sulphasalazine include nausea and skin rash. Generally, nausea that appears as a result oftreatment with this DMARD occurs in the first days of treatment and then it tends to diminish to disappearance. Toavoid nausea, specialists recommend starting with low doses and then gradually increasing them until the usualdosage is achieved. Skin rash has been reported in nearly 5% of the patients and it may present pruritus. Rare sideeffects include Stevens–Johnson syndrome and reduced fertility due to reversible oligospermia. Severe side effectsthat can appear from therapy with sulphasalazine, though rare, are aplastic anemia and neutropenia which may resultin the death of the patient. The latter is estimated to have occurred in approximately 2% of the patients but death andfurther complications were avoided by removing the drug from the patient's therapy. Also, according to WHO, therehave been approximately 700 of patients in whom this medicine caused blood dyscrasis. Leukopenia has also beenreported in therapies with sulphasalazine, but in very rare cases.Anti-malarials such as chloroquine and hydroxychloroquine have been used to treat rheumatoid arthritis. It has beenpointed out, through clinical studies, that chloroquine has a higher toxicity compared to hydroxychloroquine.Although hydroxyxhloroquine appears to be more efficient in treating rheumatoid arthritis than placebo, it is alsoinferior to sulphasalazine, especially in what concerns preventing the joint damage that is caused by the disease. Asmost drugs, anti-malarials may also produce side effects. Mild side effects from hydroxychloroquine include nauseaand skin rash. More serious, bone marrow suppression may occur, though rare. Also, aplastic anemia andagranulocytosis can develop as a result of anti-malarial therapy and may potentially cause the death of the patient. Amuch more worrisome side effect from treatment with anti-malarials is the damage that these drugs seem to becausing to the cornea and retina. Recent studies have however shown that if the dosage of hydroxychloroquine givento the patients does not exceed 6.5 mg/kg, the risks of developing ocular complications are minimal.[51]

Gold compounds are also options in treating this type of disease. Specialists agree that injectable gold is much more effective in the treatment of rheumatoid arthritis than auranofin. Yet, this type of drug has been shown to be more efficient than placebo and even though its level of toxicity is quite low, auranofin seems to be causing more side effects than any other type of DMARD. Auranofin is therefore not considered efficient in the treatment of rheumatoid arthritis because of its poor results and because it is intolerable for most patients. Sodium aurothiomalate (Myocrisin) on the other hand is another type of gold compound that is injected and which appears to be as efficient

Rheumatoid arthritis 12

as sulphasalazine, d-penicillamine and methotrexate. Given that there is not enough proof that gold compounds areindeed efficient in preventing the progression of erosions and the high toxicity of these drugs, they are usually notincluded in the treatment plan for rheumatoid arthritis.A Cochrane systematic review has determined that Abatacept was an effective treatment for rheumatoid arthritis.Against placebo, it was found to increase mobility and make patients twice as likely to achieve a 50% improvementin symptoms.[52] However Cochrane has called for more studies to be conducted, given the lack of evidence todistinguish between the biologics available for rheumatoid arthritis.[53]

Biological agents

Biological agents (biologics) include:• tumor necrosis factor alpha (TNFα) blockers[54] [55] [56] – etanercept (Enbrel), infliximab (Remicade),

adalimumab (Humira), certolizumab pegol (Cimzia), golimumab (Simponi)• Interleukin 1 (IL-1) blockers – anakinra (Kineret)• monoclonal antibodies against B cells – rituximab (Rituxan)[57]

• T cell costimulation blocker – abatacept (Orencia)• Interleukin 6 (IL-6) blockers – tocilizumab (an anti-IL-6 receptor antibody) (RoActemra, Actemra)

Anti-inflammatory agents and analgesicsAnti-inflammatory agents include:• glucocorticoids• Non-steroidal anti-inflammatory drug (NSAIDs, most also act as analgesics)Analgesics include:• paracetamol (acetaminophen in US and Canada)• opiates• diproqualone• lidocaine topicalHistoric treatments for RA have also included: rest, ice, compression and elevation, acupuncture, apple diet, nutmeg,some light exercise every now and then, nettles, bee venom, copper bracelets, rhubarb diet, extractions of teeth,fasting, honey, vitamins, insulin, magnets, and electroconvulsive therapy (ECT).[58] Most of these have either had noeffect at all, or their effects have been modest and transient, while not being generalizable.NSAIDs used in the treatment of RA include ibuprofen, naproxen, meloxicam, etodolac, nabumetone, sulindac,tolementin, choline magnesium salicylate, diclofenac, diflusinal, indomethicin, Ketoprofen, Oxaprozin, andpiroxicam.Cortisone therapy became a controversial medical solution because even though it can provide great relief, there aresome questions as to the usefulness of the procedure over a long period of time.[59]

Other therapiesOther therapies are weight loss, orthoses, occupational therapy, podiatry, physiotherapy, immunoadsorption therapy,joint injections, and special tools to improve hand movements (e.g. special tin-openers). Regular exercise isimportant for maintaining joint mobility and making the joint muscles stronger. A Cochrane Review of studiesdetermined that exercise programs designed to improve strength and stamina were safe and led to moderate benefitsfor RA sufferers.[60]

Ayurveda, mostly in southern India, is another source of treatment, and while it is popular in India there are nostudies to show that it benefits patients with RA.

Rheumatoid arthritis 13

A survey in the United Kingdom between 1998 and 2002 found that arthritis, in its various forms, was among thefive most common reasons for the medicinal use of cannabis.[61]

The Prosorba column blood filtering device (removing IgG) was approved by the FDA in 1999 for treatment ofRA[62] However it was discontinued at the end of 2006.[63]

The effectiveness of treating RA with acupuncture is inconclusive, and "more rigorous research seems to bewarranted" according to one study.[64]

One study of 873 patients with RA found that those who drank some alcohol (none drank more than 10 units ofalcohol a week) had reduced severity of symptoms compared to those who drank no alcohol.[65] [66] However aspokeswoman for the Arthritis Research UK (who co-funded the study) warned that some RA treatments, likemethotrexate, could damage the liver when taken with large amounts of alcohol.[66]

Severely affected joints may require joint replacement surgery, such as knee replacement.

PrognosisThe course of the disease varies greatly. Some people have mild short-term symptoms, but in most the disease isprogressive for life. Around 20%-30% will have subcutaneous nodules (known as rheumatoid nodules); this isassociated with a poor prognosis.

Disability• Daily living activities are impaired in most individuals.• After 5 years of disease, approximately 33% of sufferers will not be working.• After 10 years, approximately half will have substantial functional disability.

Prognostic factorsPoor prognostic factors include persistent synovitis, early erosive disease, extra-articular findings (includingsubcutaneous rheumatoid nodules), positive serum RF findings, positive serum anti-CCP autoantibodies, carriershipof HLA-DR4 "Shared Epitope" alleles, family history of RA, poor functional status, socioeconomic factors, elevatedacute phase response (erythrocyte sedimentation rate [ESR], C-reactive protein [CRP]), and increased clinicalseverity.

MortalityEstimates of the life-shortening effect of RA vary; most sources cite a lifespan reduction of 5 to 10 years. Accordingto the UK's National Rheumatoid Arthritis Society, "Young age at onset, long disease duration, the concurrentpresence of other health problems (called co-morbidity), and characteristics of severe RA—such as poor functionalability or overall health status, a lot of joint damage on x-rays, the need for hospitalisation or involvement of organsother than the joints—have been shown to associate with higher mortality".[67] Positive responses to treatment mayindicate a better prognosis. A 2005 study by the Mayo Clinic noted that RA sufferers suffer a doubled risk of heartdisease,[68] independent of other risk factors such as diabetes, alcohol abuse, and elevated cholesterol, blood pressureand body mass index. The mechanism by which RA causes this increased risk remains unknown; the presence ofchronic inflammation has been proposed as a contributing factor.[69]

Rheumatoid arthritis 14

Epidemiology

Disability-adjusted life year for rheumatoid arthritis per 100,000 inhabitants in 2004."WHO Disease and injury country estimates". World Health Organization. 2009. .

Retrieved Nov. 11, 2009.  no data  less than40  40-50  50-60  60-70  70-80  80-90  90-100  100-110  110-120  120-130  130-140  more

than 140

The incidence of RA is in the regionof 3 cases per 10,000 population perannum. Onset is uncommon under theage of 15 and from then on theincidence rises with age until the ageof 80. The prevalence rate is 1%, withwomen affected three to five times asoften as men. It is 4 times morecommon in smokers thannon-smokers. A study in 2010 foundthat those who drank modest amountsof alcohol regularly were four times less likely to get rheumatoid arthritis than those who never drank.[65] [71] SomeNative American groups have higher prevalence rates (5-6%) and people from the Caribbean region have lowerprevalence rates. First-degree relatives prevalence rate is 2-3% and disease genetic concordance in monozygotictwins is approximately 15-20%.

It is strongly associated with the inherited tissue type Major histocompatibility complex (MHC) antigen HLA-DR4(most specifically DR0401 and 0404)—hence family history is an important risk factor.

Rheumatoid arthritis affects women three times more often than men, and it can first develop at any age. The risk offirst developing the disease (the disease incidence) appears to be greatest for women between 40 and 50 years of age,and for men somewhat later.[72] RA is a chronic disease, and although rarely, a spontaneous remission may occur,the natural course is almost invariably one of persistent symptoms, waxing and waning in intensity, and aprogressive deterioration of joint structures leading to deformations and disability.

HistoryThe first known traces of arthritis date back at least as far as 4500 BC. A text dated 123 AD first describes symptomsvery similar to rheumatoid arthritis. It was noted in skeletal remains of Native Americans found in Tennessee.[73] Inthe Old World the disease is vanishingly rare before the 1600s.[74] and on this basis investigators believe it spreadacross the Atlantic during the Age of Exploration. In 1859 the disease acquired its current name.An anomaly has been noticed from investigation of Precolumbian bones. The bones from the Tennessee site show nosigns of tuberculosis even though it was prevalent at the time throughout the Americas.[75] Jim Mobley, at Pfizer, hasdiscovered a historical pattern of epidemics of tuberculosis followed by a surge in the number of rheumatoid arthritiscases a few generations later.[76] Mobley attributes the spikes in arthritis to selective pressure caused by tuberculosis.A hypervigilant immune system is protective against tuberculosis at the cost of an increased risk of autoimmunedisease.The art of Peter Paul Rubens may possibly depict the effects of rheumatoid arthritis. In his later paintings, hisrendered hands show, in the opinion of some physicians, increasing deformity consistent with the symptoms of thedisease.[77] [78] Rheumatoid arthritis appears to some to have been depicted in 16th century paintings.[79] However, itis generally recognised in art historical circles that the painting of hands in the sixteenth and seventeenth centuryfollowed certain stylised conventions, most clearly seen in the Mannerist movement. It was conventional, forinstance to show the upheld right hand of Christ in what now appears a deformed posture. These conventions areeasily misinterpreted as portrayals of disease. They are much too widespread for this to be plausible.The first recognized description of rheumatoid arthritis was in 1800 by the French physician Dr Augustin JacobLandré-Beauvais (1772–1840) who was based in the famed Salpêtrière Hospital in Paris.[15] The name "rheumatoidarthritis" itself was coined in 1859 by British rheumatologist Dr Alfred Baring Garrod.[80]

Rheumatoid arthritis 15

Notable cases• Dorothy Hodgkin, Nobel prize winning scientist, developed severe deforming rheumatoid arthritis at age 28. In

spite of this she continued her career and developed X-ray crystallography, which underpins much of theinformation known about rheumatoid arthritis. She also discovered the structure of insulin and enabled thediscovery of the genetic code.

• Auguste Renoir, impressionist painter, whose later 'softer' style might have reflected in some way his severedisability.

• Christiaan Barnard, the first surgeon to perform a human-to-human heart transplant had to retire owing to thecondition. He also wrote a book on living with arthritis.

• James Coburn claimed to have healed the condition using pills containing a sulfur-containing compound on hisreturn to acting.

• Erik Lindbergh, aviator and member of the X-Prize administration. Erik has been a spokesman for the arthritisdrug Enbrel, as a result of his success with the treatment.[81]

• Bob Mortimer British comedian and actor.[82]

• Kathleen Turner and Aida Turturro have worked to raise public awareness of the condition[83]

• Billy Bowden, international cricket umpire who had to retire from active play because of rheumatoid arhtirits.• Melvin Franklin, bass singer of the Temptations. He treated RA with cortisone shots so he could perform.• Jamie Farr, American actor, famous for his role as Max Klinger on the 1970s television series M*A*S*H.• Sandy Koufax, An American Hall-of-Fame baseball pitcher who played from 1955 to 1966 for the Los Angeles

Dodgers.

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External links• "National Rheumatoid Arthritis Society (NRAS)" (http:/ / www. rheumatoid. org. uk/ ). NRAS - National

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College of Rheumatology Research and Education Foundation.• Rheumatoid arthritis (http:/ / www. dmoz. org/ Health/ Conditions_and_Diseases/ Musculoskeletal_Disorders/

Arthritis/ Rheumatoid/ ) at the Open Directory Project• "Rheumatoid Arthritis" (http:/ / www. arthritis. org/ conditions/ DiseaseCenter/ RA/ default. asp). Arthritis

Foundation.• "Rheumatoid Arthritis" (http:/ / www. arc. org. uk/ arthinfo/ patpubs/ 6033/ 6033. asp). Arthritis Research

Campaign.• Charles Weber. "History of rheumatoid arthritis" (http:/ / charles_w. tripod. com/ arthritis2. html).• "Rheumatoid Arthritis Details" (http:/ / nihseniorhealth. gov/ rheumatoidarthritis/ toc. html). NIH Senior Health.• "National Institute of Arthritis and Musculoskeletal and Skin Diseases" (http:/ / www. niams. nih. gov/ ). National

Institute of Arthritis and Musculoskeletal and Skin Diseases.• "Rheumatoid Arthritis Condition Overview" (http:/ / www. thirdage. com/ hc/ c/ rheumatoid-arthritis). EBSCO

Publishing.• "Arthritis Related Statistics" (http:/ / www. cdc. gov/ arthritis/ data_statistics/ arthritis_related_stats. htm). Centers

for Disease Control and Prevention (CDC).• "Rheumatoid Arthritis" (http:/ / www. nlm. nih. gov/ medlineplus/ rheumatoidarthritis. html). MedlinePlus.• Rheumatoid Arthritis Australia (http:/ / www. rheumatoid-arthritis. com. au/ )

Article Sources and Contributors 19

Article Sources and ContributorsRheumatoid arthritis  Source: http://en.wikipedia.org/w/index.php?oldid=406494241  Contributors: 21655, 2over0, Acdx, Achitnis, Adi4094, Ageekgal, Aheaphy, Ahoerstemeier, AlanWolfe,Alex.tan, Alex43223, Aliveandwell, Allmightyduck, Amalthea, Amja, Animum, Arcadian, Arthritis info, ArthritisCritic, Athanos, AubreyEllenShomo, Auntof6, Axl, Axxaer, B, BBerryhill,BService, Barbara Shack, Barek, Beetstra, Bemoeial, Benbest, Bennybp, Bensnowden, Bhzmr, BinaryTed, Bisqwit, BlackDice572, Borgx, Brendan19, Briancollins, Brokenchairs, CABoge,CERminator, CHebbes, Casadelqueso, Cayte, Cburnett, Celiakozlowski, Cessator, Chamal N, Ched Davis, Chhajjusandeep, Chipmunkk, Chrisscot, CiaranG, Classic, Claus Diff, ClockworkSoul,Closedmouth, Clovis Sangrail, Coffeeholic!, Connor Behan, Contentmaven, Conversion script, Coolhandscot, Coopermd, Corvus cornix, Cyclonenim, DPG1993, DW729, Dadude3320, DaigojiGai, Darthgriz98, David Justin, DavidMendoza, Davidahearn, Davidruben, DeadEyeArrow, Debresser, Deli nk, Dgmaybury, Diberri, Doctor250, Dominicanpapi82, DoubleBlue, Dr. V. W. JagathVasanthathilaka, Dr.ahmad 87, Draeco, DuncanHill, Dwight666, Edobrzen, Ehn, Eikuch, Electrosaurus, Elfbabe, Eliz81, Emesola, Emma1303, Encephalon, Endofskull, Eneuron, Engliss,Eugeneltc, Excirial, FQ1513, Fethers, Filip em, FisherQueen, Flewis, Florescent, Fratrep, Funandtrvl, Fuzbaby, Fvasconcellos, Fæ, Gabbe, Gak, Giftlite, Gimboid13, Gordon711, GraemeL,Guanaco, Gurps npc, Gwernol, Hannabee, Hathawayc, HiDrNick, Hipocrite, Hippo99, Hotflavas300, Hsurya, Hu12, Hyacinth, Iain southern, Illuminatedwax, Immunize, Instance, Instinct,Integrativewellness, Ioeth, Iridescent, Isoptera, Ixixixi, JTN, Jebus989, Jenday, Jeremy68, Jevansen, Jfdwolff, Jfmarchini, Jgervais118, Jmh649, JohnElder, Jonathon Bolster, Jpkoester1, Jw1969,Jwollbold, KBlott, KathrynLybarger, Keakealani, Ketiltrout, Kevin Forsyth, Knowledge Seeker, Knutsi, Krashlandon, Krich, Ktanmay, Lady Cairns, Langrl2, Ldnlighthouse, Leekembel,Leevanjackson, Leolaursen, Linalouis56, Llort, Lrunge, Luk, Lukobe, Lupo, M dorothy, MER-C, Madmaxx, Maralia, Martin Hinks, Massagenj, MattDredd, Mav, Maximilli, Maynard17x1,Mccready, Medic2008, Mehrenberg, Michal Nebyla, Mikael Häggström, Mike Dill, Mike Rosoft, Mikevilkin, Mkurnali, Mmoneypenny, Momnchief, Mothball666, Mrweewee, Mwanner, MyCore Competency is Competency, Myanw, N5iln, NCurse, Nahado, Nappj, Nbauman, NeilN, Neiljpatel, Nhyty, Nicolaennio, Nihiltres, Nishanthb, Nmg20, Nono64, Nonpareility, Novickas,Nposs, Nsd, Nunquam Dormio, Obwilliams, Omega007, Osm agha, OverlordQ, OwenX, Oxymoron83, Pajast, Parkwells, Paysseh, Pbsloep, Pencil121321, PeteThePill, Pgk, Phgao, PhilipTrueman, Piano non troppo, PierreAbbat, Pigman, Pinethicket, Pocopocopocopoco, Pol098, Poor Yorick, Porqin, Private Pressery, Pspekoc61, Puldis, RC93, Ragityman, Rajah, Ratel,Rebelyell1916, Reinoutr, Reyk, Rich Farmbrough, Richieang, Rjwilmsi, Rklawton, Rmky87, Robneild, Rod57, RonaldFrits, Rowan Savage, SHCarter, Salgueiro, Salvor, SandyGeorgia, Sbmehta,ScAvenger, Scottj2250, Scray, Seans Potato Business, Search4Lancer, Selfhelp, Semperf, Sepeople, Shirik, Shoeofdeath, Sickboyra, SimonT12, Skagedal, Sliggy, Smartse, Smoe, So God createdManchester, Squirepants101, StaticGull, Steveblevins, Stevenechard, Stevenfruitsmaak, Stretchcat, Stwalkerster, Superperro, SylviaStanley, TamePhysician, Tarek, Technopete, Tedernst, Terjen,The Man in Question, The Thing That Should Not Be, The undertow, The*rising*tide, Therearentanynamesleft, Thingg, Tnxman307, Tobias Hoevekamp, Tommy2010, Tommy47, Tomstateler,Tonotdrink, Tower, Tracylau1223, Ultra megatron, Uncle Dick, Unitseven, Utcursch, Vashti, Vcelloho, Victor cure arth, Vintagedirtbiker, Vogon77, WLU, Wiki.saeid, Wikipedia brown,Wikipeterproject, Winston365, Wiz9999, Wortol, Wouterstomp, Wtmitchell, Z0OMD, ZooFari, Åkebråke, Δ, 647 anonymous edits

Image Sources, Licenses and ContributorsFile:Rheumatoid_Arthritis.JPG  Source: http://en.wikipedia.org/w/index.php?title=File:Rheumatoid_Arthritis.JPG  License: Creative Commons Attribution-Sharealike 3.0  Contributors:User:Jmh649File:Rheumatoid arthritis joint.gif  Source: http://en.wikipedia.org/w/index.php?title=File:Rheumatoid_arthritis_joint.gif  License: unknown  Contributors: Original uploader was Wouterstompat en.wikipediaImage:RheumatoideArthritisAP.jpg  Source: http://en.wikipedia.org/w/index.php?title=File:RheumatoideArthritisAP.jpg  License: Creative Commons Attribution 3.0  Contributors:User:BraegelImage:Inflamatory arthritis2010.JPG  Source: http://en.wikipedia.org/w/index.php?title=File:Inflamatory_arthritis2010.JPG  License: Creative Commons Attribution-Sharealike 3.0 Contributors: User:Jmh649Image:Rheumatoid arthritis ultrasound MRI MCP joint ar1904-2.gif  Source: http://en.wikipedia.org/w/index.php?title=File:Rheumatoid_arthritis_ultrasound_MRI_MCP_joint_ar1904-2.gif License: Creative Commons Attribution 2.0  Contributors: Marcin Szkudlarek, Mette Klarlund, Eva Narvestad, Michel Court-Payen, Charlotte Strandberg, Karl E Jensen, Henrik S Thomsen andMikkel Østergaard.Image:Rheumatoid arthritis world map - DALY - WHO2004.svg  Source: http://en.wikipedia.org/w/index.php?title=File:Rheumatoid_arthritis_world_map_-_DALY_-_WHO2004.svg License: Creative Commons Attribution-Sharealike 2.5  Contributors: User:Lokal_Profil

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