GPAtlas🧭 When to suspect
Rheumatoid arthritis (RA) is a chronic, systemic autoimmune disease affecting around 1% of the UK population, roughly three times more common in women, with a peak onset between 40 and 60 years (though it can present at any age). Suspect RA in any adult with persistent synovitis – soft-tissue swelling, warmth and tenderness of a joint – that does not settle within a few weeks.
The classic pattern is a symmetrical polyarthritis of the small joints of the hands (metacarpophalangeal [MCP] and proximal interphalangeal [PIP]) and feet (metatarsophalangeal [MTP]), with early-morning stiffness lasting more than 30 minutes (often considerably longer) and prominent systemic fatigue.
The single most important task in primary care is early recognition and rapid referral. There is a narrow “window of opportunity” in which disease-modifying therapy can prevent irreversible joint destruction, so referral is made on clinical grounds and must never be delayed while awaiting blood tests or X-rays – these are frequently normal in early disease. Smoking is the strongest modifiable risk factor.
| Feature | Inflammatory (RA) | Degenerative (osteoarthritis) |
|---|---|---|
| Early-morning stiffness | Prolonged, > 30 min (often > 1 hour) | Brief, < 30 min; stiffness after rest |
| Pattern | Symmetrical, polyarticular | Often asymmetrical |
| Joints typically involved | MCP, PIP, wrists, MTP (spares DIPs) | DIPs, first carpometacarpal, knees, hips |
| Effect of activity | Eases with movement | Worsens with use, eases with rest |
| Systemic features | Fatigue, malaise common | Absent |
|
🧠 Clinical pearl In RA the distal interphalangeal (DIP) joints are characteristically spared. Prominent DIP involvement should instead prompt thoughts of osteoarthritis or psoriatic arthritis (look for nail pitting, dactylitis and a personal or family history of psoriasis). Asymmetry, a single hot joint, or a rapid severe attack points elsewhere – gout, pseudogout or septic arthritis. |
Source: NICE NG100 · NICE QS33
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