Untreated RA Natural History — SCE Rheumatology MCQ

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EasyRheumatoid ArthritisUntreated RA Natural HistorySCE Rheumatology

A 55-year-old man has newly diagnosed, persistent active rheumatoid arthritis. He asks about the likely long-term joint outcome if the disease receives no disease-modifying antirheumatic drug therapy. Which outcome is most likely?

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Correct answer: A — Progressive synovitis with erosive damage, deformity and functional loss

The correct answer is A. Persistent active rheumatoid synovitis can cause progressive cartilage loss and marginal bone erosions, followed by irreversible deformity and impaired function. This destructive natural history underpins the UK recommendation to start a conventional DMARD as soon as possible, ideally within 3 months of persistent symptom onset. Rates of progression vary between patients, so a fixed claim that 70–80% develop erosions within exactly 2 years is unnecessarily precise. Intermittent non-destructive disease, stable symptoms and spontaneous sustained remission can occur in selected patients but are not the expected course of persistent active untreated RA. A brief, completely self-limiting arthritis would also be inconsistent with established persistent RA.

Reference: NICE. Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept for rheumatoid arthritis, TA375, section 2: Clinical need and practice, 2016. https://www.nice.org.uk/guidance/ta375/chapter/2-clinical-need-and-practice