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The choice of, and the decision to apply, disease modifying drugs.

Although rheumatoid arthritis (RA) is recognised to be a systemic illness, frequently the only manifestation is an inflammatory polyarthritis in which synovitis causes joint destruction. Extra-articular or systemic features include vasculitis which, when present, may be the cause of potentially serious or fatal manifestations. The aetiology remains unknown, although immunological disturbances are certainly involved in the perpetuation of the disease. The formation of immune complexes within the joint is probably responsible for the release of chemical mediators of inflammation. The natural history of the disease is variable, ranging from a brief episode of polyarthritis which resolves spontaneously, to a rapidly progressive arthritis with widespread systemic features. The evidence for an immunological disturbance arises from: (1) the presence of serum and synovial fluid autoantibodies-rheumatoid factors; (2) the presence of other serum antibodies, for example antinuclear antibodies; (3) the histology of the synovium which includes infiltration with plasma cells and lymphocytes; (4) reduced synovial fluid complement levels in actively inflamed joints; (5) the presence of immune complexes in synovial fluid; (6) reduced serum complement levels in patients with active systemic disease; (7) amyloid deposition.