Difference between rheumatoid vs osteoarthritis vs gout
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hand radiograph rheumatoid arthritis vs osteoarthritis joint involvement
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"arthritis, rheumatoid" AND "osteoarthritis" AND "gout"
Quick answer
RA, OA and gout differ in what drives them, which joints they hit and what the fluid and X-rays show. This answer comes from my own knowledge. I started a textbook search but did not use it, so nothing below is cited from the library.
Core differences
| Feature | Rheumatoid arthritis (RA) | Osteoarthritis (OA) | Gout |
|---|---|---|---|
| Basic process | Autoimmune, chronic inflammation of the synovium (pannus) | Degenerative: cartilage loss with abnormal bone remodeling and low-grade inflammation | Crystal arthritis: monosodium urate crystals deposit after prolonged hyperuricemia |
| Typical patient | Women more than men (about 3:1), age 30-60 | Over 50, obesity, prior joint injury or overuse | Men, postmenopausal women, and people with obesity, high alcohol or purine intake, diuretics or CKD |
| Onset | Insidious, over weeks to months | Gradual, over years | Abrupt, often at night, peaking in 12-24 hours |
| Joints | Symmetric small joints: MCP, PIP, wrists, MTP. Spares DIP. Can affect the C-spine (atlantoaxial) | Weight-bearing joints (knees, hips), DIP, PIP, first CMC, spine. Spares MCP and wrist | Usually one joint, classically the 1st MTP (podagra), then ankle and knee |
| Pattern | Symmetric polyarthritis, additive | Often asymmetric, use-related | Monoarticular, episodic flares with symptom-free gaps |
| Morning stiffness | More than 1 hour | Under 30 minutes | Not a feature |
| Pain character | Inflammatory: worse with rest, better with activity | Mechanical: worse with activity, better with rest | Severe pain, redness, heat, swelling. The patient cannot tolerate a bedsheet touching the joint |
| Deformity or nodules | Ulnar deviation, swan-neck, boutonnière, rheumatoid nodules | Heberden nodes (DIP), Bouchard nodes (PIP) | Tophi (ear, olecranon, fingers, Achilles) in chronic disease |
| Systemic features | Fatigue, low-grade fever, anemia of chronic disease, interstitial lung disease, pleuritis, vasculitis, Felty syndrome, Sjögren | None | Uric acid kidney stones, urate nephropathy |
Investigations
| RA | OA | Gout | |
|---|---|---|---|
| Blood | Raised ESR and CRP. RF positive in about 70-80%. Anti-CCP is the most specific test | ESR and CRP normal. No autoantibodies | Serum urate usually high, but it can be normal during a flare. Raised WBC, CRP and ESR during an attack |
| Synovial fluid | Inflammatory: WBC 5,000-50,000, mostly neutrophils | Non-inflammatory: WBC under 2,000 | Needle-shaped, negatively birefringent crystals under polarized light. WBC often over 20,000 |
| X-ray | Periarticular osteopenia, uniform joint space narrowing, marginal erosions | Asymmetric joint space narrowing, osteophytes, subchondral sclerosis, subchondral cysts | Punched-out erosions with overhanging edges ("rat bite"). Joint space is preserved until late disease |
| Histology | Synovial hyperplasia, pannus, lymphoplasmacytic infiltrate, germinal centers | Cartilage fibrillation, eburnation, osteophytes | Tophus: urate crystals surrounded by foreign-body giant cells and macrophages |
Management
- RA: Start a DMARD early, usually methotrexate. Add a biologic or targeted synthetic agent (TNF inhibitor, JAK inhibitor and others) if needed. Short courses of steroids and NSAIDs relieve symptoms.
- OA: There is no disease-modifying drug. Use exercise, weight loss, physiotherapy, topical NSAIDs, then oral NSAIDs and intra-articular steroid. Joint replacement is for severe disease.
- Gout, acute flare: NSAIDs, colchicine, or glucocorticoids.
- Gout, long term: Urate-lowering therapy, usually allopurinol (or febuxostat), titrated to a serum urate under 6 mg/dL. Start it with flare prophylaxis, and add lifestyle changes.
Quick memory aids
- RA: Symmetric small joints, spares the DIP, morning stiffness over 1 hour, anti-CCP positive.
- OA: Wear and tear, DIP and weight-bearing joints, osteophytes, normal inflammatory markers.
- Gout: Sudden red hot big toe, needle-shaped negatively birefringent crystals. Pseudogout is the contrast: rhomboid, positively birefringent calcium pyrophosphate crystals.
I did not check recent literature for this answer. For current treatment targets and drug choices, check the latest ACR or EULAR guidelines.
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