Rheumatoid arthritis (RA) is an idiopathic disease characterized by inflammation in synovial tissues of joints, cartilage, and bones (1, 2). RA is thought to be driven by genetic and epigenetic factors, but environmental factors such as cigarette smoke and dust exposure also play crucial roles (3–5). Uncontrolled RA can lead to joint degradation, severe disability, reduced quality of life, comorbidities, and premature death, posing a significant societal burden (6–8). Approximately 70% of RA patients in India suffer from anxiety and depression (9). A cross-sectional, hospital-based study conducted in a tertiary care private multi-specialty hospital in Tamil Nadu revealed that the average annual medical expenditure for treating RA was 44,700 rupees ($543), with a median of 39,210 rupees ($476) (10). The global prevalence of RA varies, with an estimated 0.5 to 1% of adults affected (1, 11). The prevalence is generally higher in industrialized countries, possibly due to environmental risk factors, genetic predispositions, and underreporting in other regions (12). Recent reviews indicate that the prevalence of RA in India ranges from 0.28 to 0.7%, based on only four studies (13). There is a lack of nationwide epidemiological research on RA in India.

The Global Burden of Disease (GBD) database, established by the Global Burden of Disease Study, is a comprehensive repository maintained by the Institute for Health Metrics and Evaluation (IHME). It systematically quantifies and assesses the impact of major diseases, injuries, and health risk factors globally, regionally, and nationally (14, 15). This study leverages GBD 2021 data to analyze the incidence and prevalence of RA in India and estimates the disease burden and trends across different age groups, providing a basis for developing effective RA prevention and control strategies.

This study provides a systematic overview of the burden of RA from 1990 to 2021 across India and its states. The age-standardized prevalence, incidence, and DALY rates of RA are rising across India, with a more pronounced increase from 2019 to 2021, and are predicted to continue rising over the next decade. Female rates are consistently higher and increase with age, varying across different states in India. These findings confirm that RA has become a significant public health concern in India.

Female RA incidence rates are 2.6–2.9 times higher than those in males. This gender difference may stem from multiple factors such as physiological differences, sociocultural influences, and lifestyle factors. Females may be more susceptible to autoimmune diseases due to differences in immune system functioning compared to males (18). Estrogen may play a promoting role in RA pathogenesis, while male hormone testosterone may have a protective effect (19–21). In the socio-cultural context of India, women may face greater barriers to accessing healthcare, such as unequal distribution of medical resources and prioritization of male family members’ health, which could lead to delayed diagnosis and treatment for female RA patients. This may result in higher prevalence and disease burden (22, 23). Indian women may also be more affected by certain lifestyle factors, such as a higher burden of household chores, fewer opportunities for physical activity, and potentially poor nutrition associated with poverty and low education levels (24–27).

In the analysis of the global burden of RA, the same trend was shown, namely, the proportion of women with RA was higher (28). Furthermore, in our results, we found that the prevalence of RA in India peaked at 75–79 years of age, again consistent with the results of the global RA burden, showing a clear age-specific pattern. Interestingly, however, our results show that the incidence is highest in the 65–69 age group, which may indicate that there is some delay in the diagnosis of RA in India, or that early diagnosis and treatment of RA need to be strengthened. In addition, the results of the global analysis show that RA is highly correlated with SDI, which also explains the differences in the prevalence of RA between Indian states. However, in some non-high-income regions, the prevalence of RA is significantly lower than in India, and whether this is related to the level of regional diagnosis and regional living standards needs further discussion and research. As for the change in prevalence, the reason for the increase in prevalence in recent years is also the change in diagnostic criteria. In 2010, the American College of Rheumatology (ACR) and the European League against Rheumatism (EULAR) jointly issued a new classification standard for RA. At the heart of the guidelines is a desire to be able to diagnose and intervene earlier in RA, whereas previous criteria were more inclined to diagnose “confirmed RA.” Therefore, the prevalence may increase (29).

The prevalence of RA varies considerably across different geographical unit in India, with regions like Uttarakhand and Tamil Nadu showing significantly higher prevalence rates compared to states like Goa and Madhya Pradesh. These disparities can be partially attributed to differences in the SDI and environmental factors. Environmental factors such as climate, dietary habits, and levels of pollution exposure in different regions may also influence the incidence of RA (30, 31). For instance, the cold and damp climates in certain areas may exacerbate RA symptoms, while regions with higher levels of industrialization might face increased pollution exposure, contributing to higher RA incidence. In regions with higher SDI, RA may be diagnosed more frequently, which does not necessarily indicate a lighter RA burden in low SDI regions. On the contrary, the actual burden in these areas might be underestimated due to inadequate diagnosis and treatment. It is noteworthy that Kerala, despite having a higher SDI, has the lowest disease burden, largely due to its efficient public health system and high-quality medical services. Kerala’s public health system is widely accessible, with well-developed primary healthcare facilities and a relatively equitable distribution of medical resources (32–34). This is a model worth emulating in regions like Uttarakhand. The economic gap leads to disparities in medical-related services among different regions. For instance, the economy can directly affect the development of hospitals and medical technologies in a region, thereby influencing the diagnosis and active treatment of RA. Moreover, the economy also impacts the educational level of a region. Regions with a higher educational level are more helpful in self-protection and early diagnosis of RA compared to those with a lower educational level (35, 36).

Given the increasing burden of RA in India and the pronounced differences across gender and regions, public health strategies should focus on the following areas: (1). Enhancing Identification and Treatment of RA Among Women: The identification and treatment of RA in women should be a priority, especially in rural and low-SDI regions where healthcare resources are limited. This can be achieved through the enhanced training of healthcare professionals and by raising public awareness about RA (37, 38). (2). Regional Health Planning: Due to the significant variation in RA burden across different regions, health policies need to be more flexible and adapted to the specific circumstances of each state. For instance, regions with a high burden, such as Uttarakhand and Delhi, require more intensive prevention and management strategies (13). (3). Promoting Early Diagnosis and Intervention: Early diagnosis and intervention are crucial in reducing the long-term burden of RA. The government should consider expanding RA screening programs, particularly among high-risk groups such as women and the elderly, and improving patients’ self-management capabilities (13, 39). (4). Research and Data Collection: Although substantial progress has been made, further support is necessary for epidemiological research on RA in India. This research is essential to better understand the specific factors contributing to gender and regional disparities. Increased research efforts will aid in developing more targeted interventions.

Our study still has some limitations, for example, data may be scarce for some states, so differences between different Indian states need to be explained more rigorously. In addition, our research data comes from 1990 to 2021, and our calculation and prediction are all based on this period. For future prediction, more recent data or updated data may be required to calculate more accurately.

This study, based on GBD 2021 data, reveals a growing burden of RA in India from 1990 to 2021, with the trend expected to continue. Notably, the burden is higher among females, and there are considerable regional differences in prevalence. These findings suggest that enhanced early diagnosis and treatment, especially in females and high-burden regions, are critical to reducing the disease’s impact. Efforts should focus on improving healthcare accessibility and providing targeted interventions to reduce the overall burden of RA in India.