Rheumatoid Arthritis

Arthritis is a general term that describes inflammation in joints. Inflammation is characterized by redness, warmth, swelling, and pain in the joint.

Rheumatoid arthritis is a type of chronic (ongoing) arthritis that occurs in joints on both sides of the body (such as both hands, wrists, and/or knees). This symmetric multiple joint involvement helps distinguish rheumatoid arthritis from other types of arthritis.

In addition to affecting the joints, rheumatoid arthritis may occasionally affect organs outside of the joints including the skin, eyes, lungs, heart, blood, nerves, or kidneys.

Rheumatoid arthritis is an autoimmune disease, meaning that patient's immune system (the body's infection-fighting system) is over-reacting against itself. The result can generate some or all of the symptoms as described below.

What are the symptoms of rheumatoid arthritis?

• Joint pain
• Joint swelling
• Stiffness - especially in the morning or after sitting for long periods
• Fatigue - best defined as tiredness and excessive sleepiness

How does rheumatoid arthritis affect people?

Rheumatoid arthritis affects each individual differently. In most people, joint symptoms may develop gradually over several years. In other people, rheumatoid arthritis may progress rapidly. A few people may have rheumatoid arthritis for a limited period of time and then enter a remission (a time with no symptoms).

Who is affected by rheumatoid arthritis?

Rheumatoid arthritis affects a large number of people. It is 2.5 times more common in women than men. It usually occurs between the ages of 20 to 50; however, young children and the elderly can also develop rheumatoid arthritis.

What causes rheumatoid arthritis?

The exact cause of rheumatoid arthritis is unknown. However, it is believed to be caused by a combination of genetic factors, abnormal immunity, environmental factors, and hormonal factors.

Normally, the immune system protects the body from disease. In rheumatoid arthritis, something triggers the immune system to attack the joints and sometimes other organs. Suspected triggering factors for rheumatoid arthritis are infections, cigarette smoking and stress physical or emotional. Gender, heredity, and genes largely determine a person's risk of developing rheumatoid arthritis. For example, women are about three times more likely than men to develop rheumatoid arthritis.

What happens when joint inflammation is not treated?

Ultimately, uncontrolled inflammation leads to joint deformities due to destruction and wearing down of the cartilage which normally acts as a shock absorber in between joints. Eventually, the bone itself erodes potentially leading to fusion of the joint which represents an effort of the body to protect itself from constant irritation from excessive inflammation. This process is mediated by specific cells and substances of the immune system which are produced locally in the joints but also circulate in the body causing systemic symptoms.

How is rheumatoid arthritis diagnosed?

The diagnosis of rheumatoid arthritis is based on a combination of factors, including:

• Morning stiffness that lasts at least one hour and that has been present for at least six weeks
• Swelling of three or more joints for at least six weeks
• Swelling of the wrist, hand, or finger joints for at least six weeks
• Swelling of the same joints on both sides of the body
• Changes in hand x-rays that are characteristic of rheumatoid arthritis
• Rheumatoid nodules of the skin
• Blood test positive for rheumatoid factor* and/or anti-citrullinated peptide/protein antibodies

*The rheumatoid factor may be present in people who do not have rheumatoid arthritis. Other diseases can also cause the rheumatoid factor to be produced in the blood. A test called CCP antibody can sometimes help to determine whether the rheumatoid factor antibody is due to rheumatoid arthritis or some other disease. That is why the diagnosis of rheumatoid arthritis is based on a combination of several factors and NOT just the presence of the rheumatoid factor in the blood.

It is also important to note that not all of these features are present in people with early rheumatoid arthritis, and these problems may be present in some people with other rheumatic conditions.

In some cases, it may be necessary to monitor the condition over time before a diagnosis of rheumatoid arthritis can be made with certainty.

How is rheumatoid arthritis treated?

The goals of rheumatoid arthritis treatment are as follows:

• To control a patient's signs and symptoms
• To prevent joint damage
• To maintain the patient's quality of life and ability to function

Joint damage generally occurs within the first two years of diagnosis so it is important to early diagnose and treat RA in the so-called window of opportunity to prevent long-term consequences.

There are many different ways to treat rheumatoid arthritis. Treatments include medications, rest and exercise, physical therapy/occupational therapy, and surgery to correct damage to the joint.

The type of treatment prescribed will depend on several factors including the person's age, overall health, medical history and severity of arthritis.

Non-pharmacologic therapies

Non-pharmacologic therapies include treatments other than medications and are the foundation of treatment for all people with rheumatoid arthritis.

Rest

When joints are inflamed, the risk of injury of the joint itself and the adjacent soft tissue structures (such as tendons and ligaments) is high. This is why inflamed joints should be rested. However, physical fitness should be maintained as much as possible. At the same time, maintaining a good range of motion in your joints and good fitness overall are important in coping with the systemic features of the disease.

Exercise

Pain and stiffness often prompt people with rheumatoid arthritis to become inactive. However, inactivity can lead to a loss of joint motion, contractions, and a loss of muscle strength. These, in turn, decrease joint stability and further increase fatigue.

Regular exercise, especially in a controlled fashion with the help of physical therapists and occupational therapists, can help prevent and reverse these effects. Types of exercises that have been shown to be beneficial include range-of-motion exercises to preserve and restore joint motion, exercises to increase strength and exercises to increase endurance (walking, swimming, and cycling).

Physical and occupational therapy

Physical and occupational therapy can relieve pain, reduce inflammation, and help preserve joint structure and function for patients with rheumatoid arthritis.

Specific types of therapy are used to address specific effects of rheumatoid arthritis:

• The application of heat or cold can relieve pain or stiffness
• Use of ultrasound to help reduce inflammation of the sheaths surrounding tendons (tenosynovitis)
• Passive and active exercises to improve and maintain range of motion of the joints
• Rest and splinting to reduce joint pain and improve joint function
• Finger-splinting and other assistive devices to prevent deformities and improve hand function
• Relaxation techniques to relieve secondary muscle spasm

Occupational therapists also focus on helping people with rheumatoid arthritis to be able to continue to actively participate in work and recreational activity with special attention to maintaining good function of the hands and arms.

Nutrition and dietary therapy

Weight loss may be recommended for overweight and obese people to reduce stress on inflamed joints.

People with rheumatoid arthritis have a higher risk of developing coronary artery disease. High blood cholesterol is one risk factor for coronary disease that can respond to changes in diet. A nutritionist can recommend specific foods to eat or avoid in order to achieve a desirable cholesterol level.

Changes in diet have been investigated as treatments for rheumatoid arthritis, but there is no diet that is proven to cure rheumatoid arthritis. No herbal or nutritional supplements, such as cartilage or collagen, can cure rheumatoid arthritis. These treatments can be dangerous and are not usually recommended.

Smoking and alcohol

Smoking is a risk factor for rheumatoid arthritis and it has been shown that quitting smoking can improve the condition. People who smoke need to quit completely. Assistance in quitting should be obtained if needed. Moderate alcohol consumption is not harmful to rheumatoid arthritis, although it may increase the risk of liver damage from some drugs such as methotrexate. People should discuss the safety of alcohol use with a doctor, because recommendations depend on the medications a person is taking and on their other medical conditions.

Measures to reduce bone loss

Inflammatory conditions such as rheumatoid arthritis can cause bone loss, which can lead to osteoporosis. The use of prednisone further increases the risk of bone loss, especially in postmenopausal women. It is important to do the risk assessment and address risk factors that can be changed in order to help prevent bone loss.

Patients may do the following to help minimize the bone loss associated with steroid therapy:

• Use the lowest possible dose of glucocorticoids for the shortest possible time, when possible, to minimize bone loss
• Consume an adequate amount of calcium and vitamin D, either in the diet or by taking supplements
• Use medications that can reduce bone loss, including that which is caused by glucocorticoids
• Control the disease itself with appropriate medications prescribed by your doctor

Medications

There are many medications available to decrease joint pain, swelling and inflammation and hopefully prevent or minimize the progression of the disease. The type of drugs that your doctor recommends will depend on how severe your arthritis is and how well you respond to the medications.

These medications include:

• Non-steroidal anti-inflammatory drugs (NSAIDs such as aspirin, ibuprofen or naproxen)
• Corticosteroids (oral and injectable forms)
• COX-2 inhibitors (celecoxib)
• Disease-modifying anti-rheumatic drugs (DMARDs) such as hydroxychloroquine, methotrexate, sulfasalazine, and leflunomide.An improvement in symptoms may require four to six weeks of treatment with methotrexate. Improvement may require one to two months of treatment with sulfasalazine and two to three months of treatment with hydroxychloroquine
• Biologic agents (such as infliximab, etanercept, adalimumab, certolizumab and golimumab, tocilizumab, rituximab, abatacept, anakinra, tofacitinib)

Biologics tend to work rapidly, within two weeks for some medications and within four to six weeks for others. Biologics may be used alone or in combination with other DMARDs. Usually they are reserved for patients who do not adequately respond to DMARDs, or if adverse prognostic factors are present.

DMARDs and biologic agents interfere with the immune system's ability to fight infection and should not be used in people with serious infections.

Testing for tuberculosis (TB) is needed before starting anti-TNF therapy. People who have evidence of prior TB infection should be treated because there is an increased risk of developing active TB while receiving anti-TNF therapy.

Anti-TNF agents such as infliximab, etanercept, adalimumab, certolizumab and golimumab are not recommended for people who have lymphoma or who have been treated for lymphoma in the past. People with rheumatoid arthritis--especially those with severe disease--have an increased risk of lymphoma regardless of what treatment is used. Anti-TNF agents have been associated with a further increase in the risk of lymphoma in some studies but not others. More research is needed to define this risk.

Some of these medications are traditionally used to treat other conditions such as cancer, inflammatory bowel disease, and malaria. When these drugs are used to treat rheumatoid arthritis, the doses are significantly lower and the risks of side effects tend to be considerably less than when these drugs are used to treat cancer or other conditions.

However, the risk of side effects from treatment must be weighed against the benefits on an individual basis.

When you are prescribed any medication, it is important to meet with your physician regularly so he or she can detect the development of any side effects.

Surgery

When bone damage from arthritis has become severe or pain is not controlled with medications, surgery is an option to restore function to a damaged joint.

Is there hope for people with rheumatoid arthritis?

Yes. Although there is not yet a cure for rheumatoid arthritis, there are many effective methods available for decreasing the pain and inflammation and slowing down the disease process. Early diagnosis and effective treatment are of great importance.

Extensive research is in progress to determine the cause of rheumatoid arthritis and the best method of treatment.