About Rheumatoid Arthritis

Rheumatoid Arthritis (RA) is a chronic disease that causes pain, stiffness, swelling, and limitation in the motion and function of multiple joints. Though joints are the principal body parts affected by RA, inflammation can develop in other organs as well.

The stiffness seen in active RA is typically worst in the morning and may last anywhere from one to two hours to the entire day. This long period of morning stiffness is an important diagnostic clue, as not many other arthritic diseases behave this way. For example, osteoarthritis does not generally cause prolonged morning stiffness. While RA can affect any joint, the small joints in the hands and feet tend be involved more frequently than others. This produces a pattern of joint disease that rheumatologists regard as characteristic of RA.

Other symptoms that can occur in RA include:

• loss of energy

• low-grade fevers

• loss of appetite

• dry eyes and mouth from an associated condition known as Sjogren's syndrome

• firm lumps called rheumatoid nodules beneath the skin in areas such as the elbow and hands

What causes rheumatoid arthritis

RA is classified as an autoimmune disease, which develops because certain cells of the immune system malfunction and attack healthy joints. While the cause of RA remains unknown, exciting and rapidly advancing research is revealing the factors that are important in producing inflammation. The primary focus of the inflammation is in the synovium, which is the lining tissue of the joint. Inflammatory chemicals released by the immune cells cause swelling and damage to cartilage and bone. This research is giving us a better understanding of the immune and genetic factors that may be involved in the disease. As a result of this work, new medications have been developed that specifically block certain signals in the body from the immune system that are important in causing RA symptoms and joint damage.

Who gets rheumatoid arthritis

How rheumatoid arthritis is diagnosed

RA can be difficult to diagnose because it may begin gradually with subtle symptoms. Many diseases, especially early on, behave in a manner similar to RA. For this reason, patients suspected of having RA should be evaluated by a rheumatologist, a physician with the necessary skill and experience to reach a precise diagnosis and develop the most appropriate treatment plan.

The diagnosis of RA is based on the symptoms described and physical examination findings such as warmth, swelling and pain in the joints. Certain laboratory abnormalities commonly found in RA can help in establishing a diagnosis. Tell-tale abnormalities include:

• anemia (a low red blood cell count);

• rheumatoid factor (an antibody eventually found in approximately 80% of patients with RA, but in only 30% at the start of the arthritis); and

• an elevated erythrocyte sedimentation rate or “sed rate” (a blood test that in most patients with RA tends to correlate with the amount of inflammation in the joints).

X-rays can be very helpful in diagnosing RA but may not show any abnormalities in the first 3–6 months of arthritis. X rays are useful in determining if the disease is progressing.

It is important to remember that for most patients with this disease (especially those who have had symptoms for less than six months), there is no single test that “confirms” a diagnosis of RA. Rather, diagnosis is established by skillfully evaluating the appropriate symptoms, physical examination findings, laboratory tests and X-rays.

How rheumatoid arthritis is treated

Therapy for patients with RA has improved dramatically over the past 25 years. Current treatments offer most patients good to excellent relief of symptoms and the ability to continue to function at or near normal levels. Since there is no cure for RA, the goal of treatment is to minimize patients' symptoms and disability by introducing appropriate medical therapy early on, before the joints are permanently damaged. No single therapy is effective for all patients, and many patients will need to change treatment strategies during the course of their disease.

Successful management of RA requires early diagnosis and, at times, aggressive treatment. To quickly reduce joint inflammation and symptoms, first-line treatment usually consists of non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Motrin and others), naproxen (Naprosyn, Aleve), celecoxib (Celebrex) and many others. In addition, corticosteroids such as prednisone (Deltasone and others) may be given orally at low doses or via injection into the joints.

However, all RA patients with persistent swelling in the joints are candidates for treatment with disease-modifying anti-rheumatic drugs (DMARDs), often used in conjunction with NSAIDs and/or low dose corticosteroids. DMARDs have greatly improved the symptoms and function as well as the quality of life for the vast majority of patients with RA. DMARDs include methotrexate (Rheumatrex and Folex), leflunomide (Arava), hydroxychloroquine (Plaquenil), sulfasalazine (Azulfidine), gold given orally (Auranofin) or intramuscularly (Myochrisine), minocycline (Minocin, Dynacin and Vectrin), azathiaprine (Imuran), and cyclosporine (Sandimmune and Neoral).

A new class of medications, referred to as biologic response modifiers or “biologic agents” can specifically target parts of the immune system that lead to inflammation as well as joint and tissue damage in RA. These medications are also DMARDs, because they slow the progression of the disease. FDA-approved treatments include adalimumab (Humira), anakinra (Kineret), etanercept (Enbrel), infliximab (Remicade), abatacept (Orencia), and rituximab (Rituxan). In some cases these medications are used alone; in many cases, they are combined with methotrexate for added efficacy.

The optimal treatment of RA often requires more than medication alone. Proper treatment requires comprehensive, coordinated care, patient education and the expertise of a number of providers, including rheumatologists, primary care physicians, and physical and occupational therapists .

Broader health impact of rheumatoid arthritis

Recent research indicates that people with RA, particularly those whose disease is not well controlled, may have a higher risk for heart disease and stroke. Talk with your physician about your own risk and ways that you can minimize it.

Living with rheumatoid arthritis

It is important for people with RA to remain physically active, while occasionally scaling back activities when the disease flares. A consultation with a physical or occupational therapist may help to determine what level and types of activities are appropriate. In general, rest when a joint is swollen and inflamed, or when feeling fatigued. At these times, gentle range-of-motion exercises will keep the joint flexible. When feeling better, low-impact aerobic exercises such as walking and exercises to boost muscle strength will improve overall health and reduce pressure on joints.

The diagnosis of a chronic illness is a life-changing event that can cause anxiety and occasionally feelings of isolation or depression. Because the treatments for rheumatoid arthritis have improved dramatically, these feelings usually decrease with time as energy improves and pain and limitation decrease. It is important to discuss there normal reactions to illness with your physician and health care providers, who can provide you with the information and resources you need for support during your treatment.

Prognosis

• RA has been a primary focus of rheumatologic research and the treatments now available have dramatically improved outcomes for patients. Joint pain and swelling can usually be well controlled and joint damage can be minimized by early treatment.

• Expertise is particularly needed to establish a diagnosis of RA early, to rule out diseases that mimic RA (thereby avoiding unnecessary testing, drug therapy and costs) and to design a treatment plan that is best suited and customized for the patient and addresses the need for and the risks and benefits of DMARD therapy. Accordingly, the rheumatologist, working with the primary care physician and other health care providers, should play the major role in outlining, implementing and supervising the management of the patient with RA.

• Studies have shown that people who receive early treatment of RA feel better, are more likely to be able to be lead an active life, and are less likely to experience the type of joint damage that leads to joint replacement.