Rheumatoid Arthritis

Definition

Rheumatoid arthritis (RA) is a long-term disease. It leads to inflammation of the joints and surrounding tissues. It can also affect other organs.

Alternative Names

RA; Arthritis - rheumatoid

Causes

The cause of RA is unknown. It is an autoimmune disease. This means the body's immune system mistakenly attacks healthy tissue.

RA can occur at any age, but is more common in middle age. Women get RA more often than men.

Infection, genes, and hormone changes may be linked to the disease. Smoking may also be linked to RA.

It is less common than osteoarthritis, which is a condition that occurs in many people due to wear and tear on the joints as they age.

Symptoms

Most of the time, RA affects joints on both sides of the body equally. Fingers, wrists, knees, feet, elbows, ankles, hips and shoulders are the most commonly affected.

The disease often begins slowly. Early symptoms may include:

• Minor joint pain 
• Stiffness 
• Fatigue

Joint symptoms may include:

• Morning stiffness, which lasts more than 1 hour, is common. 
• Joints may feel warm, tender, and stiff when not used for an hour.
• Joint pain is often felt in the same joint on both sides of the body. 
• Joints are often swollen.
• Over time, joints may lose their range of motion and may become deformed.

Other symptoms include:

• Chest pain when taking a breath (pleurisy)
• Dry eyes and mouth (Sjögren syndrome)
• Eye burning, itching, and discharge
• Nodules under the skin (most often a sign of more severe disease)
• Numbness, tingling, or burning in the hands and feet
• Sleep difficulties

Exams and Tests

There is no test that can determine for sure whether you have RA. Most people with RA will have some abnormal test results. However, some people will have normal results for all tests.

Two lab tests that are positive in most people and often help in the diagnosis are:

• Rheumatoid factor
• Anti-CCP antibody

Other tests that may be done include:

• Complete blood count
• C-reactive protein
• Erythrocyte sedimentation rate
• Joint x-rays 
• Fluid analysis

Treatment

RA most often requires long-term treatment. Treatment may include;

• Medicines
• Physical therapy
• Exercise
• Education
• Surgery

Early, aggressive treatment for RA with newer drug categories can be very helpful to slow joint destruction and prevent deformities.

MEDICINES

Disease modifying antirheumatic drugs (DMARDs): These are the drugs that are tried first in people with RA. They are prescribed along with rest, strengthening exercise, and anti-inflammatory drugs.

• Methotrexate is the most commonly used DMARD for RA. Leflunomide and hydroxychloroquine may also be used.
• Sulfasalazine is a drug that is often combined with methotrexate and hydroxychloroquine (triple therapy).
• It may be weeks or months before you see any benefit from these drugs.
• These drugs may have serious side effects, so you will need regular blood tests when taking them.

Anti-inflammatory medicines: These include aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs).

• These drugs work well to reduce pain and swelling. 
• Long-term use can cause stomach problems, including ulcers and bleeding, and possible heart problems.
• Since they do not prevent joint damage if used alone, DMARDS should be used as well.

Antimalarial medicines: This group of medicines includes hydroxychloroquine (Plaquenil). They are most often used along with methotrexate. It may be weeks or months before you see any benefit from these drugs.

Corticosteroids: These medicines work very well to reduce joint swelling and inflammation, but they can have long-term side effects. Therefore, they should be taken only for a short time and in low doses when possible.

Biologic agents: These drugs are designed to affect parts of the immune system that play a role in the disease process of RA.

They may be given when other medicines for RA have not worked. Sometimes, biologic drugs are started sooner, along with other RA drugs. However, because they are very expensive, insurance approval is generally required.

Most of them are given either under the skin or into a vein. There are several types of biologic agents.

Biologic agents can be very helpful in treating RA. However, people taking these drugs must be watched very closely because of serious risk factors, including:

• Infections from bacteria, viruses, and fungi
• Leukemia or lymphoma
• Psoriasis
• Allergic reactions

SURGERY

Surgery may be needed to correct severely damaged joints. Surgery may include:

• Removal of the joint lining (synovectomy)
• Total joint replacement in extreme cases: may include total knee replacement (TKR) and hip replacement.

PHYSICAL THERAPY

Range-of-motion exercises and exercise programs prescribed by a physical therapist can delay the loss of joint function and help keep muscles strong.

Sometimes, therapists will use special machines to apply deep heat or electrical stimulation to reduce pain and improve joint movement.

Other therapies that may help ease joint pain include:

• Joint protection techniques
• Heat and cold treatments
• Splints or orthotic devices to support and align joints
• Frequent rest periods between activities, as well as 8 to 10 hours of sleep per night

NUTRITION

Some people with RA may have intolerance or allergies to certain foods. A balanced nutritious diet is recommended. It may be helpful to eat foods rich in fish oils (omega-3 fatty acids). Smoking cigarettes should be stopped. Excessive alcohol should also be avoided.

Support Groups

Some people may benefit from taking part in an arthritis support group.

Outlook (Prognosis)

How well a person does depends on the severity of symptoms and the response to treatment. It is very important to have regular return visits to your health care provider, who will adjust treatment to control the arthritis.

Permanent joint damage may occur without proper treatment. Early treatment with a three-drug DMARD combination known as "triple therapy," or with the biologic drugs, can decrease joint pain and damage. This will help in improving the prognosis of this disease. It is possible to have remission of RA without needing other medicines if it is treated early with these drugs. These drugs are given by specialists called rheumatologists.

Possible Complications

If not well treated, RA can affect nearly every part of the body. Complications may include:

• Damage to the lung tissue (rheumatoid lung).
• Increased risk of hardening of the arteries.
• Spinal injury when the neck bones become damaged.
• Inflammation of the blood vessels (rheumatoid vasculitis), which can lead to skin, nerve, heart, and brain problems.
• Swelling and inflammation of the outer lining of the heart (pericarditis) and of the heart muscle (myocarditis), which can lead to congestive heart failure.

However, these complications can be avoided with proper treatment. The treatments for RA can also cause serious side effects. Talk to your provider about the possible side effects of treatment and what to do if they occur.

When to Contact a Medical Professional

Call your provider if you think you have symptoms of RA.

Prevention

There is no known prevention. Smoking cigarettes, along with long-term (chronic) gum infections, appears to worsen RA, so it is important to avoid tobacco and maintain healthy teeth and gums. Proper early treatment can help prevent further joint damage.