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Rheumatoid Arthritis

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.

Rheumatoid arthritis is another form of arthritis. The body's own immune system attacks a joint's synovial membrane, which secretes fluid and lines the joint. The synovium becomes inflamed, produces excess fluid, and the cartilage becomes rough and pitted.

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

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Symptoms

Most of the time, RA affects joints on both sides of the body equally. Wrists, fingers, knees, feet, and ankles are the most commonly affected.

The disease often begins slowly. Early symptoms may include minor joint pain, stiffness, and 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. The joints are often swollen.
  • Over time, joints may lose their range of motion and may become deformed.
The affect of rheumatoid arthritis can progress to the degree that it is crippling. Deformities distinctive to late-stage rheumatoid arthritis such as ulnar deviation of the bones of the hands, or swan-neck deviation of the fingers occur because muscles and tendons on one side of the joint may overpower those on the other side, pulling the bones out of alignment.

Other symptoms include:

  • Chest pain when taking a breath (pleurisy)
  • Dry eyes and mouth (Sjogren 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 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 
  • Joint ultrasound or MRI
  • Joint fluid analysis

Treatment

RA most often requires long-term treatment. Treatment includes medicines, physical therapy, exercise, education, and possibly surgery. Early, aggressive treatment for RA with newer drug categories can be very helpful to slow joint destruction and prevent deformities.

Most of us expect to become a little achy and creaky as we get older. It's because the cushion that protects our joints wears down over the years, a condition called osteoarthritis. But some people develop a form of arthritis at an earlier age, not because their joints are wearing away, but because their body is attacking and damaging their own joints. Let's talk about rheumatoid arthritis, or RA. The immune system normally keeps the body safe against bacteria, viruses, and other harmful invaders. But sometimes this system goes a little haywire, and the body mistakenly attacks its own tissues. That's known as an autoimmune disease. In the case of rheumatoid arthritis, the immune system attacks and damages your own joints. Like other forms of arthritis, rheumatoid arthritis makes the joints painful and stiff. If you have RA, you may notice that your joints feel stiffer in the morning, making it hard to get out of bed. Over time, you'll have trouble moving the affected joints, which can become deformed and bent out of shape. So, how do doctors diagnose rheumatoid arthritis? Well, there isn't one test that can tell for sure that you have RA. However, there are a couple of lab tests that can point your doctor to the diagnosis. You may also have an ultrasound, MRI, or x-rays so your doctor can see what's going on inside the affected joints. If you do have RA, many drugs can treat it. However, each of these drugs can have some side effects, and some of them are serious. You'll have to decide with your doctor which drug to take by weighing the benefits against the risks. If you're like most people with RA, you'll start by taking medicines called disease modifying antirheumatic drugs, or DMARDs for short. These include methotrexate. Often antimalarial drugs are given along with DMARDs. Anti-inflammatory medicines such as ibuprofen, naproxen, and celecoxib can help bring down the swelling in your joints. So can steroid drugs. If these medicines don't work, your doctor may suggest trying a biologic medicine, which targets the overactive immune response that's damaging your joints. Biologics are usually injected under the skin or into a vein. Severely deformed joints may need to be treated with surgery to remove the joint lining or even totally replace the damaged joint. Whatever treatment you use, also remember to exercise your joints on your own, or by going to a physical therapist. The right exercise can help keep your muscles strong and improve your joint mobility. When you have RA, don't try to overdo it. Think about your achy joints before doing any activity, so you don't overstress them. Also follow your doctor's treatment advice carefully. If you let this disease go, you could end up with permanent joint damage that can't be reversed. By treating RA early, you can get your joints, and the rest of you, moving more smoothly again.

MEDICINES

Disease modifying antirheumatic drugs (DMARDs): These are often 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 rheumatoid arthritis. 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 frequent blood tests when taking them.

Anti-inflammatory medicines: These include aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, naproxen and celecoxib.

  • 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 rheumatoid arthritis.

They may be given when other medicines for rheumatoid arthritis have not worked. Sometimes biologic drugs are started sooner, along with other rheumatoid arthritis 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 different types of biologic agents.

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

  • 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, hip replacement, ankle replacement, shoulder replacement, and others

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 the 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. These drugs are given by specialists called rheumatologists.

Possible Complications

If not well treated, rheumatoid arthritis 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 most often be avoided with proper treatment. The treatments for RA can also cause serious side effects. Talk to your health care provider about the possible side effects of treatment and what to do if they occur.

When to Contact a Medical Professional

Call your health care provider if you think you have symptoms of rheumatoid arthritis.

Prevention

There is no known prevention. Smoking cigarettes appears to worsen RA, so it is important to avoid tobacco. Proper early treatment can help prevent further joint damage.

References

Mason JC. Rheumatic diseases and the cardiovascular system. In: Mann DL, Zipes DP, Libby P, Bonow RO, Braunwald E, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 10th ed. Philadelphia, PA: Elsevier Saunders; 2015:chap 84.

McInnes IB, Schett G. The pathogenesis of rheumatoid arthritis. N Engl J Med. 2011;365:2205-2219. PMID: 22150039 www.ncbi.nlm.nih.gov/pubmed/22150039.

O'Dell JR. Rheumatoid arthritis. In: Goldman L, Schafer AI, eds. Goldman's Cecil Medicine. 25th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 264.

O'Dell JR, Mikuls TR, Taylor TH, et al. Therapies for active rheumatoid arthritis after methotrexate failure. N Engl J Med. 2013;369:307. PMID: 23755969 www.ncbi.nlm.nih.gov/pubmed/23755969. Singh JA, Saag KG, Bridges SL, et al. 2015 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Rheumatol. 2016;68(1):1-26. PMID: 26545940 www.ncbi.nlm.nih.gov/pubmed/26545940.

Sweeney SE, Harris ED, Firestein GS. Clinical features of rheumatoid arthritis. In: Firestein GS, Budd RC, Gabriel SE, McInnes IB, O'Dell JR, eds. Kelley's Textbook of Rheumatology. 9th ed. Philadelphia, PA: Elsevier Saunders; 2013:chap 70.

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