Rheumatoid Arthritis

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.

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.

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.