What is rheumatoid arthritis?
Arthritis is a general term for inflammation (redness, warmth, swelling, and pain) in joints. Rheumatoid arthritis is a type of chronic (ongoing) arthritis that occurs in joints on both sides of the body (for instance, both hands, wrists, and/or knees), which helps distinguish it from other types of arthritis.
In addition to affecting the joints, rheumatoid arthritis may occasionally affect other parts of the body, 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 overreacting against itself. The result can cause some or all of the symptoms of rheumatoid arthritis.
Who is affected by rheumatoid arthritis?
- Rheumatoid arthritis affects more than 1.3 million people in the United States.
- It is 2.5 times more common in women than in men.
- It usually occurs in people who are between the ages of 20 and 50; however, young children and the elderly can also develop rheumatoid arthritis.
Symptoms and Causes
What causes rheumatoid arthritis?
The exact cause of rheumatoid arthritis is unknown. However, it is believed to be caused by a combination the following factors:
- Genetics (heredity)
- Abnormal immunity
- The environment
Normally, the immune system protects the body from disease. In people who have rheumatoid arthritis, something—possibly infections, cigarette smoking, and physical or emotional stress, among other causes—triggers the immune system to attack the joints (and sometimes other organs).
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 are the symptoms of rheumatoid arthritis?
The symptoms of rheumatoid arthritis include the following:
- Joint pain and swelling
- Stiffness, especially in the morning or after sitting for long periods
- Fatigue (tiredness and excessive sleepiness)
Rheumatoid arthritis affects each person differently. In most people, joint symptoms may develop gradually over several years. In other people, rheumatoid arthritis may proceed rapidly. A few people may have rheumatoid arthritis for a limited period of time and then go into remission (a time with no symptoms).
Cartilage normally acts as a “shock absorber” between the joints. Uncontrolled inflammation causes the destruction and wearing down of the cartilage, which leads to joint deformities. Eventually, the bone itself erodes, potentially leading to fusion of the joint (an effort of the body to protect itself from constant irritation). This process is aided by specific cells and substances of the immune system, which are produced in the joints but also circulate and cause symptoms throughout the body.
Diagnosis and Tests
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 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 hallmarks of rheumatoid arthritis;
- Rheumatoid nodules (lumps) of the skin
- Blood test that is 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. This 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 definitive diagnosis of rheumatoid arthritis can be made.
Management and Treatment
How is rheumatoid arthritis treated?
The goals of rheumatoid arthritis treatment are to:
- Control a patient's signs and symptoms.
- Prevent joint damage.
- 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 diagnose and treat rheumatoid arthritis in the “window of opportunity” to prevent long-term consequences.
Treatments for rheumatoid arthritis include medications, rest, exercise, physical therapy/occupational therapy, and surgery to correct damage to the joint.
The type of treatment will depend on several factors, including the person's age, overall health, medical history, and the severity of the arthritis.
Non-pharmacologic therapy is the first step in treatment for all people who have rheumatoid arthritis. Non-pharmacologic therapies include the following:
When joints are inflamed, the risk of injury to the joint and to nearby 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. Maintaining a good range of motion in your joints and good fitness overall are important in coping with the overall features of the disease.
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 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. Beneficial workouts 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 problems of rheumatoid arthritis:
- The application of heat or cold can relieve pain or stiffness.
- Ultrasound can help reduce inflammation of the sheaths surrounding tendons (tenosynovitis).
- Exercises can improve and maintain range of motion of the joints.
- Rest and splinting can help reduce joint pain and improve joint function.
- Finger-splinting and other assistive devices can prevent deformities and improve hand function.
- Relaxation techniques can relieve secondary muscle spasm.
Occupational therapists also focus on helping people with rheumatoid arthritis 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 (a risk factor for coronary artery disease) can respond to changes in diet. A nutritionist can recommend specific foods to eat or avoid in order to reach a desirable cholesterol level.
Changes in diet have been investigated as treatments for rheumatoid arthritis, but no diet has been proven to cure it. No herbal or nutritional supplements, such as cartilage or collagen, can cure rheumatoid arthritis. These treatments can be dangerous and are not usually recommended.
There are many medications to decrease joint pain, swelling, and inflammation, and prevent or slow down 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:
- Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen, or naproxen
- Corticosteroids (oral and injectable forms)
- COX-2 inhibitor (celecoxib [Celebrex®])
- Disease-modifying anti-rheumatic drugs (DMARDs) such as hydroxychloroquine (Plaquenil), methotrexate (Rheumatrex®, Trexall®), sulfasalazine (Azulfidine®), and leflunomide (Arava®)
It may take four to six weeks of treatment with methotrexate, one to two months with sulfasalazine, and two to three months with hydroxycholoroquine to see an improvement in symptoms.
- Biologic agents, such as infliximab (Remicade®), etanercept (Enbrel®), adalimumab (Humira®), certolizumab (Cimzia®), golimumab (Simponi®), tocilizumab (Actemra®), rituximab (Rituxan®), abatacept (Orencia®), anakinra (Kineret®), tofacitinib (Xeljanz®)
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 the prognosis (outlook) for the patient is problematic.
Other precautions to note with these drugs:
- DMARDs and biologic agents interfere with the immune system's ability to fight infection and should not be used by people who have serious infections.
- 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. 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.
- Testing for tuberculosis (TB) is needed before starting anti-TNF therapy. People who have evidence of earlier TB infection should be treated for TB, because there is an increased risk of developing active TB while receiving anti-TNF therapy.
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 much lower and the risks of side effects tend to be considerably less. 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 watch for any side effects.
When bone damage from the arthritis has become severe or pain is not controlled with medications, surgery is an option to restore function to a damaged joint.
Smoking and alcohol
Smoking is a risk factor for rheumatoid arthritis. Since quitting smoking can improve rheumatoid arthritis symptoms, people who smoke should quit completely. Help in quitting is available and should be obtained, if needed.
Drinking alcohol in moderation is not harmful for people who have rheumatoid arthritis, although it may increase the risk of liver damage from some drugs such as methotrexate. Recommendations for alcohol use depend on the medications a person is taking and on his or her other medical conditions. Discuss the safety of alcohol use with your doctor.
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.
You can 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.
- Get 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 rheumatoid arthritis itself with appropriate medications prescribed by your doctor.
Outlook / Prognosis
What is the prognosis (outlook) for people who have rheumatoid arthritis?
Although there is no cure for rheumatoid arthritis, there are many effective methods for decreasing the pain and inflammation and slowing down the disease process. Early diagnosis and effective treatment are very important.
Extensive research is being done to learn the cause of rheumatoid arthritis and the best methods of treatment.