Rheumatoid Arthritis

Rheumatoid arthritis is a chronic disease, mainly characterized by inflammation of the lining, or synovium, of the joints. It can lead to long-term joint damage, resulting in chronic pain, loss of function and disability.

Rheumatoid arthritis (RA) progresses in three stages. The first stage is the swelling of the synovial lining, causing pain, warmth, stiffness, redness and swelling around the joint. Second is the rapid division and growth of cells, or pannus, which causes the synovium to thicken. In the third stage, the inflamed cells release enzymes that may digest bone and cartilage, often causing the involved joint to lose its shape and alignment, more pain, and loss of movement.

Because it is a chronic disease, RA continues indefinitely and may not go away. Frequent flares in disease activity can occur. RA is a systemic disease, which means it can affect other organs in the body. Early diagnosis and treatment of RA is critical if you want to continue living a productive lifestyle. Studies have shown that early aggressive treatment of RA can limit joint damage, which in turn limits loss of movement, decreased ability to work, higher medical costs and potential surgery.

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Causes

The exact cause of rheumatoid arthritis (RA) currently is unknown. In fact, there probably isn’t an exact cause for RA. Researchers now are debating whether RA is one disease or several different diseases with common features.

Immune System

We do know that the body’s immune system plays an important role in rheumatoid arthritis. In fact, RA is referred to as an autoimmune disease because people with RA have an abnormal immune system response.

In a healthy immune system, white blood cells produce antibodies that protect the body against foreign substances. People who have RA have an immune system that mistakes the body’s healthy tissue for a foreign invader and attacks it.

Rheumatoid factor is an antibody that is directed to regulate normal antibodies made by the body. It works well in people with small quantities of rheumatoid factor. People with high levels of rheumatoid factor, however, may have a malfunctioning immune system. This is why the doctor often request a test measuring rheumatoid factor when trying to diagnose RA. In general, the higher the level of rheumatoid factor present in the body, the more severe the disease activity is.

It is important to note that not all people with RA have an elevated rheumatoid factor and not all people with an elevated rheumatoid factor have RA. The test also can come out negative if it is done too early in the course of the disease. Approximately 20 percent of people with RA will have a negative rheumatoid factor test and some people who don’t have RA will test positive.

Deformities in RA

Gender

Women get rheumatoid arthritis two to three times more often then men and their RA typically goes into remission when they get pregnant. Women develop RA more often than expected in the year after pregnancy and symptoms can increase after a baby is born. These facts lead researchers to believe that gender might play a role in the development and progression of RA. Many are trying to understand the effects female hormones might have in the development of RA.

Genetics

Most researchers believe there are genes involved in the cause of RA. The specific genetic marker associated with RA, HLA-DR4, is found in more than two-thirds of Caucasians with RA while it is only found in 20 percent of the general population. While people with this marker have an increased risk of developing RA, it is not a diagnostic tool. Many people who have the marker either don’t have or will never get RA. While this marker can be passed from parent to child, it is not definite that if you have RA, your child will too.

Infection

Some physicians and scientists believe that RA is triggered by a kind of infection. There is currently no proof of this. Rheumatoid arthritis is not contagious, although it is possible that a germ to which almost everyone is exposed may cause an abnormal reaction from the immune system in people who already carry a susceptibility for RA.

What are the effects?

Rheumatoid arthritis can start in any joint, but it most commonly begins in the smaller joints of the fingers, hands and wrists. Joint involvement is usually symmetrical, meaning that if a joint hurts on the left hand, the same joint will hurt on the right hand. In general, more joint erosion indicates more severe disease activity.

Other common physical symptoms include:

Fatigue
Weakness
Muscle pain

Physical Examination

The doctor will perform a physical exam to determine diagnosis. He will be looking for common features reported in RA, including:

Joint swelling
Joint tenderness
Loss of motion in your joints
Joint mal-alignment
Signs of rheumatoid arthritis in other organs, including your skin, lungs and eyes.

Medical History

Medical history probably is your doctor’s best tool for diagnosing rheumatoid arthritis. The more your doctor knows about you, the faster and better he will be able to diagnose your condition and determine the best treatment for you. Taking a medical history is the first line to finding out if you have rheumatoid arthritis.

Following is a list of questions your doctor might ask in a medical history:

Do you have joint pain in many joints?
Does the pain occur symmetrically – that is, do the same joints on both sides of your body hurt at the same time? Or is the pain one-sided?
Do you have stiffness in the morning?
When is the pain most severe?
Do you have pain in your hands, wrists and/or feet?
If you have pain in your hands, which joints hurt the most?
Have you had periods of feeling weak and uncomfortable all over? Do you feel fatigued?

Lab Tests

Complete Blood Count
Erythrocyte Sedimentation Rate (ESR)
C-Reactive Protein
R A factor
Anti CCP-ANA

Antinuclear Antibodies (ANA)

This test detects a group of autoantibodies (antibodies against self), which is seen in about 30 to 40 percent of people with RA. Although it commonly is used as a screening tool, ANA testing isn’t used as a diagnostic tool because many people without RA or with other diseases can have ANAs.

Imaging Studies

Radiographs (X-rays)
Magnetic Resonance Imaging (MRI)
Joint Ultrasound

Treatment options

Because rheumatoid arthritis presents itself on many different fronts and in many different ways, treatment must be tailored to the individual, taking into account the severity of your arthritis, other medical conditions you may have and your individual lifestyle. Current treatment methods focus on relieving pain, reducing inflammation, stopping or slowing joint damage and improving your functioning and sense of well-being.

Rheumatoid arthritis is a serious disease. It is crucial that you get an early diagnosis and work with your doctor to find the best treatment for you so that you can live well with it.

Medications

The proper medication regimen is important in controlling your RA. You must help your doctor determine the best combination for you.

The main categories of drugs used to treat RA are:

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) – These drugs are used to reduce inflammation and relieve pain. These are medications such as aspirin, ibuprofen, indomethacin and aceclofenac/diclofenac.
Analgesic Drugs – These drugs relieve pain, but don’t necessarily have an effect on inflammation. Examples of these medications are acetaminophen, propoxyphene, mepeidine and morphine.
Glucocorticoids or Prednisone – These are prescribed in low maintenance doses to slow joint damage caused by inflammation.
Disease Modifying Antirheumatic Drugs (DMARDs) – These are used with NSAIDs and/or prednisone to slow joint destruction caused by RA over time. Examples of these drugs are methotrexate, injectable gold, penicillamine, azathioprine, chloroquine, hydroxychloroquine, sulfasalazine and oral gold.
Biologic Response Modifiers – These drugs directly modify the immune system by inhibiting proteins called cytokines, which contribute to inflammation. Examples of these are etanercept, infliximab, adaliumumab and anakinra.
Protein-A Immuoadsorption Therapy – This is not a drug, but a therapy that filters your blood to remove antibodies and immune complexes that promote inflammation.
DMARDs, particularly methotrexate, have been the standard for aggressively treating RA. Recently, studies have shown that the most aggressive treatment for controlling RA may be the combination of methotrexate and another drug, particularly biologic response modifiers. The dual drug treatment seems to create a more effective treatment, especially for people who may not have success with or who have built up a resistance to, methotrexate or another drug alone. Doctors now are prescribing combination drug therapy more often and studies continue. It appears that these combination drug therapies might become the new road to follow in treating RA.

Here are some medications your doctor may suggest you combine with methotrexate:

Lefluonomide (Arava), Etanercept (Enbrel), Adalimumab (Humira) and Infliximab (Remicade).

Surgery

Many people with rheumatoid arthritis might consider surgery as part of their treatment plan. The surgical options available today can contribute greatly to improving your quality of life with RA.

The following are different surgical options available to people with RA.

Synovectomy – When one or two joints are affected more severely than others, this procedure is used to reduce the amount of inflammatory tissue by removing the diseased synovium or lining of the joint. It may result in less swelling and pain and the slowing or prevention of further joint damage.
Arthroscopic Surgery – In this procedure, the surgeon inserts a very thin tube with a light at the end into the joint through a small incision. It is connected to a closed-circuit television and allows the surgeon to see the extent of the damage in the joint. Once there, the doctor can take tissue samples, remove loose cartilage, repair tears, smooth a rough surface or remove diseased synovial tissue. It is most commonly performed on the knee and shoulder.
Joint Replacement Surgery or Arthroplasty – This is the surgical reconstruction or replacement of a joint. Successfully used to help people who otherwise might be in a wheelchair, joint replacement surgery involves the removal of the joint, resurfacing and relining of the ends of bones and replacing the joint with a man-made component. This procedure is usually recommended for people over 50 or who have severe disease progression. Typically a new joint will last between 20 and 30 years.
Arthrodesis or fusion – This procedure fuses two bones together. While it limits movement, it does decrease pain and increase stability of the joints in the ankles, wrists, fingers, toes and spine.

RA can affect anyone, including children, but 70 percent of people with RA are women. Onset usually occurs between 30 and 50 years of age.

RA often goes into remission in pregnant women, although symptoms tend to increase in intensity after the baby is born. RA develops more often than expected the year after giving birth.

While women are two to three times more likely to get RA than men, men tend to be more severely affected when they get it.

People with the genetic marker HLA-DR4 may have an increased risk of developing RA. This marker is found in white blood cells and plays a role in helping your body distinguish between its own cells and foreign invaders.