What
is Rheumatoid Arthritis (RA)?Rheumatoid arthritis is an autoimmune disease which causes chronic inflammation of the joints, the tissue around the joints, as well as other organs in the body. Autoimmune diseases are illnesses which occur when the body tissues are mistakenly attacked by its own immune system. The immune system is a complex organization of cells and antibodies designed normally to "seek and destroy" invaders of the body, particularly infections. Patients with these diseases have antibodies in their blood which target their own body tissues, where they can be associated with inflammation. Because it can affect multiple other organs of the body, rheumatoid arthritis is referred to as a systemic illness and is sometimes called rheumatoid disease. While rheumatoid arthritis is a chronic illness, meaning it can last for years, patients may experience long periods without symptoms.
A joint is where two bones meet to allow movement of body parts. Arthritis means joint inflammation. The joint inflammation of rheumatoid arthritis causes swelling, pain, stiffness, and redness in the joints. The inflammation of rheumatoid disease can also occur in tissues around the joints, such as the tendons, ligaments, and muscles. In some patients with rheumatoid arthritis, chronic inflammation leads to the destruction and deformity of the joints.
Rheumatoid arthritis is a common rheumatic disease, affecting more than two million people in the United States. The disease is three times more common in women as in men. It afflicts people of all races equally. The disease can begin at any age, but most often starts after age forty and before sixty. In some families, multiple members can be affected, suggesting a genetic basis for the disorder.
The cause of rheumatoid arthritis is unknown. Even though infectious agents such as viruses, bacteria, and fungi have long been suspected, none has been proven as the cause. The cause of rheumatoid arthritis is a very active area of worldwide research. Some scientists believe that the tendency to develop rheumatoid arthritis may be genetically inherited. It is suspected that certain infections or environmental factors might trigger the immune system to attack the body's own tissues, resulting in inflammation in various organs of the body.
The symptoms of rheumatoid arthritis come and go, depending on the degree of tissue inflammation. When body tissues are inflamed, the disease is active. When tissue inflammation subsides, the disease is inactive (in remission). Remissions can occur spontaneously or with treatment, and can last weeks, months, or years. During remissions, symptoms of the disease disappear, and patients generally feel well. When the disease becomes active again, symptoms return. The return of disease activity and symptoms is called a flare. The course of rheumatoid arthritis varies from patient to patient, and periods of flares and remissions are typical.
When the disease is active, symptoms can include fatigue, lack of appetite, low grade fever, muscle and joint aches, and stiffness. Muscle and joint stiffness are most notable in the morning and after long periods of inactivity. Arthritis is common during disease flares. During flares, joints become red, swollen, painful, and tender. This occurs because the lining tissue of the joint (synovium) becomes inflamed, resulting in the production of excessive joint fluid (synovial fluid). The synovium also thickens with inflammation (synovitis).
In rheumatoid arthritis, multiple joints are usually inflamed in a symmetrical pattern (both sides of the body affected). The small joints of both the hands and wrists are frequently involved. Simple tasks of daily living, such as turning door knobs and opening jars can become difficult during flares. The small joints of the feet are also commonly involved. In occasional patients, only one joint is inflamed. When only one joint is involved, the arthritis can mimic the arthritis caused by gout or infection. Chronic inflammation can cause damage to body tissues, cartilage and bone. This leads to a loss of cartilage and erosion and weakness of the bones as well as the muscles, resulting in joint deformity and destruction.
Since rheumatoid arthritis is a systemic disease, inflammation can affect other organs and areas of the body. Inflammation of the glands of the eyes and mouth can cause dryness of these areas and is referred to as Sjogren's syndrome. Rheumatoid inflammation of the lung lining (pleuritis) causes chest pain with deep breathing or coughing. Inflammation around the heart (pericarditis) causes chest pain which changes when lying down or leaning forward. The disease can reduce the number of red blood cells (anemia), and white blood cells. Decreased white cells can increase the risk of infections. Firm lumps under the skin (rheumatoid nodules) can occur around the elbows and fingers where there is frequent pressure. Even though these nodules usually do not cause symptoms, occasionally they can become infected. A rare, serious complication, usually with long-standing rheumatoid disease, is blood vessel inflammation (vasculitis). Vasculitis can impair blood supply to tissues and lead to tissue death. This is most often initially visible as tiny black areas around the nail beds or as legs ulcers.
The first step in the diagnosis of rheumatoid arthritis is a meeting between the doctor and the patient. Several visits may be necessary before the doctor can be certain of the diagnosis. The doctor will review the history of symptoms, examine the joints for inflammation and deformity, the skin for rheumatoid nodules, and other parts of the body for inflammation, as well as ordering certain blood and x-ray tests. The diagnosis will be based on the pattern of symptoms, the distribution of the inflamed joints, and the blood and x-ray findings. A doctor with special training in arthritis and related diseases is called a rheumatologist.
The distribution of joint inflammation is important to the doctor in making a diagnosis. In rheumatoid arthritis, the small joints of the hands, wrists, feet, and knees are typically inflamed in a symmetrical distribution (affecting both sides of the body). When only one or two joints are inflamed, the diagnosis of rheumatoid arthritis becomes more difficult. The doctor may then perform other tests to exclude arthritis due to infection or gout. The detection of rheumatoid nodules (described above), most often around the elbows and fingers, can suggest the diagnosis.
Abnormal blood antibodies can be found in patients with rheumatoid arthritis. A blood antibody called "the rheumatoid factor" can be found in 80% of patients. Another antibody called "the antinuclear antibody" (ANA) is also frequently found in patients with rheumatoid arthritis. A blood test called the sedimentation rate (sed rate) is a measure of how fast red blood cells fall to the bottom of a test tube. The sed rate is usually faster during disease flares, and slower during remissions. The rheumatoid factor, ANA, and sed rate tests can also be abnormal in other systemic autoimmune conditions. Therefore, abnormalities in these blood tests alone are not sufficient for a firm diagnosis of rheumatoid arthritis.
Joint x-rays can show bony erosions typical of rheumatoid arthritis in the joints. Joint x-rays can also be helpful in monitoring the progression of disease and joint damage over time. Bone scanning, a radioactive test procedure, can demonstrate the inflamed joints.
The doctor may elect to perform an office procedure called arthrocentesis. In this procedure, a sterile needle and syringe are used to drain joint fluid out of the joint for study in the laboratory. Joint fluid analysis can help to exclude other causes of arthritis, such as infection and gout. Arthrocentesis can also be helpful in relieving joint swelling and pain. Occasionally, cortisone medications are injected into the joint during the arthrocentesis in order to rapidly relieve joint inflammation and further reduce symptoms.
There is no known cure for rheumatoid arthritis. To date, the goal of treatment in rheumatoid arthritis is to reduce joint inflammation and pain, maximize joint function, and prevent joint destruction and deformity. Optimal treatment for the disease involves a combination of medications, rest, joint strengthening exercises, joint protection, and patient education. Treatment is customized according to factors such as disease activity, types of joints involved, general health, age, and patient occupation. Treatment is most successful when there is close cooperation between the doctor, patient, and family members.
Two classes of medications are used in treating rheumatoid arthritis: fast-acting "first-line drugs," and slow-acting "second-line drugs." The first-line drugs, such as aspirin and cortisone (corticosteroids), are used to reduce pain and inflammation. The slow-acting second-line drugs, such as gold, methotrexate and PLAQUENIL promote disease remission and prevent progressive joint destruction, but they are not anti-inflammatory agents.
The degree of destructiveness of rheumatoid arthritis varies from patient to patient. Patients with less destructive forms of the disease can be managed with rest and anti-inflammatory agents only. Patients with more aggressive disease require second-line drugs, such as gold, in addition to anti-inflammatory agents. In some patients with severe joint deformity, surgery may be necessary.
Acetylsalicylate (ASPIRIN), naproxen (NAPROSYN), ibuprofen (ADVIL, MEDIPREN, MOTRIN), and etodolac (LODINE) are examples of nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs are medications that can reduce tissue inflammation, pain and swelling. NSAIDs are not cortisone. Aspirin, in doses higher than that used in treating headaches and fever, is an effective anti-inflammatory medication for rheumatoid arthritis. Aspirin has been used for joint problems since the ancient Egyptian era. The newer NSAIDs are just as effective as aspirin in reducing inflammation and pain, and require fewer dosages per day. Patients' responses to different NSAID medications vary. Therefore, it is not unusual for a doctor to try several NSAID drugs in order to identify the most effective agent with the fewest side effects. The most common side effects of aspirin and other NSAIDs include stomach upset, abdominal pain, ulcers, and even gastrointestinal bleeding. In order to reduce stomach side effects, NSAIDs are usually taken with food. Additional medications are frequently recommended to protect the stomach from the ulcer effects of NSAIDs. These medications include antacids, sucralfate (CARAFATE), and misoprostol (CYTOTEC).
Corticosteroid medications can be given orally or injected directly into tissues and joints. They are more potent than NSAIDs in reducing inflammation, and in restoring joint mobility and function. Corticosteroids are useful for short periods during severe flares of disease activity, or when the disease is not responding to NSAIDs. However, corticosteroids can have serious side effects, especially when given in high doses for long periods of time. These side effects include weight gain, facial puffiness, thinning of the skin and bone, easy bruising, cataracts, risk of infection, muscle wasting, and destruction of large joints, such as the hips. These side effects can be partially avoided by gradually tapering the doses of corticosteroids after the patient has achieved a remission of the disease. Abruptly discontinuing corticosteroids can lead to flares of the disease or other symptoms of corticosteroid withdrawal, and is discouraged. Thinning of the bones due to osteoporosis may be prevented by calcium and vitamin D supplements.
While "first-line" medications (NSAIDs and corticosteroids) can relieve joint inflammation and pain, they do not necessarily prevent joint destruction or deformity. For patients with an aggressively destructive form of rheumatoid arthritis, medications other than NSAIDs and corticosteroids are needed. These "second-line" or "slow-acting" medicines (listed below) may take weeks to months to become effective. They are used for long periods of time, even years, at varying doses. If effective, they can promote remission, thereby retarding the progression of joint destruction and deformity.
Hydroxychloroquine (PLAQUENIL) is related to quinine, and is used in the treatment of malaria. It is used over long periods for the treatment of rheumatoid arthritis. Side effects include upset stomach, skin rashes, muscle weakness, and vision changes. Even though vision changes are rare, patients taking PLAQUENIL should be monitored by an eye doctor (opthalmologist).
Sulfasalazine (AZULFADINE) is an oral medication traditionally used in the treatment of mild to moderately severe inflammatory bowel diseases, such as ulcerative colitis and Crohn's colitis. AZULFADINE is used to treat rheumatoid arthritis in combination with anti-inflammatory medications. AZULFADINE is generally well tolerated. Common side effects include rash and upset stomach. Because AZULFADINE is made up of sulfa and salicylate compounds, it should be avoided by patients with known sulfa allergies.
Gold salts have been used to treat rheumatoid arthritis throughout most of this century. Gold thioglucose (SOLGANAL) and gold thiomalate (MYOCHRYSINE) are given by injection, initially on a weekly basis for months to years. Oral gold, auranofin (RIDAURA) was introduced in the 1980's. Side effects of gold (oral and injectable) include skin rash, mouth sores, kidney damage with leakage of protein in the urine, and bone marrow damage with anemia and low white cell count. Patients receiving gold treatment are regularly monitored with blood and urine tests. Oral gold can cause diarrhea.
D-penicillamine (DEPEN, CUPRIMINE) can be helpful in selected patients with progressive forms of rheumatoid arthritis. Side effects are similar to those of gold. They include fever, chills, mouth sores, a metallic taste in the mouth, skin rash, kidney and bone marrow damage, stomach upset, and easy bruising. Patients on this medication require routine blood and urine tests. D-penicillamine can rarely cause symptoms of other autoimmune diseases.
Immunosuppressive medicines are powerful medications that suppress the body's immune system. They include methotrexate (RHEUMATREX), azathioprine (IMURAN), cyclophosphamide (CYTOXAN), chlorambucil (LEUKERAN), and cyclosporin (SANDIMMUNE). Because of potentially serious side effects, immunosuppressive medicines are generally reserved for patients with very aggressive disease, or those with serious complications of rheumatoid inflammation, such as blood vessel inflammation (vasculitis). Methotrexate, however, is gaining in popularity among physicians as an initial second-line drug because of both its effectiveness and relatively infrequent side effects. Immunosuppresive medications can depress bone marrow function and cause anemia, a low white cell count and low platelets counts. A low white count can increase the risk of infections, while a low platelet count can increase the risk of bleeding. Methotrexate can also lead to liver cirrhosis and allergic reactions in the lung. Cyclosporin can cause kidney damage and high blood pressure. Because of potentially serious side effects, immunosuppressive medications are used in low doses, usually in combination with anti-inflammatory agents.
There is no special diet for rheumatoid arthritis. Fish oil may have anti-inflammatory effects, but so far this has only been shown in laboratory experiments studying inflammatory cells. Antibiotics have been tried for rheumatoid arthritis, but without proven effectiveness. Likewise, the benefits of cartilage preparations remain unproven. Symptomatic pain relief can often be achieved with oral acetaminophen (TYLENOL) or over-the-counter topical preparations, which are rubbed into the skin.
The areas of the body, other than the joints, that are affected by rheumatoid inflammation are treated individually. Sjogren's syndrome (described above) can be helped by artificial tears and humidifying rooms of the home or office. Regular eye check-ups and early antibiotic treatment for infection of the eyes are important. Inflammation of the tendons (tendinitis), bursae (bursitis) and rheumatoid nodules can be injected with cortisone. Inflammation of the lining of the heart and/or lungs may require high doses of oral cortisone.
Proper, regular exercise is important in maintaining joint mobility, and in strengthening the muscles around the joints. Swimming is particularly helpful because it allows exercise with minimal stress on the joints. Physical and occupational therapists are trained to provide specific exercise instructions and can offer splinting supports. For example, wrist and finger splints can be helpful in reducing inflammation and maintaining joint alignment. Devices, such as canes, toilet seat raisers, and jar grippers can assist daily living. Heat and cold applications are modalities that can ease symptoms before and after exercise.
Surgery may be recommended to restore joint mobility or repair damaged joints. Doctors who specialize in joint surgery are orthopedic surgeons. The types of joint surgery range from arthroscopy to partial and complete replacement of the joint. Arthroscopy is a surgical technique whereby a doctor inserts a tube-like instrument into the joint to see and repair abnormal tissues.
"Total joint replacement" is a surgical procedure whereby a destroyed joint is replaced with artificial materials. For example, the small joints of the hand can be replaced with plastic material. Large joints, such as the hips or knees, are replaced with metals.
Finally, minimizing emotional stress can help improve the overall health of the patient with rheumatoid arthritis. Support and extracurricular groups afford patients time to discuss their problems with others and learn more about their illness.
Scientists throughout the world are studying many promising areas of new treatment approaches for rheumatoid arthritis. These areas include monoclonal antibody therapy directed against a special inflammation factor called the tumor necrosis factor (TNFalpha), and against certain critical white blood cells involved in rheumatoid inflammation. Also, new NSAIDs with mechanisms of action which are different from current drugs are on the horizon. Studies involving various types of collagen are in progress and show encouraging signs of reducing rheumatoid disease activity.
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