Rheumatoid arthritis

Definition

Rheumatoid arthritis (RA) is a long-term disease that causes inflammation of the joints and surrounding tissues. It can also affect other organs.

Alternative Names

Causes

The cause of RA is unknown. It is considered autoimmune disease. The body's immune system normally fights off foreign substances, like viruses. But in an autoimmune disease, the immune system confuses healthy tissue for foreign substances. As a result, the body attacks itself.

RA can occur at any age. Women are affected more often than men.

RA usually affects joints on both sides of the body equally. Wrists, fingers, knees, feet, and ankles are the most commonly affected. The course and the severity of the illness can vary considerably. Infection, genes, and hormones may contribute to the disease.

Symptoms

The disease usually begins gradually with:

• Fatigue
• Morning stiffness (lasting more than 1 hour)
• Widespread muscle aches
• Loss of appetite
• Weakness

Eventually, joint pain appears. When the joint is not used for a while, it can become warm, tender, and stiff. When the lining of the joint becomes inflamed, it gives off more fluid and the joint becomes swollen. Joint pain is often felt on both sides of the body, and may effect the wrist, knees, elbows, fingers, toes, ankle or neck.

Additional symptoms include:

• Anemia due to failure of the bone marrow to produce enough new red cells
• Eye burning, itching, and discharge
• Hand and feet deformities
• Limited range of motion
• Low-grade fever
• Lung inflammation (pleurisy)
• Numbness or tingling
• Paleness
• Round, painless nodules under the skin (usually a sign of more severe disease)
• Skin redness or inflammation
• Swollen glands

Joint destruction may occur within 1-2 years after the appearance of the disease.

Exams and Tests

A specific blood test is available for diagnosing RA and distinguishing it from other types of arthritis. It is called the anti-CCP antibody test. Other tests that may be done include:

• Complete blood count
• C-reactive protein
• Erythrocyte sedimentation rate
• Joint x-rays
• Rheumatoid factor test (positive in about 75% of people with symptoms)
• Synovial fluid analysis

Treatment

RA usually requires lifelong treatment, including medications, physical therapy, exercise, education, and possibly surgery. Early, aggressive treatment for RA can delay joint destruction.

MEDICATIONS

Disease modifying antirheumatic drugs (DMARDs): These drugs are the current standard of care for RA, in addition to rest, strengthening exercises, and anti-inflammatory drugs. Methotrexate (Rheumatrex) is the most commonly used DMARD for rheumatoid arthritis. Leflunomide (Arava) may be substituted for methotrexate.

Anti-inflammatory medications: These include aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and others. Although NSAIDs work well, long-term use can cause stomach problems, such as ulcers and bleeding, and possible heart problems. NSAIDs now carry warning labels on their product that alerts users of an increased risk for cardiovascular events and gastrointestinal bleeding.

Cyclooxygenase-2 (COX-2) inhibitors: These drugs block an inflammation-promoting enzyme called COX-2. This class of drugs was initially believed to work as well as traditional NSAIDs, but with fewer stomach problems. However, numerous reports of heart attacks and stroke have prompted the FDA to re-evaluate the risks and benefits of the COX-2s. Celecoxib (Celebrex) is still available, but labeled with strong warnings and a recommendation that it be prescribed at the lowest possible dose for the shortest duration possible. Talk to your doctor about whether COX-2s are right for you.

Antimalarial medications: This group of medicine includes hydroxychloroquine (Plaquenil) and sulfasalazine (Azulfidine), and is usually with methotrexate. It may be weeks or months before you see any benefit from these medications. Because they are associated with toxic side effects, you will need frequent blood tests.

Tumor necrosis factor (TNF) inhibitors: This relatively new class of medications block an inflammatory protein. Such medicines include etanercept (Enbrel), infliximab (Remicade), and adalimumab (Humira).

Human interleukin-1 receptor antagonist: Anakinra (Kineret) is a man-made protein that blocks the inflammatory protein interleukin-1. The drug is used to slow the progression of moderate to severe active RA in patients over 18 who have not responded to one or more of the DMARDs. Kineret can be used with other DMARDs or TNF inhibitors.

Biologics: Two new medicines are available for persons with some types of RA that do not respond to TNF inhibitors. They include Orencia (abatacept) and Rituxan (rituximab). They are both given through a vein.

Immunosuppressants: These drugs are sometimes used in people who have failed other therapies. These medications are associated with toxic side effects and usually reserved for severe cases of RA.

Corticosteroids: These medications have been used to reduce inflammation in RA for more than 40 years. However, because of potential long-term side effects, corticosteroid use is usually limited to short courses and low doses where possible.

SURGERY

Occasionally, surgery is needed to correct severely affected joints. Surgeries can relieve joint pain, correct deformities, and modestly improve joint function.

The most successful surgeries are those performed on the knees and hips. The first surgical treatment is a synovectomy, which is the removal of the joint lining (synovium).

A later alternative is total joint replacement with a joint prosthesis. In extreme cases, total knee or hip replacement can mean the difference between being totally dependent on others and having an independent life at home.

PHYSICAL THERAPY

Range-of-motion exercises and individualized exercise programs prescribed by a physical therapist can delay the loss of joint function.

Joint protection techniques, heat and cold treatments, and splints or orthotic devices to support and align joints may be very helpful.

Sometimes therapists will use special machines to apply deep heat or electrical stimulation to reduce pain and improve joint mobility.

Occupational therapists can construct splints for your hand and wrist, and teach you how to best protect and use your joints when they are affected by arthritis. They also show people how to better cope with day-to-day tasks at work and at home, despite limitations caused by RA.

Frequent rest periods between activities, as well as 8 to 10 hours of sleep per night, are recommended.

Support Groups

For additional information and resources, see arthritis support group.

Outlook (Prognosis)

Regular blood or urine tests should be done to determine how well medications are working and if drugs are causing any side effects.

The course of RA differs from person to person. People with rheumatoid factor or subcutaneous nodules seem to have a more severe form of the disease. People who develop RA at younger ages also have a more rapidly progressive course.

Many people with RA work full-time. However, after many years, about 10% of patients are severely disabled, and unable to do simple daily living tasks such as washing, dressing, and eating.

The average life expectancy for a patient with RA may be shortened by 3 to 7 years. Those with severe forms of RA may die 10-15 years earlier than expected. However, as treatment for rheumatoid arthritis improves, severe disability and life-threatening complications appear to be decreasing.

Possible Complications

Rheumatoid arthritis is not solely a disease of joint destruction. It can involve almost all organs.

A life-threatening joint complication can occur when the cervical spine becomes unstable as a result of RA.

Rheumatoid vasculitis (inflammation of the blood vessels) is a serious, potentially life-threatening complication of RA. It can lead to skin ulcerations and infections, bleeding stomach ulcers, and nerve problems that cause pain, numbness, or tingling. Vasculitis may also affect the brain, nerves, and heart, which can cause stroke, heart attack, or heart failure.

RA may cause the the outer lining of the heart to swell (pericarditis) and cause heart complications. Inflammation of heart muscle, called myocarditis, can also develop. Both of these conditions can lead to congestive heart failure.

The treatments for RA can also cause serious side effects. If you experience any side effects, immediately tell your health care provider.

When to Contact a Medical Professional

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

Prevention

Rheumatoid arthritis has no known prevention. However, it is often possible to prevent further damage of the joints with proper early treatment.

Because RA may cause eye complications, patients should be have regular eye exams.

US Food and Drug Administration. FDA Announces Series of Changes to the Class of Marketed Non-Steroidal Anti-Inflammatory Drugs (NSAIDs). Rockville, MD: National Press Office; April 7, 2005. Press Release P05-16.

US Food and Drug Administration. FDA Issues Public Health Advisory Recommending Limited Use of Cox-2 Inhibitors. Rockville, MD: National Press Office; December 23, 2004. Talk Paper T04-61.