CONDITIONS

Rheumatoid Arthritis

What Is Rheumatoid Arthritis

Rheumatoid Arthritis (RA) is a chronic, autoimmune, inflammatory arthritis. In rheumatoid arthritis, the body’s immune system attacks the synovium, a layer of tissue that lines the joints, causing painful swelling and inflammation that can eventually result in bone erosion and joint deformity. RA most often affects the joints of the hands and feet, although the inflammation can also affect other parts of the body, such as the skin, eyes, and blood vessels. According to the Arthritis Foundation, RA affects 1.3 million Americans, typically between the ages of 30 and 60.The CDC reports that as of 2009, arthritis and other rheumatic conditions (AORC) were the most common cause of disability among U.S. adults and had been for the previous 15 years. Out of those, RA was among the most debilitating; accounting for 22% of deaths due to AORC. People with RA are two times more likely to die than people of the same age without RA, though advancements in technology and research are producing promising treatment options.

What Causes Rheumatoid Arthritis

Rheumatoid arthritis occurs when the immune system attacks the membranous lining  of your joints, known as the synovium.  When this happens the inflammation thickens the lining. Eventually this process destroys cartilage and soft tissue between the bones, resulting in bone to bone contact. The friction caused by bone to bone contact can cause damage to the bones,  further inflammation in the joint, and severe pain with movement. The tendons and ligaments that hold the joint together also weaken and stretch. As the disease progresses, the joint may lose its shape and alignment.

B cells and T cells are components of the immune system that help create the inflammation typical of the rheumatoid arthritis. Both of these are lymphocytes, a classification of white blood cells. When a T cell discovers an antigen, it produces chemicals called cytokines. Cytokines make B cells proliferate and release antibodies to trigger inflammation   intended to fight the intruders. However, this beneficial process goes awry in autoimmune disorders such as RA so that T cells and B cells fight the body itself rather than foreign antigens.

The precise cause of the auto-immune response behind rheumatoid arthritis remains unknown, but researchers suspect that several factors, alone or in combination, may trigger this autoimmune disease. These triggers include an abnormal autoimmune response, genetics, a viral infection and hormonal changes such as those that occur during perimenopause and menopause.

Risk Factors For Rheumatoid Arthritis

While scientists are unsure of what exactly causes the immune system to attack The following factors may increase your risk of rheumatoid arthritis:

  • Gender. Seventy percent of people with rheumatoid arthritis are women.  Scientists at the Arthritis Research UK Epidemiology Unit at The University of Manchester in the UK recently identified genes specific to the female X-chromosome that may be associated with RA.
  • Age. Rheumatoid arthritis usually strikes between the ages of 40 and 60, but it can occur at any time.  According to the Centers for Disease Control, of peopleages 18–44, 7.3% report doctor-diagnosed arthritis. Of peopleages 45–64, 30.3% report doctor-diagnosed arthritis. Of people ages 65 or older, 49.7% report doctor-diagnosed arthritis.These statistics include both osteoarthritis and rheumatoid arthritis and are not broken down by type. However, the data clearly shoe the incidence of RA increases with age and is most likely to occur during midlife and beyond.
  • Genetics. People with specific human leukocyte antigen (HLA) genes have a greater chance of developing rheumatoid arthritis than people who do not have these genes. If someone in your immediate family has rheumatoid arthritis, you have an increased risk of the disease. An article published in the Journal of Rheumatology based on research done at the University of Athens Medical School in Greece reported that the odds ratio (OR) for developing RA is 4.4if a firstdegree relative (immediate family member) has the disease and 5.4if a female first degree relative has the disease. For women, the OR is 7.0if the first degree relative is female. When the analysis was restricted to parents only, it was found that mothers with RA predispose their daughters and sons to develop RA more (OR = 8.6 for daughters an, for both sexes) than fathers (OR = 1.1 and 1.9, respectively).

Diagnosing Rheumatoid Arthritis

Since there is no one definitive test for rheumatoid arthritis, doctors rely on a combination of the following:

  • Medical history. Patients are asked what symptoms they have been experiencing and for how long. Symptoms like joint pain, swelling, and difficulty moving might be indicators of MS.
  • Physical exam. With a physical exam, doctors can catch even tell tale signs of rheumatoid arthritis that the patient may have been unable to explain. These include swelling and tenderness around joints, limited joint mobility, and rheumatoid nodes (small lumps of tissue found under the skin near affected joints.)
  • Blood tests. Anemia (low red blood cell count) is one of the most common symptoms of rheumatoid arthritis. A red blood cell count, or RBC count, might be one of the first blood tests a doctor will conduct. Other blood tests can check for levels of certain proteins in the blood that may be indicators of RA, including: 
    • Rheumatoid factor, an antibody (immune system blood protein that fights against certain foreign invaders and even the body’s own cells) that can indicate RA-associated inflammation in the body. About 80% of people with RA will test positive for rheumatoid factor in time, though only 30% of people test positively at the time of their diagnosis.
    • Antibodies to cyclic citullinated peptides, or Anti-CCP,  which are found in 60-70% of people with RA.
  • Erythrocyte sedimentation rate (ESR). Also called ESR or “sed rate,” this test measures how fast red blood cells settle like sediment in the bottom of a glass tube over the course of about an hour. A high rate indicates inflammation that may be attributed to RA. However, an elevation of the sedimentation rate can sometimes develop as we age without the presence of illness. The physician will take into consideration the complete diagnostic picture in making a diagnosis of RA
  • C-reactive protein (CRP). This is a protein produced by the liver. For patients with rheumatoid arthritis, a high rate of CRP points to significant inflammation in the body. The test is more conclusive that ESR and is not affected by age so it a better indication of the presence of disease.

Imaging tests, including:

  • X-rays of the affected joints will show the following sings that are characteristic of RA:
  •   Bones that are closer to each other than they should be. This occurs as cartilage wears away and the joint space narrows.
  • Cysts in bones. In response to cartilage destruction, the body attempts to stabilize the joint and this can result in the formation of cysts or fluid-filled cavities in bones.
  • Increased bone density or uneven joints. Without a sufficient cushion of cartilage, bones rub against each other. In response to the resulting friction, the body creates extra layers of bone. The results are increased density and uneven joint surfaces, often with protrusions called osteophytes or bone spurs.
  • MRI (magnetic resonance imaging). This diagnostic tool can show soft tissue swelling and small cartilage or bone fragments in the joint that are indicative of RA.
  • CT (computed tomography) examinations demonstrate the degree of osteophyte (bone spur) formation and its relationship to the adjacent soft tissues.
  • Ultrasound can identify synovial cysts that may form in patients with RA.
  • Radionuclide Nuclear Medicine Bone Scans can image the entire skeleton, which is helpful if RA is suspected in multiple areas.

Symptoms of Rheumatoid Arthritis

Symptoms of RA can vary from patient to patient and may be mild, moderate, or severe. The following symptoms may be signs of rheumatoid arthritis:

  • Tender, warm , or swollen joints
  • Morning stiffness that may last for hours
  • Firm bumps of tissue under the skin on your arms (rheumatoid nodules)
  • Fatigue
  • Fever
  • Weight loss

Prognosis

RA is a progressive disease. Over time it causes increased joint destruction and restricted movement. Symptoms can vary greatly among people and  can often be controlled with treatment. According to the Arthritis Foundation, achieving arthritis remission may be well within the grasp of nearly half of the 1.5 million Americans with rheumatoid arthritis. The earlier you begin rheumatoid arthritis treatment, the better your odds are. MedlinePlus, a service of the National Library of Medicine, states that how well a person does depends on the severity of symptoms. People with rheumatoid factor, the anti-CCP antibody, or subcutaneous nodules seem to have a more severe form of the disease. People who develop RA at a younger age also seem to get worse more quickly.

Living With Rheumatoid Arthritis

The American College of Rheumatology offers the following tips:

  • Be physically active, but scale back when the disease flares. Rest when a joint is inflamed or when you feel tired.
  • Engage in gentle range-of-motion exercises daily, such as stretching. This will keep the joints flexible.
  • Eat a healthy diet. While there is no special diet for RA, certain foods and nutrients can help keep inflammation at bay. For example, omega-3 fatty acids found in fatty fish. Calcium-rich foods are important for countering the bone loss that can happen if you take corticosteroids. Good sources of calcium include dairy products, green, leafy vegetables, and fortified breakfast cereals and juices.
  • Seek early treatment. Studies show that people who receive early treatment feel better sooner and are more likely to lead an active life.
  • Take your medications as prescribed
  • If you feel down, speak with your doctor about visiting a mental health expert.
  • Get plenty of rest but don’t stay in bed. In general, it’s better to take short rest breaks during the day than to spend long periods in bed, because staying active helps to keep joints as mobile as possible. Long periods of simply lying down can make you more stiff than necessary.
  • Protect your joints. Immobilizing a sore joint with a splint allows it to rest and may help reduce pain and swelling. Walking aids such as canes and a walker can also help you rest and protect sore joints

Screening

There is no one blood test or physical finding to confirm an RA diagnosis. There are currently no tests that can accurately screen for rheumatoid arthritis in people who aren’t experiencing symptoms. RA is therefore not screened for by most primary care physicians. If you are experiencing any of the symptoms of RA, schedule a visit with your doctor. He or she will be able to perform the appropriate diagnostic tests to determine whether or not you have the disease

Prevention

There is no way to prevent RA but there are medications and treatments that may slow its progression and help reduce inflammation and pain.

Medication And Treatment

There are several drugs available to help slow RA progression and lessen the severity of symptoms. As the disease progresses, you may require stronger doses or a combination of drugs.

Speak with your doctor about side effects of the following frequently prescribed medications:

Medications

  • NSAIDs. Non-steroidal anti-inflammatory drugs (NSAIDs) can relieve pain and reduce inflammation.  You can purchase over-the-counter NSAIDs including ibuprofen (Advil, Motrin IB) and naproxen sodium (Aleve). Stronger NSAIDs are available by prescription.  Side effects may include Edema (swelling of the feet) heartburn, stomach upset and stomach ulcers and possibly increased risk of blood clots, heart attack and stroke. Prescription NSAIDs include:
    •  Celecoxib (Celebrex)
    • Diclofenac (Cataflam, Voltaren)
    • Diflunisal (Dolobid)
    • Etodolac (Lodine)
    • Fenoprofen (Nalfon)
    • Flurbiprofen (Ansaid)
    • Indomethacin (Indocin)
      Ketoprofen (Oruvail, Orudis)
    • Ketorolac (Toradol)
    • Meloxicam (Mobic)
    • Nabumetone (Relafen)
    • Oxaprozin (Daypro)
    • Piroxicam (Feldene)
    • Salsalate (Amigesic)
    • Sulindac (Clinoril)
    • Tolmetin (Tolectin)
  • Steroids. Corticosteroid medications, such as prednisone, reduce inflammation and pain and slow joint damage. Side effects may include cataracts, elevated blood fats and blood sugar levels, increased appetite and bone loss.
  • Disease-modifying antirheumatic drugs (DMARDs) can slow the progression of rheumatoid arthritis and save the joints and other tissues from permanent damage. Common DMARDs include methotrexate (Trexall), leflunomide (Arava), hydroxychloroquine (Plaquenil) and sulfasalazine (Azulfidine). Side effects may include Stomach upset and increased susceptibility to infection. Other side effects vary by drug.
  • Immunosuppressants can slow an out of control immune system. Examples include azathioprine (Imuran, Azasan) and cyclosporine (Neoral, Sandimmune, Gengraf). These may increase the risk of infections.
  • TNF-alpha inhibitors can help reduce pain, morning stiffness, and tender or swollen joints. Examples include etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira), golimumab (Simponi) and certolizumab (Cimzia).  Side effects of these injectable drugs can include injection or infusion site reactions, including redness and swelling, and increased risk of serious infections.

Treatments

  • Physical therapy. A physical therapist can be helpful in rehabilitating stiff or immobile joints. A recent study suggested that a warm wax bath, in combination with physical exercises, can amount to more significant improvements than just exercise alone. The wax bath alone was not effective.
  • Hot and Cold Compresses.  Most doctors recommend cold compresses to reduce joint swelling and inflammation and heat to relax your muscles and stimulate blood flow.]
  • Surgery. There are several types of surgery that may be beneficial for arthritis patients:

o   Arthroplasty (Total Joint Replacement) is a procedure in which damaged joints including hips, knees, and shoulders are excised and replaced with internal prostheses made of plastic and metal. Risks include infections, blood clots, and the possibility that the artificial joint may loosen over time so that another surgery is necessary. The failure rate for total hip replacements among women is higher than that among men, according to a study done at Southern California Permanente Medical Group, San Diego. Women with an average age of 66 made up 57.5% of the participants. After an average of three years following the operation, 2.3% of women and 1.9% of men underwent an additional surgery to correct a problem.

o   Tendon Repair. If the whole joint does not need to be removed, doctors may choose to repair damaged tendons or remove portions of inflamed tissue or debris.

o   Joint Fusion. Surgically fusing joints may be a favorable option for patients who do not need complete joint replacement but are in need of increased joint stability. This procedure is common in cases where RA affects the neck or joints, locations where joint replacement is not as accessible as in the knee or hips.

Patients with RA are not good candidates for osteotomy (bone realignment) of the knee, a procedure often used to treat osteoarthritis.  RA patients are also not good candidates for partial knee replacements, another procedure often used to treat osteoarthritis.

Complementary and Alternative Treatment

According to the National Center for Complementary and Alternative Medicine (NCCAM), although some of these natural treatments, supplements and dietary choices may help RA, none of these approaches is fully grounded in science and many have not have been completely tested for side effects. Speak with your doctor before you use any of the following remedies

  • Mind/Body therapies. These include meditation, deep breathing, progressive muscle relaxation, visualization, tai chi, biofeedback and acupuncture. Studies show these methods can relieve stress, and in some instances reduce pain.
  • Supplements. There’s some research that shows RA may be eased with fish oil and thunder god vine supplements. But the studies are small and preliminary. Fish oil studies show that omega-3 fatty acids in fish oil have an anti-inflammatory effect in the body. A few studies have shown a  decrease in inflammation and tender joints in people with RA taking thunder god vine. A large government-funded study that compared this root with sulfasalazine (a traditional drug used to treat RA) found that symptoms improved more with the use of thunder god vine.

When To Contact A Doctor

Call your doctor if:

  • You have persistent discomfort and swelling in your joints.
  • You may experience side effects from medications
  • You experience complications of joint surgery. 

Questions For A Doctor

If your doctor has diagnosed your condition as rheumatoid arthritis, you might be feeling anxious about your future. Knowledge is power so don’t be afraid to ask questions such as the following:

  • How far along is my arthritis? How damaged are my joints?
  • What medications do you think are right for me?
  • What are their potential side effects? What should I do if I experience any of the side effects?
  • Is there anything special I should take if the pain gets really bad? 
  • What lifestyle changes should I make to reduce or prevent RA flare ups?
  •  Should I go to physical therapy or get an occupational therapist?
  • How frequently should I see you?
  • How will I know when it’s time to change my treatment plan?