Rheumatoid Arthritis



What is rheumatoid arthritis?

  • Arthritis is a general term that describes inflammation in joints. Inflammation is characterized by redness, warmth, swelling, and pain in the joint.
  • Rheumatoid arthritis is a type of chronic (ongoing) arthritis that occurs in joints on both sides of the body (such as both hands, wrists, and/or knees). This symmetric multiple joint involvement helps distinguish rheumatoid arthritis from other types of arthritis.
  • In addition to affecting the joints, rheumatoid arthritis may occasionally affect organs outside of the joints including the skin, eyes, lungs, heart, blood, nerves, or kidneys.

 

RA is the most common form of autoimmune arthritis, affecting more than 0.8-1% Indian population. Of these, about 75 percent are women. In fact, 1–3 percent of women may get rheumatoid arthritis in their lifetime.

 

  • The disease most often begins between the fourth and sixth decades of life. However, RA can start at any age ; however, young children and the elderly can also develop rheumatoid arthritis.
  • Treatments have improved greatly and help many of those affected. For most people with RA, early treatment can control joint pain and swelling, and lessen joint damage.
  • Perform low-impact aerobic exercises, such as walking, and exercises to boost muscle strength. This will improve your overall health and reduce pressure on your joints.
  • Studies show that people who receive early treatment for RA feel better sooner and more often, and are more likely to lead an active life. They also are less likely to have the type of joint damage that leads to joint replacement.

 

 

What causes rheumatoid arthritis?

  • The exact cause of rheumatoid arthritis is unknown. However, it is believed to be caused by a combination of genetic factors, abnormal immunity,environmental factors, and hormonal factors.
  • Normally, the immune system protects the body from disease. In rheumatoid arthritis, something triggers the immune system to attack the joints and sometimes other organs.
  • Suspected triggering factors for rheumatoid arthritis are infections, cigarette smoking and stress physical or emotional.
  • Gender ,heredity, and genes largely determine a person’s risk of developing rheumatoid arthritis.
  • In RA, the focus of the inflammation is in the synovial, the tissue that lines the joint. Immune cells release inflammation-causing chemicals. These chemicals can damage cartilage (the tissue that cushions between joints) and bone.

What are the results of joint inflammation?

  • Ultimately, uncontrolled inflammation leads to joint deformities due to destruction and wearing down of the cartilage which normally acts as a “shock absorber” in between joints.
  • Eventually the bone itself erodes potentially leading to fusion of the joint which represents an effort of the body to protect itself from constant irritation from excessive inflammation.
  • This process is mediated by specific cells and substances of the immune system which are produced locally in the joints but also circulate in the body causing systemic symptoms

What are the symptoms of rheumatoid arthritis?

  • Joint pain RA is a chronic (long-term) disease that causes pain, stiffness, swelling and limited motion and function of many joints. While RA can affect any joint, the small joints in the hands and feet tend to be involved most often
  • Stiffness – especially in the morning or after sitting for long periods
  • Inflammation sometimes can affect organs as well, for instance, the eyes or lungs.
  • Other signs and symptoms that can occur in RA include: Loss of energy, Low fevers, Loss of appetite, Dry eyes and mouth from a related health problem, Sjogren’s syndrome
  • Firm lumps, called rheumatoid nodules, which grow beneath the skin in places such as the elbow and hands

How does rheumatoid arthritis affect people?

  • Rheumatoid arthritis affects each individual differently. In most people, joint symptoms may develop gradually over several years. In other people, rheumatoid arthritis may progress rapidly.
  • A few people may have rheumatoid arthritis for a limited period of time and then enter a remission (a timewith no symptoms).

How is rheumatoid arthritis diagnosed?

  • RA can be hard to detect because it may begin with subtle symptoms, such as achy joints or a little stiffness in the morning. Also, many diseases behave like RA early on.
  • Diagnosis of RA depends on the symptoms and results of a physical exam, such as warmth, swelling and pain in the joints.
  • Some blood tests also can help confirm RA. Telltale signs include:
    • Anemia (a low red blood cell count)
    • Rheumatoid factor (an antibody, or blood protein, found in about 80 percent of patients with RA in time, but in as few as 30 percent at the start of arthritis)
    • Antibodies to cyclic citrullinated peptides (pieces of proteins), or anti-CCP for short (found in 60–70 percent of patients with RA)
    • Elevated erythrocyte sedimentation rate (a blood test that, in most patients with RA, confirms the amount of inflammation in the joints)
    • X-rays can help in detecting RA, but may not show anything abnormal in early arthritis. Even so, these first X-rays may be useful later to show if the disease is progressing. Often, MRI and ultrasound scanning are done to help judge the severity of RA.
  • There is no single test that confirms an RA diagnosis for most patients with this disease. (This is above all true for patients who have had symptoms fewer than six months.) Rather, a doctor makes the diagnosis by looking at the symptoms and results from the physical exam, lab tests and X-rays.

How is rheumatoid arthritis treated?

The goals of rheumatoid arthritis treatment are as follows:

  • To control a patient’s signs and symptoms
  • To prevent joint damage
  • To 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 early diagnose and treat RA in the so called “window of opportunity” to prevent long term consequences.

Non-pharmacologic therapies

Non-pharmacologic therapies include treatments other than medications and are the foundation of treatment for all people with rheumatoid arthritis.

Rest
  • When joints are inflamed, the risk of injury of the joint itself and the adjacent 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. At the same time, maintaining a good range of motion in your joints and good fitness overall are important in coping with the systemic features of the disease.
Exercise :
  • 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 further 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. Types of exercises that have been shown to be beneficial 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.
  • Occupational therapists also focus on helping people with rheumatoid arthritis to be able to 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 is one risk factor for coronary disease that can respond to changes in diet.
  • A nutritionist can recommend specific foods to eat or avoid in order to achieve a desirable cholesterol level.
  • Changes in diet have been investigated as treatments for rheumatoid arthritis, but there is no diet that is proven to cure rheumatoid arthritis.
  • No herbal or nutritional supplements, such as cartilage or collagen, can cure rheumatoid arthritis. These treatments can be dangerous and are not usually recommended.

Smoking and alcohol

  • Smoking is a risk factor for rheumatoid arthritis and it has been shown that quitting smoking can improve the condition. People who smoke need to quit completely.
  • Moderate alcohol consumption is not harmful to rheumatoid arthritis, although it may increase the risk of liver damage from some drugs such as methotrexate.

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. It is important to do risk assessment and address risk factors that can be changed in order to help prevent bone loss. Patients may do the following to help minimize the bone loss associated with steroid therapy:

  • Therapy for RA has improved greatly in the past 30 years. Current treatments give most patients good or excellent relief of symptoms and let them keep functioning at, or near, normal levels. With the right medications, many patients can achieve “remission” — that is, have no signs of active disease.
  • There is no cure for RA. The goal of treatment is to lessen your symptoms and poor function.
  • Doctors do this by starting proper medical therapy as soon as possible, before your joints have lasting damage.
  • No single treatment works for all patients. Many people with RA must change their treatment at least once during their lifetime.
  • Good control of RA requires early diagnosis and, at times, aggressive treatment.
  • Thus, patients with a diagnosis of RA should begin their treatment with disease-modifying antirheumatic drugs — referred to as DMARDs. These drugs not only relieve symptoms but also slow progression of the disease.
  • Often, doctors prescribe DMARDs along with nonsteroidal anti-inflammatory drugs or NSAIDs and/or low-dose corticosteroids, to lower swelling, pain and fever.
  • DMARDs have greatly improved the symptoms, function and quality of life for nearly all patients with RA. Common DMARDs include methotrexate ,leflunomide (Arava), hydroxychloroquine and sulfasalazine
  • An improvement in symptoms may require four to six weeks of treatment with methotrexate. Improvement may require one to two months of treatment with sulfasalazine and two to three months of treatment with hydroxycholoroquine.

Patients with more serious disease may need medications called biologic response modifiers or “biologic agents.” Usually they are reserved for patients who do not adequately respond to DMARDs, or if adverse prognostic factors

  • They can target the parts of the immune system and the signals that lead to inflammation and joint and tissue damage. FDA-approved drugs of this type include abatacept (Orencia), adalimumab (Humira), anakinra,certolizumab (Cimzia), etanercept (Enbrel), golimumab (Simponi) infliximab (Remicade), rituximab  and tocilizumab  (Actemra). Most often, patients take these drugs with methotrexate, as the mix of medicines is more helpful.
  • DMARDs and biologic agents interfere with the immune system’s ability to fight infection and should not be used in people with serious infections.
  • Testing for tuberculosis (TB) is needed before starting DMARD and antiTNF therapy.
  • People who have evidence of prior TB infection should be treated for TB because there is an increased risk of developing active TB while receiving antiTNF therapy.
  • AntiTNF agents are not recommended for people who have lymphoma or who have been treated for lymphoma in the past. People with rheumatoid arthritis speciall those with severe diseasehave an increased risk of lymphoma regardless of what treatment is used.
  • Janus kinase (JAK) inhibitors are another type of DMARD. People who cannot be treated with methotrexate alone may be prescribed a JAK inhibitor such as tofacitinib (Xeljanz).
  • The best treatment of RA needs more than medicines alone.
  • You will need frequent visits through the year with your rheumatologist. These checkups let your doctor track the course of your disease and check for any side effects of your medications.
  • You likely also will need to repeat blood tests and X-rays or ultrasounds from time to time.

Surgery

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.

Living with rheumatoid arthritis

  • Research shows that people with RA, mainly those whose disease is not well controlled, have a higher risk for heart disease and stroke. Talk with your doctor about these risks and ways to lower them.
  • It is important to be physically active most of the time, but to sometimes scale back activities when the disease flares.
  • In general, rest is helpful when a joint is inflamed, or when you feel tired. At these times, do gentle range-of-motion exercises, such as stretching. This will keep the joint flexible.
  • When you feel better, do low-impact aerobic exercises, such as walking, and exercises to boost muscle strength. This will improve your overall health and reduce pressure on your joints.
  • A physical or occupational therapist can help you find which types of activities are best for you, and at what level or pace you should do them.
  • Finding that you have a chronic illness is a life-changing event. It can cause worry and sometimes feelings of isolation or depression. Use the lowest possible dose of glucocorticoids for the shortest possible time, when possible, to minimize bone loss.
  • Consume an adequate amount of calcium and vitamin D, either in the diet or by taking supplements.