Rheumatoid Arthritis
Rheumatoid Arthritis (RA) is a chronic (long-term) condition that causes pain, swelling, and stiffness in the joints. It is a systemic rheumatic disease, which means that the disease can affect the entire body.
It is one of the most common types of inflammatory arthritis and is estimated to affect 1% of the population.
Autoimmune Disease
RA is an autoimmune disease, meaning that it occurs when the body’s immune system attacks its own healthy cells and tissues. The reason why it does this is not well understood. When the body’s immune system is “activated” in this way, it can make a person feel very tired, similar to when they have the flu.
Importance of Early Treatment
It is very important that RA is treated as early and aggressively as possible to put out the “fire” in patients’ joints. This prevents further joint damage that can ultimately have crippling effects, and can reduce the risk of other problems associated with chronic inflammation, such as heart disease.
With proper treatment, many patients with RA can enjoy active and productive lives, and prevent long-term damage to their joints.
Who Gets RA
People usually notice the first signs of RA between the ages of 25 and 50. The disease is about three times more common in women than men.
Understanding RA
Symptoms
Pain and Swelling in the Joints
Rheumatoid arthritis causes pain and swelling in the joints. This causes them to feel stiff and sore, especially in the morning. Rheumatoid arthritis usually starts slowly and affects only a few joints. It might start in a knee, a wrist, the hands, or even the feet. Over weeks to months, it can start to affect other joints.
In some people, RA seems to jump around from joint to joint. One day one joint will be stiff and sore, and then the next day that joint feels fine but something else is sore. When this happens, people might start to feel like they’re going crazy. Some patients describe RA as having a mind of its own.
Although it’s rare, RA can sometimes seem to appear suddenly overnight. Those unlucky people might go to bed feeling well, but in the morning they might feel like they can’t get out of bed.
Like many other autoimmune disorders, RA tends to flare. These are periods of increased activity where signs and symptoms are more pronounced and severe, versus other periods when they are more mild.
Fatigue
Fatigue is a common symptom because the body’s immune system is “activated” and attacking its own joints and tissues. This can make a person feel very tired, similar to when they have the flu.
Other Symptoms
RA can also affect other organs and tissues throughout the body including the skin, eyes, lungs, heart, kidneys, glands, nerves, bone marrow and blood vessels. This can cause a variety of other symptoms depending on which parts of the body are affected.
Diagnosis
Rheumatoid arthritis is best diagnosed by a rheumatologist, a type of doctor that is a specialist in arthritis and autoimmune diseases.
To diagnose RA, a doctor will take a complete history and perform a thorough physical examination. They will usually order blood tests and x-rays to help confirm their diagnosis.
Common Tests to Diagnose RA
No single test can diagnose RA so the doctor will piece together clues from all of their investigations to reach the diagnosis.
In some patients, certain blood tests can appear normal even though they have RA.
Blood Tests
Looking for inflammation: RA is an inflammatory arthritis so these tests are expected to have abnormal results. Common tests include a Complete Blood Count (CBC), Erythrocyte Sedimentation Rate (ESR), and C-Reactive Protein (CRP).
Looking for antibodies – Rheumatoid Factor: Rheumatoid Factor (RF) is a type of autoantibody, an antibody that target the body’s own tissues. Elevated levels are present in 80% of people with RA. Positive tests are possible from other causes, and people who test negative can still have RA, so the test results are taken into context with other symptoms and tests.
Looking for antibodies – anti-CCP: The Anti-Cyclic Citrullinated Peptide Antibody (anti-CCP) test looks for anti-citrullinated protein antibodies (ACPAs). These are autoantibodies, or antibodies that target something the body’s own tissues are made of. ACPAs specifically target a type of protein that is described as citrullinated. This type of autoantibody is present in 60-70% of people who get RA. Since not everyone with RA will test positive, the test results are taken into context with other symptoms and tests.
Scans
X-Rays: X-rays can show damage to the joints caused by RA and can help doctors track the progression of the disease over time.
Causes
Rheumatoid arthritis (RA) is an autoimmune disease that occurs when the body’s immune system begins to attack its own joints. The reason that it does this is not yet understood.
A variety of factors may be involved including genetics, hormones, and environmental factors.
Treatments
Rheumatoid arthritis should be treated early and aggressively. Research tells us that if RA is treated early, patients are much more likely to get into remission, a state where they no longer feel the signs or symptoms of the disease. Even a few months can make a difference.
RA is linked to heart disease, so patients should also keep their blood pressure and cholesterol at healthy levels.
For those with diabetes, it’s important to keep blood sugar under control.
Any patients who smoke should quit as soon as possible because smoking is known to worsen symptoms and can make RA a lot more difficult to treat.
It is important for patients to attend their rheumatologist appointments regularly, and promptly get any blood tests requested by their doctors.
Surgery for Severe Cases
In the most severe cases of RA, some joints can become so badly damaged that they no longer function. If this happens, surgery might help. Surgery usually involves replacing a damaged joint with an artificial joint. Surgery can help people with severe, advanced RA by reducing pain, improving mobility, and restoring function.
Medications that Treat RA
Medications for RA fall into two broad groups. The first group is medications that help control the symptoms of RA. The second group of medications control the disease and prevent long-term joint damage.
Patients prescribed any of these should ask their doctor to confirm that alcohol, or any supplements or alternative therapies they take, will not cause negative interactions.
No known natural remedies or complementary therapies that have been proven to help RA in any significant way.
NSAID Medications for Inflammation and Pain
Non-Steroidal Anti-Inflammatory Drugs or NSAIDs are medications that reduce the inflammation of joints caused by RA. They also help to reduce symptoms such as pain. There are about 20 different anti-inflammatory medications available, so if one doesn’t work for someone, their doctor can recommend another one to try. NSAIDs do not prevent disease progression.
Corticosteroids (prednisone)
Medications like prednisone can help control inflammation in some people. It can also help control symptoms of pain and stiffness. It is usually used in high doses for short periods of time. When used for long periods of time, prednisone can have side effects.
Some people with RA also benefit from cortisone injections directly into affected joints.
People with RA should to discuss the risks and benefits of using corticosteroids with their rheumatologist.
Analgesic Medications for Pain
Analgesic medications only control pain. They do nothing to control the disease or to prevent further joint damage. Analgesics can range from simple things like acetaminophen (paracetamol, Tylenol) to more potent narcotics like morphine.
Disease Modifying Anti-Rheumatic Drugs (DMARDs)
Disease Modifying Anti-Rheumatic Drugs (DMARDs) should be used to treat everyone with Rheumatoid Arthritis. They are often used in combination to provide effective treatment.
Methotrexate is the most commonly used DMARD to treat RA. It is given once a week as tablets or a small injection under the skin. The injection tends to work better than the tablets and can have fewer side effects.
Other types of DMARDs work well for treating RA include: Sulfasalazine, Arava (leflunomide), Gold (myochrisine), and Plaquenil (Hydroxychloroquine). DMARDs are often combined together. A common combination called triple therapy consists of Methotrexate, Sulfasalazine, and Plaquenil.
Advanced Therapeutics
Patients with RA whose joint pain and stiffness aren’t adequately controlled by anti-inflammatory medications and DMARDs can be treated by a class of medications called advanced therapeutics. Advanced therapeutics consist of biologic medications and small molecules. These medications are extremely effective and can make a big difference for people with the disease.
A type of biologic called anti-TNF biologics was first introduced in 1998. These work very well for many people with PsA. Today, a number of anti-TNF biologics are available including Humira, Remicade/Inflectra/Remsima, Enbrel, Cimzia, and Simponi. Other biologics target other aspects of the inflammatory response, including Orencia, Rituxan, Actemra, Kevzara, and Kineret. Biologics are given by an injection under the skin or an intravenous infusion.
A newer class of medications called small molecules which block other parts of the immune system can be very effective treatments. Examples of available small molecules include Xeljanz.
With many advanced therapeutics to choose from, if one doesn’t work for someone, their rheumatologist may suggest another.