Alternate Names: RA

Causes and Risks:

The cause of rheumatoid arthritis (RA) is unknown. In fact, it is possible that there is no single cause of RA. Infectious, genetic, and hormonal factors may play a role. The disease can occur at any age, but the peak incidence of disease onset is between the ages of 25 and 55. The incidence increases with age. Women are affected 2.5 times more often than men. Approximately 1-2% of the total population is affected. The course and the severity of the illness can vary considerably between patients. Most importantly, RA can eventually affect an individual’s functional ability to perform daily activities and overall quality of life.

The onset of the disease is usually gradual, with fatigue, morning stiffness lasting more than one hour, diffuse muscular aches, loss of appetite, and weakness. Eventually, joint pain appears, with warmth, swelling, tenderness, and stiffness of the joint after inactivity.

Joint involvement in RA affects both sides of the body equally; the arthritis is therefore referred to as symmetrical. Wrists, fingers, knees, feet and ankles are the most commonly affected joints. Severe disease is associated with larger joints that contain more synovium (joint lining). When the synovium becomes inflamed, it secretes more fluid and the joint becomes swollen. Later, the cartilage becomes rough and pitted. The underlying bone eventually becomes affected. Joint destruction begins 1-2 years after the appearance of the disease. Characteristic deformities result from cartilage destruction, bone erosions, and tendon inflammation and rupture. A life-threatening joint complication can occur when the cervical spine becomes unstable secondary to RA.

Other features of the disease that do not involve the joints may occur. Rheumatoid nodules are painless, hard round or oval masses that appear under the skin, usually on pressure points such as the elbow or Achilles tendon. These are present in about 20% of cases. On occasion, they appear in the eye where they sometimes cause inflammation. If they occur in the lungs, inflammation of the lining of the lung (pleurisy) may occur, causing shortness of breath.

Anemia may occur due to failure of the bone marrow to produce enough new red cells to make up for the lost ones. Iron supplements will not help this condition because iron utilization in the body becomes impaired. Other blood abnormalities can also be found, for example, platelet counts that are either too high or too low (cells important in blood clotting).

Rheumatoid vasculitis (inflammation of the blood vessels) is a serious complication of RA and can be life threatening. It can lead to skin ulcerations (and subsequent infections); bleeding stomach ulcers (which can lead to massive hemorrhage) and neuropathies Vasculitis may also affect the brain, nerves and heart causing strokes, sensory neuropathies (numbness and tingling), heart attacks or heart failure.

Heart complications of RA commonly affect the outer lining of the heart. When inflamed, the condition is referred to as pericarditis. Inflammation of the heart muscle, called myocarditis, can also develop. Both of these conditions can lead to congestive heart failure characterized by shortness of breath and fluid accumulation in the lung.

Lung involvement is frequent in RA. Fibrosis of the lung tissue leads to shortness of breath and has been reported to occur in 20% of patients with RA. Inflammation of the lining of the lung, called pleuritis, can also lead to fluid accumulation. Pulmonary nodules, similar to rheumatoid nodules, can also develop.

Eye complications include inflammation of various parts of the eye; these must be screened for in RA patients.

Prevention:

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

Symptoms:

• fatigue
• general discomfort, uneasiness, or malaise
• loss of appetite
• low-grade fever
• joint pain, joint stiffness and joint swelling
• usually symmetrical
• may involve wrist pain, knee pain, elbow pain, finger pain, toe pain, ankle pain, or neck pain
• limited range of motion
• morning stiffness lasting more than one hour
• deformities of hands and feet
• round, painless nodules under the skin
• skin redness or inflammation
• paleness
• swollen glands
• eye burning, itching and discharge
• numbness and/or tingling

Signs and Tests:

• joint X-rays
• A rheumatoid factor test is positive in about 75% of people with symptoms.
• the erythrocyte sedimentation rate is elevated.
• a CBC may show low hematocrit (anemia) or abnormal platelet counts.
• a C-reactive protein (may be a positive indication for patients with no detectable rheumatoid factor).
• a synovial fluid analysis

Treatment:

RA usually requires lifelong treatment. There is no cure for RA. The treatment includes various medications, physical therapy, education, and possibly surgery aimed at relieving the signs and symptoms of the disease.

MEDICATIONS
For the past 10 years, studies have shown that early, aggressive treatment for RA can delay the onset of joint destruction. If rest, exercise, and anti-inflammatory agents are ineffective after several months, aggressive therapy with disease-modifying anti-rheumatic drugs (DMARDs) may be in order.

Anti-inflammatory agents traditionally included aspirin and non-steroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen (Motrin, Advil), fenoprofen, indomethacin, naproxen (Naprosyn) and others. These are widely used medications that are effective in relieving pain and inflammation associated with RA. Side effects associated with many of these medications include life threatening gastrointestinal bleeding. Cox-2 inhibitors are now a mainstay of anti-inflammatory therapy because the risk of gastrointestinal bleeding is significantly reduced. Currently, there are only two available; rofecoxib (Vioxx) and celecoxib (Celebrex).

As mentioned, DMARDs alter the course of the disease. Included in this group are gold compounds, which can be injectible (Myochrysine and Solganal) or oral. Oral therapies include (auranofin/Ridaura), D-penicillamine, antimalarial medications (Plaquenil), and antineoplastic drugs, especially methotrexate (Rheumatrex). The benefits from these medications may take weeks or months to be apparent. Because they are associated with toxic side effects constant monitoring while on these medications is imperative.

In the last few years, new and exciting medications have been introduced. A promising medication that is fast becoming a first-line agent for the aggressive treatment of RA is called etanercept (Enbrel). Enbrel acts by inhibiting an inflammatory protein called tumor necrosis factor (TNF). Other new medications include infliximab (Remicade) that also blocks TNF and leflunomide (Arava), which blocks the growth of new cells.

Drugs that suppress the immune system, like azathioprine (Imuran) and cyclophosphamide (Cytoxan), may be used in people who have failed other therapies. These medications are associated with toxic side effects.

Corticosteroids have been used to reduce inflammation in RA for greater than 40 years. However, because of potential long-term side effects, corticosteroid use is limited to short courses when other therapies fail. Side effects may include bruising, psychosis, thinning of the bones (osteoporosis), cataracts, weight gain, susceptibility to infections, diabetes, and high blood pressure.

Consult a health care provider before long-term use of any medication, including over-the-counter medications.

SURGERY:
Occasionally, surgery is indicated for severely affected joints. The most successful surgeries are those on the knees and hips. Usually, the first surgical treatment is removal of the synovium (synovectomy). A later alternative is total joint replacement with a joint prosthesis. Surgeries can be expected to relieve joint pain, correct deformities, and modestly improve joint function. 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.

LIFESTYLE CHANGES:
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.

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

OTHER THERAPY:
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.

MONITORING:
Depending on the medications being taken, regular blood or urine tests should be done to monitor both progress and negative side effects.

Support Groups:

The stress of illness can often be helped by joining a support group in which members share common experiences and problems. See arthritis - support group.

Prognosis:

Frequently, the disease can be controlled with a combination of treatments. Treatment may vary as the disease course waxes and wanes. Surgery may be needed if medications fail.

The course of the disease varies between individuals. People with rheumatoid factor and/or subcutaneous nodules seem to have more severe course of disease. People who develop RA at younger ages also have a more rapidly progressive course.

Remission is most likely to occur in the first year and the probability decreases as time progresses. By 10 to 15 years from diagnosis, about 20 percent of people will have had remission. Fifty to 70% will remain capable of full-time employment. After 15 to 20 years, only 10 percent of patients are severely disabled, and unable to perform simple activities of daily living (washing, toileting, dressing, eating). The average life expectancy may be shortened by 3 to 7 years with this disease. Patients with severe forms of RA may die 10-15 years earlier than expected.

Complications:

Rheumatoid arthritis is not solely a disease of joint destruction. It involves almost all organ systems. The treatments for RA have also yielded serious side effects. Quality of life can be reduced and mortality can increase.

As mentioned previously, the complications of RA include joint destruction, gastrointestinal bleeding, heart failure, pericarditis, pleuritis, lung disease, anemia, low or high platelets, eye disease, cervical (neck) spine instability, neuropathy, and vasculitis.

Call for an appointment with a health care provider if you think you have symptoms of rheumatoid arthritis.