Rheumatoid Arthritis

Rheumatoid arthritis causes chronic inflammation of the joints. It is an autoimmune disease in which the joints, that hold two or more bones together, become inflamed. This leads to pain, stiffness, and swelling. It can also lead to aching, throbbing and eventually the affected joint may become deformed. It most commonly affects the joints in the hands and feet. However, it can also affect the shoulders, jaw, hips, and knees. Rheumatoid arthritis (RA) attacks the lining of your joints, which is called the synovium.

RA is more common in women than in men and usually occurs between the ages of 40 and 60. RA can also affect young children and older adults. More than likely, people do not directly inherit rheumatoid arthritis (RA). However, you could inherit a predisposition to RA.

Causes

Currently, RA is a very active area of medical research. More than likely, RA occurs because of a combination of factors, including your genes, lifestyle choices such as smoking, and environmental causes such as viruses. Regardless of the cause, it is a type of autoimmune disease. Normally, our immune system attacks and destroys foreign invaders such as bacteria, viruses, and fungi. With RA, the immune cells, called antibodies, attacks joints and occasionally other tissues of the body. These immune cells or white blood cells move from your bloodstream into the membranes that surround your joints (synovium). This causes the synovium to become inflamed. Inflammation of the synovium causes a release of proteins which eventually lead to thickening of the synovium. These proteins also damage the cartilage, tendons, bone, and ligaments near your joints. With time, the affected joints may become deformed and destroyed. Interestingly, food allergies have been linked to autoimmune disorders. RA flare-ups may occur after eating certain types of foods.

Signs and symptoms of RA may include

  • joint pain,
  • joint swelling,
  • fever,
  • weight loss,
  • morning stiffness,
  • fatigue,
  • joint nodules (small bumps) under the skin, and
  • muscle aches.

The disease of RA is active when the body tissues are inflamed. The disease is inactive when tissue inflammation subsides. Inactive (in remission) and active (relapse) periods can come and go. These relapses and remissions often last for weeks, months or years. The course of RA varies from patient to patient.

In RA, several joints are usually affected simultaneously. In early RA, the smaller joints are affected first. These include the joints in your hands, ankles, wrists, and feet. With progression, the neck, jaw, knees, elbows, shoulders, and hips can become affected. During flare-ups, joints become swollen, tender, red and painful. This results from the tissue lining the joint (synovium) becoming inflamed. This inflammation leads to the production of excessive synovial fluid contained in the joint. Synovitis also occurs as the synovium thickens with inflammation.

In RA, the joints of both sides of the body are usually affected. Occasionally, only one joint is affected, and this may confuse the diagnosis. Examples of other diseases which cause inflammation of one joint at a time include gout or joint infections.

Diagnosis

First, your doctor will review the history of symptoms and perform a physical examination. The physical examination will focus on but not be limited to an examination of your affected joints.

The smaller joints of the hands, wrists, feet, and knees are usually inflamed in a symmetrical distribution (both sides of the body are affected). The diagnosis is less clear when only one or two joints are inflamed. Rheumatoid nodules (small bumps under the skin) usually occur around the fingers and elbows and support the diagnosis of RA.

Other complications of RA include infections, osteoporosis, carpal tunnel syndrome, peripheral neuropathy, heart disease, lung disease, anemia, vasculitis, scleritis and gastrointestinal tract problems. The risk for lymphoma is higher in people with RA. Felty syndrome, which is an abnormality of the immune system combined with an enlarged spleen, can occur with RA. Aside from Felty syndrome, other abnormalities of the immune system may occur.

Your doctor may also recommend

  • blood tests: Rheumatoid factor, citrulline antibody (anti-CCP) and antinuclear antibody are frequently found in patients with RA. These antibodies are not present in all cases of RA. Sedimentation rate and C-reactive protein are blood tests which can measure inflammation present in the body. These two tests can also be abnormal in other autoimmune and inflammatory conditions and cannot make a clear diagnosis of RA.
  • x-rays: X-rays may be normal or show swelling of soft tissues early in RA. Your doctor may order x-rays to monitor the progression of the disease and joint damage.
  • arthrocentesis : Laboratory studies may be performed on the joint fluid removed using a needle and syringe. Other causes of joint inflammation such as infection and gout can be excluded. Also, joint swelling and pain can be relieved with arthrocentesis. During arthrocentesis, cortisone medications may be injected to reduce joint inflammation and reduce symptoms.
  • biopsy : Your doctor may remove a small tissue sample of any rheumatoid nodules to examine under a microscope.

Treatment

There is no cure for RA. The goal of treatment is to reduce inflammation in the joints affected. Reducing inflammation in the affected joints can relieve pain and prevent or slow damage to the joints. Improved outcomes occur with aggressive early medical intervention. By treating RA aggressively and early, function can be improved, and work disability can be prevented. Joint damage as seen on x-rays can also be slowed. Typically, treatment involves medications, joint protection, joint-strengthening exercises, rest, education and occasionally surgery.

  • medications: Nonsteroidal anti-inflammatory drugs (NSAIDs), such as indomethacin, ibuprofen, and naproxen are effective in relieving pain and swelling. Aspirin is also effective in relieving pain and swelling. NSAIDs have risks of side effects that are increased when high doses are used for long periods. Examples of side effects include gastric ulcers, heart problems, ringing in your ears and kidney disease. Corticosteroid medications, such as prednisone and methylprednisolone, reduce inflammation and pain. They can also slow joint damage. Unfortunately, they become less effective and cause serious side effects when used for many months or years. Side effects include diabetes, osteoporosis, osteopenia, cataracts, weight gain, easy bruising and moon facies (facial puffiness). For this reason, corticosteroid medications are often prescribed to relieve acute symptoms and then gradually tapered. If the disease is progressing rapidly, disease-modifying antirheumatic drugs (DMARDs) may be used. The benefits of DMARDs may not occur for weeks or months. They may be combined with other medications such as NSAIDs or corticosteroids. Examples of DMARDs include but are not limited to antimalarials, gold compounds, sulfasalazine, minocycline, and methotrexate. Drugs that suppress the immune system may also be prescribed. These include but are not limited to azathioprine, cyclosporine, cyclophosphamide, and leflunomide. Serious side effects which may occur with immune system suppressing drugs are increased susceptibility to infection. TNF-alpha is a cytokine or cell protein that acts as an inflammatory agent in RA. TNF inhibitors target this cytokine and within one or two weeks of treatment can reduce pain, morning stiffness and swelling of the joints. Examples of TNF inhibitors include but are not limited to etanercept (Enbrel), infliximab (Remicade) and adalimumab (Humira). Potential side effects include congestive heart failure, blood disorders, lymphoma, injection site irritation, and infection.  RA patients who have not improved with TNF-alpha inhibitors might consider abatacept. Side effects include headache, nausea, and infections. Rituximab (Rituxa) targets B-cells involved in inflammation. It is usually given with methotrexate and is administered as an infusion into a vein in your arm. Side effects include fever, chills, nausea, heart problems, and difficulty breathing.
  • surgery : Surgery is considered when medications have failed to slow or prevent joint damage. Surgery may reduce pain, correct deformities and improve the function of the joint. Examples of surgery include total joint replacement, tendon repair, and removal of the joint lining (synovectomy).
  • exercise: This is important to maintain joint mobility and to strengthen the muscles around the joints. Swimming is effective because minimal stress is placed on the joints during exercise. Physical and occupational therapy are important to decrease pain and improve functionality.
  • assistive devices : Canes, grabbers, and toilet seat raisers can assist in daily living. Wrist and finger splints can maintain joint alignment, reduce pain and reduce inflammation.
  • cold therapy: Cold may decrease inflammation, decrease muscle spasms and decrease pain. Place a barrier between the cold device and your skin. Avoid cold treatments if poor circulation or numbness is present. Examples of cold treatments include cold packs and soaking the affected joints in cold water.
  • heat treatments : Heat can decrease pain and muscle spasms. Once again, avoid heat treatments if numbness or poor circulation is present. Hot showers, hot baths, hot packs and electric heating pads are effective ways to decrease pain. Use these treatment modalities for only short periods at a time. An electric heat pad should be used on the lowest setting.
  • stress reduction: Coping with pain is easier with relaxation techniques such as deep breathing, bio-feedback, hypnosis and guided imagery.
  • diet : Anti-inflammatory diets may reduce pain and inflammation.
  • joint protection : Joint stress can be reduced by using your forearms or body to lift or push objects.
  • coping strategies : Your doctor may be familiar with support groups that may help you cope with RA. Pace yourself and rest when fatigue occurs. Seek hobbies which can distract you from your pain and that give you pleasure. Seek family members willing to listen to your concerns about the disease. Finally, psychotherapy may enlighten you on strategies to cope with RA.
  • alternative treatments: Acupuncture, tai chi, yoga, hypnosis, meditation, and gentle massage can help relieve the pain of RA. All alternative therapies should be performed gently and should not cause pain. Examples of nutritional supplements that are available include fish oils, plant oils and vitamins (A, C, E). Unfortunately, few treatments have been extensively studied in clinical trials. The benefits and risks of these treatments for rheumatoid arthritis pain are not known. Some plant oils may cause liver damage or interfere with medications. Side effects of fish oils include nausea, gas, bleeding, mercury poisoning, and interference with medications. For these reasons, it is important to discuss these nutritional supplements with your doctor if they are being used.

Jose Veliz MD is the medical director of Palomar Spine & Pain, in Escondido, CA (North San Diego County).

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