Rheumatoid Arthritis

Rheumatoid arthritis is a chronic (long-term) disease that causes inflammation of the joints and surrounding tissues. It can also affect other organs. Usually, rheumatoid arthritis affects joints on both sides of the body equally. The wrists, fingers, knees, feet, and ankles are most commonly affected.

What causes Rheumatoid Arthritis and who is at risk?

The cause of rheumatoid arthritis is unknown. It is considered an autoimmune disease; that is, a disease where the body's immune system, which normally fights off foreign substances such as viruses, confuses healthy tissue for foreign substances. The result of this is that the body attacks itself.

Rheumatoid arthritis can occur at any age but it is usually seen in people aged between 25 and 55. Women are affected more often than men. The course and the severity of the illness can vary considerably. Infection, genes, and hormones may all contribute to the development of the disease.

What are the symptoms of Rheumatoid arthritis?

Rheumatoid arthritis usually begins gradually with fatigue, morning stiffness (lasting more than one hour), widespread muscle aches, loss of appetite, and weakness. Eventually, joint pain appears. When the joint is not used for a while, it can become warm, tender, and stiff. When the lining of the joint (synovium) becomes inflamed, it gives off more fluid and the joint becomes swollen. Joint pain is often felt on both sides of the body, and may effect the wrist, knees, elbows, fingers, toes, ankle or neck. Additional symptoms include:

• Loss of appetite
• Low-grade fever
• Limited range of motion
• Deformities of hands and feet
• Round, painless nodules under the skin (usually a sign of more severe disease)
• Inflammation of the lung (pleurisy)
• Skin redness or inflammation
• Paleness
• Swollen glands
• Eye burning, itching, and discharge
• Numbness or tingling
• Anemia may occur due to failure of the bone marrow to produce enough new red cells.

Joint destruction may occur within 1-2 years after the appearance of the disease.

How is Rheumatoid arthritis diagnosed?

Rheumatoid  arthritis is diagnosed based on the results of Joint x-rays and a Rheumatoid factor test (which is positive in about 75% of people with symptoms). In addition, the Erythrocyte sedimentation rate is elevated and the complete blood count (CBC) may show low hematocrit (anemia) or abnormal platelet counts. A C-reactive protein test may also be positive for patients with no detectable rheumatoid factor and Synovial fluid analysis may be used to diagnose the cause of pain and swelling in joints.

There is no known way of preventing the development of rheumatoid arthritis. However, proper early treatment can prevent further damage of the joints. It is also important to note that because rheumatoid arthritis may cause eye complications, patients should have regular eye exams.

Treatment Options

Rheumatoid arthritis usually requires lifelong treatment with medications, physical therapy, exercise, education, and possibly surgery. Early, aggressive treatment of rheumatoid arthritis can delay joint destruction.

Medications

Once a diagnosis of rheumatoid arthritis has been confirmed, the current standard of care (in addition to rest, strengthening exercises, and anti-inflammatory drugs) is aggressive therapy with disease-modifying anti-rheumatic drugs (DMARDs).

• Methotrexate (Rheumatrex) is the most commonly used DMARD for rheumatoid arthritis. Others include leflunomide (Arava), gold thiomalate (Myochrysine), aurothioglucose (Solganal), or auranofin (Ridaura).
• Anti-inflammatory agents used to treat rheumatoid arthritis include aspirin and non-steroidal anti-inflammatory drugs (NSAIDS), such as ibuprofen (Motrin, Advil), fenoprofen, indomethacin, and naproxen (Naprosyn). NSAIDS are commonly used to relieve joint pain and inflammation but, although they work well, long-term use of NSAIDs can cause stomach problems, such as ulcers and bleeding, and possible heart problems. In April 2005, the FDA asked drug manufacturers of NSAIDs to include a warning label on their product that alerts users of an increased risk for cardiovascular events and gastrointestinal bleeding.
• COX-2 inhibitors block an inflammation-promoting enzyme called COX-2. This class of drugs was initially believed to work as well as traditional NSAIDs, but with fewer stomach problems. However, numerous reports of heart attacks and stroke have prompted the FDA to re-evaluate the risks and benefits of the COX-2s. Rofecoxib (Vioxx) and valdecoxib (Bextra) have been withdrawn from the U.S. market following reports of heart attacks in patients taking the drugs. Celecoxib (Celebrex) is still available, but has been labeled with strong warnings and a recommendation that it be prescribed at the lowest possible dose for the shortest duration possible. Patients should ask their doctor whether the drug is appropriate and safe for them.
• Antimalarial medications such as hydroxychloroquine (Plaquenil) and sulfasalazine (Azulfidine) are also beneficial, usually in conjunction with methotrexate. It may be weeks or months before a patient sees any benefit from these medications. Because they are associated with toxic side effects, the patient must have frequent blood tests.
• Tumor necrosis factor (TNF) inhibitors are a relatively new class of medications used to treat autoimmune disease. They include etanercept (Enbrel), infliximab (Remicade), and adalimumab (Humira). Adalimumab and etanercept are injectable medications. Infliximab is given by IV.
• Another relatively new medication is injectable anakinra (Kineret), which is a man-made protein that blocks the inflammatory protein interleukin-1. The drug is used to slow the progression of moderate-to-severe active rheumatoid arthritis in patients over 18 who have not responded to one or more of the DMARDs. Kineret can be used with other DMARDs or TNF inhibitors.
• Other drugs that suppress the immune system, like azathioprine (Imuran) and cyclophosphamide (Cytoxan), are sometimes used in people who have failed other therapies. These medications are associated with toxic side effects and usually reserved for severe cases of rheumatoid arthritis.
• Corticosteroids have been used to reduce inflammation in rheumatoid arthritis for more than 40 years. However, because of potential long-term side effects, corticosteroid use is usually limited to short courses and low doses where possible. Side effects may include bruising, psychosis, cataracts, weight gain, susceptibility to infections, diabetes, high blood pressure, and thinning of the bones (osteoporosis). A number of medications can be administered with steroids to minimize the risk for osteoporosis.

Consult a health care provider before using any medication, including over-the-counter drugs.

Surgery

Occasionally, surgery is needed to correct severely affected joints. Surgery can relieve joint pain, correct deformities, and modestly improve joint function. The most successful surgeries are those performed on the knees and hips. The first surgical treatment is a synovectomy or knee arthroscopy, which involves removing the joint lining (synovium).

A later alternative is total joint replacement with a joint prosthesis. 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.

Physical Therapy

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 also be very helpful.

Sometimes therapists will use special machines to apply deep heat or electrical stimulation to reduce pain and improve joint mobility. Occupational therapists can also 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 rheumatoid arthritis.

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

Prosorba column

The Prosorba column is a device that removes inflammatory antibodies from the blood; it is used for the treatment of moderate-to-severe rheumatoid arthritis in adults with long-standing disease who have not responded to DMARDs. The procedure takes 2-3 hours and must be done once a week for 12 weeks.

Studies have reported that rheumatoid arthritis slows down or stops getting worse in about one third to one half of the people who receive this treatment. Side effects include anemia, fatigue, fever, low blood pressure, and nausea. Some people have developed an infection from the tube used to remove the blood. Often there is a flare-up of joint pain for several days after the treatment.

Regular blood or urine tests should be done to determine how well medications are working and if drugs are causing any side effects.

The course of rheumatoid arthritis differs from person to person. People with rheumatoid factor or subcutaneous nodules seem to have a more severe form of the disease. People who develop rheumatoid arthritis at younger ages also have a more rapidly progressive course. Remission is most likely to occur in the first year. The probability decreases over time. By 10 to 15 years from diagnosis, about 20% of people have remission.

More than half (50 - 70%) of patients are able to work full-time. After 15-20 years, 10% of patients are severely disabled, and unable to do simple daily living tasks such as washing, dressing, and eating. The average life expectancy for a patient with rheumatoid arthritis may be shortened by 3 to 7 years. Those with severe forms of rheumatoid arthritis may die 10-15 years earlier than expected. However, as treatment for rheumatoid arthritis improves, severe disability and life-threatening complications appear to be decreasing.

Possible Complications

Rheumatoid arthritis is not solely a disease of joint destruction. It can involve almost all organs. A life-threatening joint complication can occur when the cervical spine becomes unstable as a result of rheumatoid arthritis.

Rheumatoid vasculitis (inflammation of the blood vessels) is a serious, potentially life-threatening complication of rheumatoid arthritis. It can lead to skin ulcerations and infections, bleeding stomach ulcers, and nerve problems that cause pain, numbness, or tingling. Vasculitis may also affect the brain, nerves, and heart, which can cause stroke, heart attack, or heart failure.

Rheumatoid arthritis may also cause the outer lining of the heart  to swell (pericarditis) and cause heart complications. Inflammation of heart muscle, called myocarditis, can also develop. Both of these conditions can lead to congestive heart failure.