What Is Rheumatoid Arthritis?
Rheumatoid arthritis is a common, persistent systemic disorder that can cause inflammation of joints throughout the body. Joints contain a number of structures that allow for ease of movement. The ends of the bones in a joint are protected from rubbing together by an elastic cushioning material, known as cartilage. The entire joint is surrounded by a capsule, known as the synovial sac. A thin layer of tissue (synovial membrane) lines the sac and secretes synovial fluid, which provides lubrication to ease movement.
In the early stage of rheumatoid arthritis, the synovial membrane becomes inflamed and thickened, causing pain and limiting joint movement. As the disease progresses, the cartilage and the ends of the bones erode. The result is severe joint damage and deformity. Joint pain is often preceded by general, nonspecific symptoms, such as fever, fatigue, and loss of appetite. It may also be prefaced by stiffness in the joints, particularly in the morning.
The hallmark of the disorder is involvement of the small joints of the hands and wrists with painful, warm, swollen, tender, and reddish joints. The process can also involve the elbows, shoulders, knees, hips, ankles, feet, and neck. Symptoms tend to occur symmetrically; that is, joints on both sides of the body are usually affected at the same time. In some cases other organ systems of the body—including the eyes, heart, and lung—may become inflamed too. Symptoms occur in lengthy episodes that may be separated by remission periods of reduced or total absence of pain and stiffness.
Current research suggests that rheumatoid arthritis is an autoimmune disorder caused by an attack of the immune system on some of the body’s own cells. The disease usually develops between the ages of 20 and 50, and its prevalence increases with age. Women are affected approximately three times more frequently than men. Treatment is aimed at relieving pain and inflammation, preventing joint deformity, and preserving function.
Who Gets Rheumatoid Arthritis?
According to the Arthritis Foundation, RA is the second most common type of arthritis. It affects approximately 1.3 million people in the United States, and about 70 percent of patients who have the disease are women. Rheumatoid arthritis usually develops between the ages of 30 and 50, but it can occur at any age.
Rheumatoid arthritis also affects men and children (called juvenile rheumatoid arthritis and also juvenile idiopathic arthritis). In women who are of childbearing age, RA often improves during pregnancy, but symptoms may increase in severity after the patient gives birth.
- Early symptoms, preceding obvious joint involvement: fatigue and weakness; low-grade fever; general feeling of poor health; loss of appetite and weight loss.
- Red, swollen, painful joints that may be warm to the touch. Joints on both sides of the body are usually involved. With long-term rheumatoid arthritis, joints may become bent and gnarled.
- Stiffness (often the second manifestation), especially after awakening in the morning.
- Red, painless skin lumps, known as rheumatoid nodules, on the elbows, knees, or toes.
- Chest pain and breathing difficulty (advanced cases).
- Dry mouth and dry, painful eyes.
- The cause of rheumatoid arthritis is unknown.
- Genetic factors play a role. Several genes have been identified that increase the risk for developing rheumatoid arthritis. For example, the genetic marker HLA-DR4 has been identified in as many as 66% of patients with disease.
- Since the ratio of women to men with RA is three to one, some experts believe hormonal factors may play a role.
- Rheumatoid arthritis occurs as a result of an abnormal immune system response, but the cause for this abnormal response has not been identified.
- Flare-ups of rheumatoid arthritis may be triggered by emotional stress or other concurrent illness.
What If You Do Nothing?
A small number of patients diagnosed with RA (about 10%) experience a complete remission in one year, and roughly 40% go into remission within two years. But if the disease progresses and is not treated, it may severely restrict the range of motion of some joints, or worse, destroy the joints altogether.
- Rheumatoid arthritis is diagnosed based on the patient's medical history, a physical examination, laboratory tests, and imaging tests (e.g., x-rays). Long-term observation of joint changes may be necessary for definitive diagnosis.
- Laboratory tests that may be used to help diagnose rheumatoid arthritis include the following:
- Anti-CCP antibodies (this is one of the most specific laboratory tests to help diagnose RA)
- Complete blood count (CBC; used to measure levels of red blood cells, white blood cells, and platelets)
- C-reactive protein (CRP; used to detect inflammation)
- Erythrocyte sedimentation rate (ESR; used to detect inflammation)
- Rheumatoid factor (latex agglutination test; used to detect levels of this antibody, which are elevated in most patients who have RA)
- Imaging tests (e.g., x-rays) are used to help diagnose rheumatoid arthritis and to monitor progression of the disease. X-rays can detect swelling in surrounding tissue and loss of bone density in affected joints. Other imaging tests that may be used include magnetic resonance imaging (MRI) and ultrasound, which can detect inflammation earlier than standard x-rays.
- Under local anesthetic, synovial fluid is drawn from the affected joint and analyzed. This procedure may also be done therapeutically to relieve pain and swelling caused by accumulation of fluid in a joint.
There is no cure for rheumatoid arthritis. The goals of treatment are to relieve symptoms, improve function, slow progression of the disease, and prevent disability. It is important to diagnose RA early and begin aggressive treatment as soon as possible.
Treatment for RA includes medications, therapy, and, if needed, surgery.
- NSAIDS. To reduce fever and treat pain, your doctor may prescribe large doses of aspirin, or one of the many other nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, naproxen, nabumetone, salsalate, or COX-2 inhibitors, a newer class of NSAIDs that have pain-relieving and anti-inflammatory effects with a lower risk of bleeding or stomach ulcers (common side effects of other NSAIDs).
- DMARDs. The current trend is to move patients more rapidly to other, more potent antirheumatic drugs called DMARDs (disease-modifying anti-rheumatic drugs), if initial anti-inflammatories fail to control symptoms. These include methotrexate, sulfasalazine, leflunomide, or hydroxychloroquine. Because of potential side effects, patients receiving such therapy must be closely monitored.
- Steroids. Oral corticosteroids, such as prednisone, offer quick relief from symptoms of rheumatoid arthritis and can prevent inflammation from harming the eyes and internal organs in advanced cases. Because prednisone has serious side effects when used for extended periods, it is often reserved for severe flare-ups of the disease or when other treatments are ineffective. Injection of corticosteroids into an affected joint may also be helpful.
- Biologic response modifiers. These medications are designed to specifically control certain parts of the immune system. Drugs such as etanercept, adalimumab, infliximab, golimumab, and certolizumab inhibit the action of tumor necrosis factor (TNF), a naturally occurring substance that is overproduced in people with rheumatoid arthritis. Newer BRMs include rituximab, abatacept, anakinra, tocilizumab, and tofacitinib. BRMs can slow the progression of RA and can even bring about long periods of remission.
- Movement. Your doctor may prescribe an exercise program or may advise you to see a physical therapist. While exercise that is too vigorous may worsen symptoms, such programs outline gentle exercises that can be done to increase the range of motion of the joints. Some exercises are easier to perform in a pool or hot tub, because water helps support the body; these techniques should be discussed with your doctor or physical therapist.
- Sleep. People with rheumatoid arthritis often need 8 or more hours of sleep nightly.
- Pain relief. Hot or cold compresses may provide pain relief. A solution containing gold salts may be taken orally or injected to reduce inflammation and pain. Creams or lotions containing capsaicin may be applied to relieve minor joint pain. Those containing camphor, menthol, or turpentine oil may mask pain and provide some relief from minor symptoms. Splints may be prescribed to relieve pain by immobilizing the joints during severe episodes.
- Synovectomy. Surgery to remove the diseased synovial membrane from affected joints (synovectomy) may be performed in advanced cases.
- Arthroplasty. Surgery to remove the damaged joint and replace it with a mechanical joint (arthroplasty, or total joint replacement) may be performed in advanced cases. Almost 90 percent of the 150,000 joint replacements each year are of the hip or knee, but the shoulders, elbows, and joints in the hands and feet may be replaced as well. Discussion of the types of activities the patient would like to continue after joint replacement aids the surgeon in selecting the appropriate type of prosthesis and implantation technique, while making the patient more aware of the risks and limitations of surgery.
- There is no known way to prevent rheumatoid arthritis.
When To Call Your Doctor
- Make an appointment with a doctor if painful joints interfere with normal activities. Also contact your doctor if you have RA and new symptoms develop.
Reviewed by Diane M. Horowitz, M.D., Rheumatologist, North Shore Long Island Jewish Health System, Great Neck, NY. Review provided by VeriMed Healthcare Network.