Rheumatoid Arthritis

Background

Rheumatoid arthritis (RA) is an autoimmune inflammatory disease that causes pain, swelling, stiffness and loss of function in the joints. It is a condition in which the immune system, which normally protects the body by fighting infections and diseases, targets the body. In RA, the immune system attacks the tissues that line the joints and affect their ability to work properly. Over time, RA may damage bone and cartilage in the joints and weaken the muscles and tendons that support the joints. This can lead to the destruction of the joint. Some people with RA may also have other health problems such as anemia, dry eyes or mouth, and heart or lung problems.

Certain features of RA make it different from other types of arthritis. The disease usually occurs in a symmetrical pattern, which means that if one hand is affected, usually the other hand is also affected. RA also usually occurs in more than one joint and can affect any joint in the body. However, it often affects the wrist joints and finger joints closest to the hand.

Some people have this disease for only a few months or a year or two before it goes away without causing damage. Other people have times when the symptoms get worse, called flares, and times when they feel better, called remissions. Others have a severe form of the disease that can last for many years or a lifetime.

Scientists estimate that about 1.3 million people — or about 0.6 percent of the U.S. adult population — have RA. The disease often begins in middle age, although older people are most affected and children and young adults can also develop RA. About two to three times as many women as men have RA and it can occur in all races and ethnic groups.

Causes

Scientists still do not know exactly what causes RA, but research has shown certain factors that may be involved:

Genetic factors
There are certain genes passed from parent to child that are known to play a role in the immune system with a tendency to develop RA. Although these genes may be linked to RA, they are not the only factor that determines if a person will develop RA.
Environmental factors
Some scientists believe there is something in the environment that may trigger a person whose genetic makeup makes them more likely to develop the disease. An infection appears as a likely trigger but the exact agent is not yet known.
Other factors
Because women are more likely to develop RA than men, this suggests hormones could play a role. Low levels of hormones, or changes in certain hormones, may lead to the development of RA.

Symptoms

Symptoms of RA can include:

  • Tender, warm, swollen joints
  • Fatigue
  • Weakness
  • Fever
  • Pain and stiffness lasting for more than 30 minutes in the morning or after a long rest

Diagnosis

It can be difficult to diagnose RA in its early stages for several reasons. First, there is no single test for the disease. In addition, symptoms can be similar to those of other types of arthritis and joint conditions, and it may take some time for other conditions to be ruled out. Finally, the full range of symptoms may take time to develop. Therefore, doctors use a variety of tools to diagnose RA and rule out other conditions:

Medical history — The doctor will ask questions about the patient’s symptoms, as well as how the symptoms have changed over time. This information will help the doctor’s initial assessment of the disease and how it develops.

Physical examination — The doctor will check the patient’s reflexes and muscle strength, examine the bothersome joints, and observe the patient’s ability to walk, bend and carry out activities of daily living.

Laboratory tests — A number of tests may be used to confirm a diagnosis of RA:

Rheumatoid factor (RF)
Rheumatoid factor is an antibody that is present in the blood of most people with RA. However, not all people with RA test positive for RF, and some people test positive for RF yet never develop the disease.
Anti-CCP antibodies
This blood test detects antibodies to cyclic citrullinated peptide (anti-CCP). This test is positive in most people with RA and can be positive before symptoms of RA even develop.
White blood cell count
High levels will show if inflammation is present.
Red blood cell count
Low levels may mean the patient has anemia.
Erythrocyte sedimentation rate (ESR)
Measures inflammation in the body.
C-reactive protein
This is a common test for inflammation that is helpful in making a diagnosis of RA and in monitoring the disease over time.
X-rays
The degree of joint destruction can be shown with x-rays. This may not be as useful in the early stages of RA, however x-rays may be used to rule out other causes of joint pain and may be used later to monitor the progression of the disease.

Treatment

Specialty drug list

The goals of treatment for RA are to relieve pain, reduce swelling in the joints, slow down or stop joint damage and help people feel better and stay active.

Doctors use a variety of approaches to treat RA and are often used in combination and at different times during the course of the disease. Current treatment approaches include health behavior changes, medications, surgery, routine monitoring and ongoing care.

A person’s general health and severity of RA, along with the length of time they will take a medication and its potential side effects, are important considerations in prescribing medications to treat RA. Some medications — called analgesics — are used only for pain relief. Other medications, like corticosteroids and disease-modifying anti-rheumatic drugs (DMARDs), are used to try to slow down the course of the disease. The newest class of medications are biological response modifiers that are genetically engineered and help reduce inflammation and structural damage to the joints.

Side Effects

Treatment can cause side effects, but it is important that a person never change their dosage or stop taking their medication without talking to their doctor or pharmacist.

Common side effects for the different treatment options for RA include:

Analgesics
Nausea, vomiting, heartburn, diarrhea and headache
Steroids
Weight gain, increased appetite, anxiety, nervousness and increased risk of developing an infection
DMARDs
Nausea, vomiting, diarrhea, weakness and increased risk of developing an infection
Biologic therapy
Cough, nausea, vomiting, rash, weakness, abdominal pain and increased risk of infection

Resources

There are many resources and organizations available to help, providing support, advocacy and information:

Arthritis Foundation

American College of Rheumatology

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)

References

Centers for Disease Control and Prevention. http://www.cdc.gov/arthritis/basics/rheumatoid.htm. Accessed November 30, 2011.

National Institutes of Health. NIAMS. Handout on Rheumatoid Arthritis. NIH Publication No. 09-4179. April 2009.

National Center for Complementary and Alternative Medicine. NCCAM. http://www.nccam.nih.gov/health/RA/getthefacts.htm. Accessed November 30, 2011.