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What Is Rheumatoid Arthritis?
Rheumatoid arthritis (RA) is an autoimmune disease where the body attacks itself, causing chronic joint inflammation. While it primarily affects joints, it can also cause inflammation of organs as the disease progresses. People with RA may experience an increase in symptoms –called flares – that can last for days or weeks. They may also have periods of remission where they have few or no symptoms. There is no cure for rheumatoid arthritis, but medications can slow the progression of the disease and ease symptoms.
Who Is at Risk for Rheumatoid Arthritis?
According to the Arthritis Foundation, rheumatoid arthritis affects about 1.5 million people in the U.S. Women develop RA two to three times more often than men, and symptoms in women tend to appear between the ages of 30 and 60, while symptoms usually develop later in life for men.
There may also be a genetic basis for the disease. Cigarette smoking is also a risk factor, as are certain infections.
What Is Juvenile Rheumatoid Arthritis?
Juvenile rheumatoid arthritis (JRA), also called juvenile idiopathic arthritis (JIA), is a type of arthritis that occurs in children age 1 to 16. Symptoms include stiff, sowllen, painful joints, and sometimes fever and rash. To be diagnosed with JRA the child's symptoms must last at least six weeks.
What Is the Difference Between Normal, Healthy Joints and Arthritic Joints?
Arthritis refers to more than 100 conditions that affect the musculoskeletal system, specifically, the joints. The joints are the parts of the body where bones connect. When arthritis is present, the joints may become inflamed, stiff, red, and painful. Rheumatoid arthritis is one type of arthritis classified as 'systemic,' meaning it can affect the entire body. Damage from RA may occur in tissues surrounding the joints including the tendons, ligaments, and muscles. In some patients, symptoms may extend to the skin and eyes, and internal organs including the liver, kidneys, heart, and lungs.
What Causes Rheumatoid Arthritis?
The exact cause of rheumatoid arthritis remains unknown, but several risk factors have been identified. Women are diagnosed with RA more often, and it is suspected estrogen may play a role. Several studies have shown there is a genetic component to developing RA. Cigarette smoking appears to increase the risk of developing the disease. Occupational exposure to certain dusts such as silica, wood, or asbestos can also lead to a higher risk for developing the illness. It is thought there may be a viral or bacterial infectious cause of RA but that is still being studied.
Remission, Relapse, and Flares
When a person with rheumatoid arthritis has symptoms including joint inflammation and pain, this is called a flare. Flares may last from weeks to months. This can alternate with periods of remission, when symptoms are minimal to nonexistent. Periods of remission can last weeks, months, or even years. After a period of remission, if the symptoms return this is called a relapse. It is common for RA patients to have periods of flares, remissions, and relapses, and the course of the illness varies with each patient.
What Are the Symptoms of Rheumatoid Arthritis?
In addition to the hallmark symptoms of swollen, painful, and stiff joints and muscles, rheumatoid arthritis patients may also experience symptoms such as fatigue, low-grade fever, lack of energy, and loss of appetite. The muscle and joint stiffness is usually worst in the morning or after extended periods of inactivity.
Other symptoms include bumps under the skin (rheumatoid nodules), shortness of breath due to inflammation or damage to the lungs, hoarseness, and eye problems.
What Are the Symptoms of Rheumatoid Arthritis? (continued)
With rheumatoid arthritis hands are almost always affected. However, RA can affect any joint in the body, including wrists, elbows, knees, feet, hips, and even the jaw. In most cases joints are affected symmetrically, meaning the same joints on both sides of the body are affected.
Rheumatoid arthritis can be very painful, and chronic inflammation can lead to debilitating loss of cartilage, bone weakness, and joint deformity.
Rheumatoid Arthritis and Inflammation of Organs
Rheumatoid arthritis is a systemic disease, meaning it can affect the entire body. In addition to the joints and muscles, RA can cause problems in many other areas of the body:
- Eyes and mouth: inflammation of the glands in the eyes and mouth causes dryness, and a condition called Sjögren's syndrome. It can also lead to inflammation of the white part of the eye (scleritis).
- Lungs: inflammation of the lung lining (pleuritis) or the lungs themselves can cause shortness of breath and chest pain.
- Heart: inflammation of the tissue surrounding the heart (pericarditis) can cause chest pain, which tends to be worse when lying down. RA patients are also at greater risk for heart attacks.
- Spleen: inflammation of the spleen (Felty's syndrome) can cause a decrease in white blood cells, which raises the risk of infections.
- Skin: firm lumps under the skin (rheumatoid nodules), typically located around affected joints, often on pressure points such as elbows, fingers, and knuckles.
- Blood vessels: inflammation of the blood vessels (vasculitis) can limit blood supply to surrounding tissues, causing tissue death (necrosis).
What is a Rheumatologist?
A rheumatologist is a physician who specializes in treatment of arthritis, and other disorders of the joints, muscles, and bones, autoimmune diseases, and soft tissue diseases.
A rheumatologist is usually an internal medicine specialist or pediatrician, with additional specialized rheumatology training to identify and treat the more than 100 different types of arthritis in addition to other autoimmune disorders such as lupus, gout, and osteoporosis.
How Is Rheumatoid Arthritis Diagnosed?
There is not a singular test to diagnose rheumatoid arthritis. First, the patient will meet with a rheumatologist who will perform a physical and take a history of symptoms. The joints will be examined to determine if there is inflammation and tenderness, and the skin may be examined to look for rheumatoid nodules. The doctor may order blood tests or X-rays to help diagnose the condition.
Many other diseases such as gout, fibromyalgia, and lupus may resemble rheumatoid arthritis, so the doctor will rule out these conditions before making a diagnosis of RA.
RA Diagnostic Test: Citrulline Antibody Test
Blood tests are usually run to help make a diagnosis of rheumatoid arthritis. These tests check for certain antibodies including anti-cyclic citrullinated peptide antibodies (ACPA), rheumatoid factor (RF), and antinuclear antibodies (ANA), which are present in a majority of RA patients.
Rheumatoid factor (RF) is present in about 75% to 80% of RA patients, and a high RF may indicate a more aggressive for of the disease. An advantage of anti-cyclic citrullinated peptide antibody (ACPA) tests is that they can often detect the disease earlier on, and the sooner treatment begins the better patients can manage the disease. The presence of antinuclear antibodies (ANA) is not a definitive diagnosis for RA, but their presence can indicate to the doctor that an autoimmune disorder may be present.
RA Diagnostic Test: Sedimentation Rate (Sed Rate)
Other blood tests that may be run can help the doctor determine the extent of the inflammation in the joints and elsewhere in the body. The erythrocyte sedimentation rate (ESR, or "sed rate") measures how quickly red blood cells fall to the bottom of a test tube. Usually, the higher the sed rate, the more inflammation there is in the body.
Another blood test that measures inflammation is the C-reactive protein (CRP) test. If the CRP is high, inflammation levels are usually high as well, such as during a flare.
RA Diagnostic Test: Joint X-rays
Another test used to diagnose rheumatoid arthritis is X-ray. Early in the disease X-rays are not as helpful because they do not show soft tissue damage, but they can be useful in later stages to monitor how the disease progresses over time because they show bone erosion. Other imaging tests used may include bone density scans (DXA or DEXA scans), ultrasound, and magnetic resonance imaging (MRI).
RA Diagnostic Test: Arthrocentesis
A joint aspiration procedure (arthrocentesis) may be performed to obtain joint fluid to test in the laboratory. A sterile needle and syringe drain fluid from the joint, which is then analyzed to detect causes of joint swelling such as arthritis. Removing this joint fluid can also help relieve joint pain. In some cases, cortisone may be injected into the joint during the aspiration procedure for more immediate pain relief.
How Is Rheumatoid Arthritis Treated?
Currently, there is no cure for rheumatoid arthritis, but there are a number of medications that can ease symptoms. Most treatments are aimed at remission, where the patient has few to no symptoms of RA. When treatment is started early on in the disease process, this can help minimize or slow damage to the joints and improve quality of life for patients. Treatment usually involves a combination of medication, exercise, rest, and protecting the joints. In some cases, surgery may be needed.
What Medications Are Used to Treat Rheumatoid Arthritis?
If you are diagnosed with rheumatoid arthritis, the sooner the treatment begins, the better your outcome is likely to be. There are many different medications used to help alleviate symptoms of RA and with the goal of bringing a patient into remission. The main types of RA drugs include:
- Disease-modifying antirheumatic drugs (DMARDs) such as methotrexate, hydroxycholorquine (Plaquenil), sulfasalazine (Azulfidine, Azulfidine EN-Tabs), leflunomide (Arava), and azathioprine (Imuran)
- Biologic response modifiers (another type of DMARD) such as abatacept (Orencia), adalimumab (Humira), anakinra (Kineret), certolizumab and pegol (Cimzia) etanercept (Enbrel), infliximab (Remicade), golimumab (Simponi), and rituximab (Rituxan)
- Nonsteroidal anti-inflammatories (NSAIDs) such as ibuprofen (Advil, Motrin), ketoprofen (Actron, Orudis KT), naproxen sodium (Aleve), and celecoxib (Celebrex)
- Janus kinase (JAK) Inhibitor – a new drug called tofacitinib (Xeljanz)
- Analgesics (painkillers)
Drugs used to reduce pain (analgesics) and inflammation (NSAIDs) are often considered "first-line" drugs as they are fast-acting and can relieve symptoms quickly. Medications such as DMARDs and biologic drugs take longer to have an effect, but they can help prevent inflammation and joint damage.
Other Treatments for Rheumatoid Arthritis
While there is no special diet people with rheumatoid arthritis should follow, eating a healthy, balanced diet is always recommended, and some foods may help ease inflammation.
- Omega-3 fatty acids found in fish oil may offer anti-inflammatory benefits, so fish such as herring, mackerel, trout, salmon, and tuna may be a part of a healthy diet. If you choose to take fish oil supplements, check with your doctor for the proper dosage.
- Extra fiber from fruits, vegetables, and whole grains can result in a lower C-reactive protein (CRP) in the blood. High levels of CRP indicate inflammation.
- Many people with RA have low levels of the mineral selenium. This can be found in whole-grain wheat products and shellfish. Consult your doctor before taking selenium supplements for the proper dosage as it can increase your risk for developing diabetes.
- Vitamin D may help lower the risk for RA in women. Eggs, fortified breads and cereals, and low-fat milk contain Vitamin D.
While some foods can ease inflammation, others may trigger it. Fried foods, grilled meats, margarine, egg yolks, and certain oils may contribute to inflammation and should be eaten in moderation or avoided if possible.
Other Treatments for Rheumatoid Arthritis (cont.)
Rheumatoid arthritis can also affect other areas of the body, and these symptoms may be treated individually.
- Sjögren's syndrome can cause eye dryness and may be treated with eye drops to moisturize, and also drops to increase tear production such as cyclosporine (Restasis). Dry mouth related to Sjögren's may be treated with prescription mouthwashes and toothpastes.
- Inflammation of the lung lining (pleuritis) or the lungs themselves may require treatment with corticosteroids.
- Inflammation of the tissue surrounding the heart (pericarditis) usually requires keeping the overall inflammation levels down and many RA drugs can help.
- Inflammation of the spleen (Felty's syndrome) can cause a decrease in white blood cells, which raises the risk of infections and may be treated with a stimulating factor (granulocyte stimulating factor/GSF) used to increase the amount of white blood cells.
- Rheumatoid nodules may require injections of steroids, or surgery to remove them if they are severe.
- Inflammation of the blood vessels (vasculitis) may be treated with painkillers, antibiotics, and protecting the areas affected.
Why Are Rest and Exercise Important?
A balance of physical activity and rest periods are important in managing rheumatoid arthritis. Exercise more when your symptoms are minimal, rest more when your symptoms are worse.
Exercise helps maintain joint flexibility and motion. There are therapeutic exercises, such as physical therapy that is prescribed, that can help with strength, flexibility, and range of motion of specific joints or body parts affected by your RA. Many recreational activities such as walking swimming are helpful because allow movement with little to no impact on the joints. Consult your rheumatologist or physical therapist to find out what exercises are right for you.
Just as physical activity is important, so is rest. When you have an RA flare and your symptoms are worse, it is best to rest to help reduce joint inflammation and pain, and to cope with the fatigue that may accompany it.
Is Surgery an Option for Rheumatoid Arthritis?
In severe cases of rheumatoid arthritis, surgery may be needed to reduce pain and improve joint function. Some surgeries include joint replacement, fusion of joints (arthrodesis), tendon reconstruction, and removal of inflamed tissues (synovectomy). Discuss your treatment options with your doctor to find out what is right for you.
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