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Rheumatoid Arthritis

Rheumatoid Arthritis

Rheumatoid arthritis is a chronic (long-standing) joint disease that damages the joints of the body. The damage is caused by inflammation of the joint lining tissue. Inflammation is normally a response by the body's immune system to "assaults" such as infections, wounds, and foreign objects. In rheumatoid arthritis, the inflammation is misdirected to attack the joints. Rheumatoid arthritis is often referred to as RA.

 

  • The inflammation in the joints causes pain, stiffness and swelling, as well as many other symptoms.

 

  • The inflammation often affects other organs and systems of the body.

 

  • If the inflammation is not slowed or stopped, it can permanently damage the affected joints and other tissues.

 

Rheumatoid arthritis should not be confused with other forms of arthritis, such as osteoarthritis or arthritis associated with infections. Rheumatoid arthritis is anautoimmune disease. This means that the body's immune system mistakenly attacks the tissues it is supposed to protect.

 

  • The immune system produces specialized cells and chemicals, which are released into the bloodstream and begin to attack body tissues.

 

  • This abnormal immune response causes an inflamed, thickened synovium, the membrane that lines the joint. Inflammation of the synovium is called synovitis and is the hallmark of an inflammatory arthritis such as rheumatoid arthritis.

 

  • As the synovitis expands inside and outside of the joint, it can damage the bone and cartilage of the joint and the surrounding tissues, such as ligaments, tendons, nerves, and blood vessels.

 

Rheumatoid arthritis most often affects the smaller joints, such as those of the hands and/or feet, wrists, elbows, knees, and/or ankles. The symptoms often lead to significant discomfort and disability.

 

  • Many people with rheumatoid arthritis have difficulty carrying out normal activities of daily living, such as standing, walking, dressing, washing, using the toilet, preparing food, and carrying out household chores.

 

  • The symptoms of rheumatoid arthritis interfere with work for many people. As many as half of those with rheumatoid arthritis are no longer able to work 10-20 years after their condition is diagnosed.

 

  • On average, life expectancy is somewhat shorter for people with rheumatoid arthritis than for the general population. This does not mean that everyone with rheumatoid arthritis has a shortened life span. Rheumatoid arthritis itself is not a fatal disease. However, it can be associated with many complications and treatment-related side effects that can contribute to premature death.

 

Although rheumatoid arthritis most often affects the joints, it is a disease of the entire body. It can affect many organs and body systems besides the joints. Therefore, rheumatoid arthritis is sometimes referred to as a systemic disease.

 

  • Musculoskeletal structures: Damage to muscles surrounding joints may cause atrophy (shrinking and weakening). This is most common in the hands. Atrophy also may result from not using a muscle, usually because of pain or swelling. Damage to bones and tendons can cause deformities, especially of the hands and feet. Osteoporosis and carpal tunnel syndrome are other common complications of rheumatoid arthritis.

 

  • Skin: Many people with rheumatoid arthritis form small nodules on or near the joint that are visible under the skin. These rheumatoid nodules are most noticeable under the skin on the bony areas that stick out when a joint is flexed. Dark purplish areas on the skin (purpura) are caused by bleeding into the skin from blood vessels damaged by rheumatoid arthritis. This damage to the blood vessels is called vasculitis and these vasculitic lesions also may cause skin ulcers.

 

  • Heart: A collection of fluid around the heart from inflammation is not uncommon in rheumatoid arthritis. This usually causes only mild symptoms, if any, but it can be very severe. Rheumatoid arthritis-related inflammation can affect the heart muscle, the heart valves, or the blood vessels of the heart (coronary arteries).

 

  • Lungs: Rheumatoid arthritis' effects on the lungs may take several forms. Fluid may collect around one or both lungs and is referred to as pleuritis. Less frequently, lung tissues may become stiff or overgrown, referred to as pulmonary fibrosis. Any of these effects can have a negative effect on breathing.

 

  • Digestive tract: The digestive tract is usually not affected directly by rheumatoid arthritis. Dry mouth, related to Sjögren syndrome, is the most common symptom of gastrointestinal involvement. Digestive complications are much more likely to be caused by medications used to treat the condition, such as gastritis (stomach inflammation) or stomach ulcer caused by NSAID therapy. Any part of the digestive tract may become inflamed if the patient develops vasculitis, but this is uncommon. If the liver is involved (10%), it may become enlarged and cause discomfort in the abdomen.

 

  • Kidneys: The kidneys are not usually affected directly by rheumatoid arthritis. Kidney problems in rheumatoid arthritis are much more likely to be caused by medications used to treat the condition.

 

  • Blood vessels: Inflammation of the blood vessels can cause problems in any organ but are most common in the skin, where they appear as purpura or skin ulcers.

 

  • Blood: Anemia or "low blood" is a common complication of rheumatoid arthritis. Anemia means that you have an abnormally low number of red blood cells and that these cells are low in hemoglobin, the substance that carriesoxygen through the body (anemia has many different causes and is by no means unique to rheumatoid arthritis). A low white blood cell count (leukopenia) can occur from Felty's syndrome, a complication of rheumatoid arthritis that is also characterized by enlargement of the spleen.

 

  • Nervous system: The deformity and damage to joints in rheumatoid arthritis often lead to entrapment of nerves. Carpal tunnel syndrome is one example of this. Entrapment can damage nerves and may lead to serious consequences.

 

  • Eyes: The eyes commonly become dry and/or inflamed in rheumatoid arthritis. This is called Sjögren syndrome. The severity of this condition depends on which parts of the eye are affected. There are many other eye complications of rheumatoid arthritis that often require the attention of an ophthalmologist.

 

Like many autoimmune diseases, rheumatoid arthritis typically waxes and wanes. Most people with rheumatoid arthritis experience periods when their symptoms worsen (known as flares or active disease) separated by periods in which the symptoms improve. With successful treatment, symptoms may even go away completely (remission, or inactive disease).

 

About 1.3 million people in the United States are believed to have rheumatoid arthritis.

 

  • About 75% of these are women. Women are two to three times more likely to develop rheumatoid arthritis than men.

 

  • Rheumatoid arthritis affects all ages, races, social and ethnic groups.

 

  • It is most likely to strike people 35-50 years of age, but it can occur in children, teenagers, and elderly people (a similar disease affecting young people is known as juvenile rheumatoid arthritis).

 

  • Worldwide, about 1% of people are believed to have rheumatoid arthritis, but the rate varies among different groups of people. For example, rheumatoid arthritis affects about 5%-6% of some Native American groups, while the rate is very low in some Caribbean peoples of African descent.

 

  • The rate is about 2%-3% in people who have a close relative with rheumatoid arthritis, such as a parent, brother or sister, or child.

 

Although there is no cure for rheumatoid arthritis, the disease can be controlled in most people. Early, aggressive therapy to stop or slow down inflammation in the joints can prevent or reduce symptoms, prevent or reduce joint destruction and deformity, and prevent or lessen disability and other complications.

Symptoms

Although rheumatoid arthritis can have many different symptoms, joints are always affected. Rheumatoid arthritis almost always affects the joints of the hands (such as the knuckle joints), wrists, elbows, knees, ankles, and/or feet. The larger joints, such as the shoulders, hips, and jaw may be affected.

 

The vertebrae of the neck are sometimes involved in people who have had the disease for many years. Usually at least two or three different joints are involved on both sides of the body, often in a symmetrical (mirror image) pattern. The usual joint symptoms include the following:

 

  • Stiffness: The joint does not move as well as it once did. Its range of motion (the extent to which the appendage of the joint, such as the arm, leg, or finger, can move in different directions) may be reduced. Typically, stiffness is most noticeable in the morning and improves later in the day.

 

  • Inflammation: Redness, tenderness, and warmth are the hallmarks of inflammation.

 

  • Swelling: The area around the affected joint is swollen and puffy.

 

  • Nodules: These are hard bumps that appear on or near the joint. They often are found near the elbows. They are most noticeable on the part of the joint that juts out when the joint is flexed.

 

  • Pain: Pain in rheumatoid arthritis has several sources. Pain can come from inflammation or swelling of the joint and surrounding tissues or from working the joint too hard. The intensity of the pain varies by the individual.

 

These symptoms may keep you from being able to carry out your normal activities.

 

General symptoms include the following:

 

  • malaise (a "blah" feeling);
  • fever;
  • fatigue;
  • loss of appetite;
  • weight loss;
  • myalgias (muscle aches);
  • weakness or loss of energy.

 

The symptoms usually come on very gradually, although in some people they come on very suddenly. Sometimes, the general symptoms come before the joint symptoms and you may think you have the flu or a similar illness.

 

The following suggest that rheumatoid arthritis is in remission:

 

  • morning stiffness lasting less than 15 minutes;
  • no fatigue;
  • no joint pain;
  • no joint tenderness or pain with motion;
  • no soft-tissue swelling.

Causes

Rheumatoid arthritis occurs when your immune system attacks the synovium, the lining of the membranes that surround your joints. The resulting inflammation thickens the synovium, which can eventually invade and destroy the cartilage and bone within the joint. The tendons and ligaments that hold the joint together weaken and stretch.

 

Gradually, the joint loses its shape and alignment.

 

Doctors don't know what starts this process, although a genetic component appears likely. While your genes don't actually cause rheumatoid arthritis, they can make you more susceptible to environmental factors — such as infection with certain viruses and bacteria — that may trigger the disease.

Treatment

There is no cure for rheumatoid arthritis. Medications can reduce inflammation in your joints in order to relieve pain and prevent or slow joint damage. Occupational and physical therapy can teach you how to protect your joints. If your joints are severely damaged by rheumatoid arthritis, surgery may be necessary.

 

Medications

 

Many drugs used to treat rheumatoid arthritis have potentially serious side effects. Doctors typically prescribe medications with the fewest side effects first. You may need stronger drugs or a combination of drugs as your disease progresses.

 

  • NSAIDs. Nonsteroidal anti-inflammatory drugs (NSAIDs) can relieve pain and reduce inflammation. Over-the-counter NSAIDs include ibuprofen (Advil, Motrin, others) and naproxen sodium (Aleve). Stronger versions of these NSAIDs and others are available by prescription. Side effects may include ringing in your ears, increased bruising, gastric ulcers, heart problems, stomach bleeding, and liver and kidney damage.
  • Steroids. Corticosteroid medications, such as prednisone and methylprednisolone (Medrol), reduce inflammation and pain and slow joint damage. Side effects may include easy bruising, thinning of bones, cataracts, weight gain, a round face and diabetes. Doctors often prescribe a corticosteroid to relieve acute symptoms, with the goal of gradually tapering off the medication.
  • Disease-modifying antirheumatic drugs (DMARDs). These drugs can slow the progression of rheumatoid arthritis and save the joints and other tissues from permanent damage. Common DMARDs include methotrexate (Rheumatrex, Trexall), leflunomide (Arava), hydroxychloroquine (Plaquenil), sulfasalazine (Azulfidine) and minocycline (Dynacin, Minocin). Side effects vary but may include liver damage, bone marrow suppression and severe lung infections.
  • Immunosuppressants. These medications act to tame your immune system, which is out of control in rheumatoid arthritis. Examples include azathioprine (Imuran, Azasan), cyclosporine (Neoral, Sandimmune, Gengraf) and cyclophosphamide (Cytoxan). These medications can increase your susceptibility to infection.
  • TNF-alpha inhibitors. Tumor necrosis factor-alpha (TNF-alpha) is an inflammatory substance produced by your body. TNF-alpha inhibitors can help reduce pain, morning stiffness, and tender or swollen joints — usually within one or two weeks after treatment begins. Examples include etanercept (Enbrel), infliximab (Remicade) and adalimumab (Humira). Potential side effects include injection site irritation, congestive heart failure, blood disorders, lymphoma, demyelinating diseases and increased risk of infection.
  • Other drugs. Several other rheumatoid arthritis drugs target a variety of inflammatory substances produced by your body. These drugs include anakinra (Kineret), abatacept (Orencia) and rituximab (Rituxan). Potential side effects include injection site reactions, decreased white blood cell counts, headache and an increase in upper respiratory infections.

 

Therapy

 

An occupational therapist can help you find different ways to approach everyday tasks in order to take stress off your painful joints. For instance, if your fingers are sore, pick up an object using your forearms. Lean into a glass door to force it open, rather than pushing on the door with sore arms.

 

Assistive devices can make it easier to go about your day without stressing your painful joints. For instance, using specially designed gripping and grabbing tools may make it easier to work in the kitchen if you have pain in your fingers. Try a cane to help you get around. Your doctor or occupational therapist may have ideas about what sorts of assistive devices may be helpful to you. Catalogs and medical supply stores also may be places to look for ideas.

 

Surgery

 

If medications fail to prevent or slow joint damage, you and your doctor may consider surgery to repair damaged joints. Surgery may help restore your ability to use your joint. It can also reduce pain and correct deformities. Rheumatoid arthritis surgery may involve one or more of the following procedures:

 

  • Total joint replacement (arthroplasty). During joint replacement surgery, your surgeon removes the damaged parts of your joint and inserts a prosthesis made of metal and plastic.
  • Tendon repair. Inflammation and joint damage may cause tendons around your joint to loosen or rupture. Your surgeon may be able to repair the tendons around your joint.
  • Removal of the joint lining (synovectomy). If the lining around your joint (synovium) is inflamed and causing pain, your surgeon may recommend removing the lining of the joint.
  • Joint fusion (arthrodesis). Surgically fusing a joint may be recommended to stabilize or realign a joint and for pain relief when a joint replacement isn't an option.
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Surgery carries a risk of bleeding, infection and pain. Discuss the benefits and risks with your doctor.

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