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Rheumatoid arthritis
Definition
Rheumatoid arthritis (RA) is a long-term disease that leads to inflammation of the joints and surrounding tissues. It can also affect other organs.
Alternative Names
RA; Arthritis - rheumatoid
Causes
The cause of RA is unknown. It is an autoimmune disease, which means the body's immune system mistakenly attacks healthy tissue.
RA can occur at any age, but is more common in middle age. Women get RA more often than men.
Infection, genes, and hormone changes may be linked to the disease.
Symptoms
RA usually affects joints on both sides of the body equally. Wrists, fingers, knees, feet, and ankles are the most commonly affected.
The disease often begins slowly, usually with only minor joint pain, stiffness, and fatigue.
Joint symptoms may include:
- Morning stiffness, which lasts more than 1 hour, is common. Joints may feel warm, tender, and stiff when not used for an hour.
- Joint pain is often felt on the same joint on both sides of the body.
- Over time, joints may lose their range of motion and may become deformed.
Other symptoms include:
- Chest pain when taking a breath (pleurisy)
- Dry eyes and mouth (Sjogren syndrome)
- Eye burning, itching, and discharge
- Nodules under the skin (usually a sign of more severe disease)
- Numbness, tingling, or burning in the hands and feet
- Sleep difficulties
Exams and Tests
There is no test that can determine for sure whether you have RA. Most patients with RA will have some abnormal test results, although for some patients, all tests will be normal.
Two lab tests that often help in the diagnosis are:
- Rheumatoid factor test
- Anti-CCP antibody test
Other tests that may be done include:
- Complete blood count
- C-reactive protein
- Erythrocyte sedimentation rate
- Joint ultrasound or MRI
- Joint x-rays
- Synovial fluid analysis
Treatment
RA usually requires lifelong treatment, including medications, physical therapy, exercise, education, and possibly surgery. Early, aggressive treatment for RA can delay joint destruction.
MEDICATIONS
Disease modifying antirheumatic drugs (DMARDs): These drugs are the first drugs usually tried in patients with RA. They are prescribed in addition to rest, strengthening exercises, and anti-inflammatory drugs.
- Methotrexate (Rheumatrex) is the most commonly used DMARD for rheumatoid arthritis. Leflunomide (Arava) and chloroquine may also be used.
- These drugs may have serious side effects, so you will need frequent blood tests when taking them.
Anti-inflammatory medications: These include aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naprosen.
- Although NSAIDs work well, long-term use can cause stomach problems, such as ulcers and bleeding, and possible heart problems.
- Celecoxib (Celebrex) is another anti-inflammatory drug, but it is labeled with strong warnings about heart disease and stroke. Talk to your doctor about whether COX-2 inhibitors are right for you.
Antimalarial medications: This group of medicines includes hydroxychloroquine (Plaquenil), and is usually used along with methotrexate. It may be weeks or months before you see any benefit from these medications.
Corticosteroids: These medications work very well to reduce joint swelling and inflammation. Because of long-term side effects, corticosteroids should be taken only for a short time and in low doses when possible.
BIOLOGIC AGENTS:
Biologic drugs are designed to affect parts of the immune system that play a role in the disease process of rheumatoid arthritis.
They may be given when other medicines for rheumatoid arthritis have not worked. At times, your doctor will start biologic drugs sooner, along with other rheumatoid arthritis drugs.
Most of them are given either under the skin (subcutaneously) or into a vein (intravenously). There are different types of biologic agents:
- White blood cell modulators include: abatacept (Orencia) and rituximab (Rituxan)
- Tumor necrosis factor (TNF) inhibitors include: adalimumab (Humira), etanercept (Enbrel), infliximab (Remicade), golimumab (Simponi), and certolizumab (Cimzia)
- Interleukin-6 (IL-6) inhibitors: tocilizumab (Actemra)
Biologic agents can be very helpful in treating rheumatoid arthritis. However, people taking these drugs must be watched very closely because of serious risk factors:
SURGERY
Occasionally, surgery is needed to correct severely damaged joints. Surgery may include:
- Removal of the joint lining (synovectomy)
- Total joint replacement in extreme cases; may include total knee, hip replacement, ankle replacement, shoulder replacement, and others
PHYSICAL THERAPY
Range-of-motion exercises and exercise programs prescribed by a physical therapist can delay the loss of joint function and help keep muscles strong.
Sometimes therapists will use special machines to apply deep heat or electrical stimulation to reduce pain and improve joint movement.
Joint protection techniques, heat and cold treatments, and splints or orthotic devices to support and align joints may be very helpful.
Frequent rest periods between activities, as well as 8 to 10 hours of sleep per night, are recommended.
NUTRITION
Some people with RA may have intolerance or allergies to certain foods. A balanced nutritious diet is recommended. It may be helpful to eating foods rich in fish oils (omega-3 fatty acids).
Support Groups
Outlook (Prognosis)
How well a person does depend on the severity of symptoms.
People with rheumatoid factor, the anti-CCP antibody, or subcutaneous nodules seem to have a more severe form of the disease. People who develop RA at younger ages also seem to get worse more quickly.
Without proper treatment, permanent joint damage may occur. However, early treatment with many of the newer medicines have decreased joint pain and damage.
Possible Complications
Rheumatoid arthritis can affect nearly every part of the body. Complications may include:
- Damage to the lung tissue (rheumatoid lung)
- Increased risk of hardening of the arteries
- Spinal injury when the neck bones become damaged
- Inflammation of the blood vessels (rheumatoid vasculitis), which can lead to skin, nerve, heart, and brain problems
- Swelling and inflammation of the outer lining of the heart (pericarditis) and of the heart muscle (myocarditis), which can lead to congestive heart failure
The treatments for RA can also cause serious side effects. Talk to your doctor about the possible side effects of treatment and what to do if they occur.
When to Contact a Medical Professional
Call your health care provider if you think you have symptoms of rheumatoid arthritis.
Prevention
There is no known prevention. Proper early treatment can help prevent further joint damage.
References
Huizinga TW, Pincus T. In the clinic. Rheumatoid arthritis. Ann Intern Med. 2010 Jul 6;153(1).
Scott DL, Wolfe F, Huizinga TW. Rheumatoid arthritis. Lancet. 2010 Sep 25;376(9746):1094-108.
Harris ED Jr, Firestein GS. Clinical features of rheumatoid arthritis. In: Firestein GS, Budd RC, Harris ED Jr, et al., eds. Kelley's Textbook of Rheumatology. 8th ed. Philadelphia, Pa: Saunders Elsevier; 2008:chap 66.
McBeth J, Prescott G, Scotland G, Lovell K, Keeley P, Hannaford P, et al. Cognitive behavior therapy, exercise, or both for treating chronic widespread pain.Arch Intern Med. 2011 Nov 14.
Reviewed By: Ariel D. Teitel, MD, MBA, Clinical Associate Professor of Medicine, NYU Langone Medical Center. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
