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Rheumatoid Arthritis

Rheumatoid Arthritis

Definition

Rheumatoid arthritis (RA) is a chronic autoimmune disease that causes inflammation and deformity of the joints. Other problems throughout the body (systemic problems) may also develop, including inflammation of blood vessels (vasculitis ), the development of bumps (called rheumatoid nodules) in various parts of the body, lung disease, blood disorders, and weakening of the bones (osteoporosis ).

Description

The skeletal system of the body is made up of different types of strong, fibrous tissue called connective tissue. Bone, cartilage, ligaments, and tendons are all forms of connective tissue that have different compositions and different characteristics.

The joints are structures that hold two or more bones together. Some joints (synovial joints) allow for movement between the bones being joined (articulating bones). The simplest synovial joint involves two bones, separated by a slight gap called the joint cavity. The ends of each articular bone are covered by a layer of cartilage. Both articular bones and the joint cavity are surrounded by a tough tissue called the articular capsule. The articular capsule has two components, the fibrous membrane on the outside and the synovial membrane (or synovium) on the inside. The fibrous membrane may include tough bands of tissue called ligaments, which are responsible for providing support to the joints. The synovial membrane has special cells and many tiny blood vessels (capillaries). This membrane produces a supply of synovial fluid that fills the joint cavity, lubricates it, and helps the articular bones move smoothly about the joint.

In rheumatoid arthritis (RA), the synovial membrane becomes severely inflamed. Usually thin and delicate, the synovium becomes thick and stiff, with numerous infoldings on its surface. The membrane is invaded by white blood cells, which produce a variety of destructive chemicals. The cartilage along the articular surfaces of the bones may be attacked and destroyed, and the bone, articular capsule, and ligaments may begin to wear away (erode). These processes severely interfere with movement in the joint.

RA exists all over the world and affects men and women of all races. In the United States alone, about two million people suffer from the disease. Women are three times more likely than men to have RA. About 80% of people with RA are diagnosed between the ages of 35-50. RA appears to run in families, although certain factors in the environment may also influence the development of the disease.

Causes and symptoms

The underlying event that promotes RA in a person is unknown. Given the known genetic factors involved in RA, some researchers have suggested that an outside event occurs that triggers the disease cycle in a person with a particular genetic makeup.

Many researchers are examining the possibility that exposure to an organism (like a bacteria or virus) may be the first event in the development of RA. The body's normal response to such an organism is to produce cells that can attack and kill the organism, protecting the body from the foreign invader. In an autoimmune disease like RA, this immune cycle spins out of control. The body produces misdirected immune cells, which accidentally identify parts of the person's body as foreign. These immune cells then produce a variety of chemicals that injure and destroy parts of the body.

RA can begin very gradually, or it can strike quickly. The first symptoms are pain, swelling, and stiffness in the joints. The most commonly involved joints include hands, feet, wrists, elbows, and ankles, although other joints may also be involved. The joints are affected in a symmetrical fashion. This means that if the right wrist is involved, the left wrist is also involved. Patients frequently experience painful joint stiffness when they first get up in the morning, lasting for perhaps an hour. Over time, the joints become deformed. The joints may be difficult to straighten, and affected fingers and toes may be permanently bent (flexed). The hands and feet may curve outward in an abnormal way.

Many patients also notice increased fatigue, loss of appetite, weight loss, and sometimes fever. Rheumatoid nodules are bumps that appear under the skin around the joints and on the top of the arms and legs. These nodules can also occur in the tissue covering the outside of the lungs and lining the chest cavity (pleura), and in the tissue covering the brain and spinal cord (meninges). Lung involvement may cause shortness of breath and is seen more in men. Vasculitis (inflammation of the blood vessels) may interfere with blood circulation. This can result in irritated pits (ulcers) in the skin, tissue death (gangrene ), and interference with nerve functioning that causes numbness and tingling.

Juvenile RA is a chronic inflammatory disease that affects the joints of children less than 16 years old. It is estimated to affect as many as 250,000 children in the United States alone. Most children with juvenile RA have arthritis when the illness starts, which affects multiple joints in 50% of these children, and only one joint in 30%. In all, 20% of the children affected by juvenile RA have the acute systemic form of the disease, which is characterized by fever, joint inflammation, rash, liver disease, and gastrointestinal disease.

Two periods of childhood are associated with an increased incidence of onset of juvenile RA. The first is from one to three years of age, and the second, from eight to 12 years. When more than four joints are affected, the disease is described as being polyarticular. If less than four joints are affected, the disease is known as pauciarticular. juvenile RA and this particular manifestation falls into two categories. The first occurs in girls aged one to four years old, and the onset of joint involvement is in the knees, ankles, or elbows. The second form occurs in boys aged eight years and older, and involves the larger joints, such as those of the hips and legs.

Diagnosis

There are no tests available that can absolutely diagnose RA. Instead, a number of tests exist that can suggest the diagnosis of RA. Blood tests include a special test of red blood cells (called erythrocyte sedimentation rate ), which is positive in nearly 100% of patients with RA. However, this test is also positive in a variety of other diseases. Tests for anemia are usually positive in patients with RA, but can also be positive in many other unrelated diseases. Rheumatoid factor is another diagnostic test that measures the presence and amounts of rheumatoid factor in the blood. Rheumatoid factor is an autoantibody found in about 80% of patients with RA. It is often not very specific however, because it is found in about 5% of all healthy people and in 10-20% of healthy people over the age of 65. In addition, rheumatoid factor is also positive in a large number of other autoimmune diseases and other infectious diseases, including systemic lupus erythematosus, bacterial endocarditis, malaria, and syphilis. In addition, young people who have a process called juvenile rheumatoid arthritis often have no rheumatoid factor present in their blood.

Finally, the clinician may examine the synovial fluid, by inserting a thin needle into a synovial joint. In RA, this fluid has certain characteristics that indicate active inflammation. The fluid is cloudy, with increased protein and decreased or normal glucose. It also contains a higher than normal number of white blood cells. While these findings suggest inflammatory arthritis, they are not specific to RA.

Treatment

There is no cure available for RA. However, treatment is available to combat the inflammation in order to prevent destruction of the joints, and to prevent other complications of the disease. Efforts are also made to maintain flexibility and mobility of the joints.

The "first line" agents for the treatment of RA include nonsteroidal anti-inflammatory agents (NSAIDs) and aspirin, which are used to decrease inflammation and to treat pain. The NSAIDs include naproxen (Naprosyn), ibuprofen (Advil, Medipren, Motrin), and etodolac (Lodine). While these medications can be helpful, they do not interrupt the progress of the disease. Low-dose steroid medications can be helpful at both managing symptoms and slowing the progress of RA. Disease-modifying antirheumatic drugs, including gold compounds, D-penicillamine, certain antimalarial-like drugs, and sulfasalazine (Azulfadine) are also often the first agents clinicians use to treat RA, but in patients with the aggressive destructive type of RA, more slow-acting medications are needed. Methotrexate, azathioprine, and cyclophosphamide are all drugs that suppress the immune system and can decrease inflammation. All of the drugs listed have significant toxic side effects, which require healthcare professionals to carefully compare the risks associated with these medications versus the benefits.

Recently, several categories of drugs have been explored and developed for the treatment of RA. The first is a category of agents known as biological response modifiers. These work to reduce joint inflammation by blocking a substance called tumor necrosis factor (TNF). TNF is a protein that triggers inflammation during the body's normal immune responses. When TNF production is not regulated, the excess TNF can cause inflammation. Three agents in this class have become "second line" drugs for the treatment of RA. These are etanercept (Enbrel), leflunamide (Arava), and infliximab (Remicade), and they are recommended for patients in whom other medications have not been effective. Etanercept is approved by the FDA but is not recommended for patients with active infection. It is given twice weekly via subcutaneous injections by either the patient or a health care professional. Because this agent is so new, long-term side effects have not been fully studied. Infliximab is given intravenously once every eight weeks, and is approved for combined use with methotrexate to combat RA.

The cyclo-oxygenase-2 (COX-2) inhibitors are another category of drugs used to treat RA. Like the traditional NSAIDs, the COX-2 inhibitors work to block COX-2, which is an enzyme that stimulates inflammatory responses in the body. Unlike the NSAIDs, the COX-2 inhibitors do not carry a high risk of gastrointestinal ulcers and bleeding, because they do not inhibit COX-1, which is the enzyme that protects the stomach lining. These new agents include celecoxib (Celebrex) and rofecoxib (Vioxx). Celecoxib has been approved by the FDA for the treatment of RA and osteoarthritis, and is taken once or twice daily by mouth. Rofecoxib is approved for RA and osteoarthritis, and for acute pain caused by primary dysmenorrhea and surgery.

Total bed rest is sometimes prescribed during the very active, painful phases of RA. Splints may be used to support and rest painful joints. Later, after inflammation has somewhat subsided, physical therapists may provide a careful exercise regimen in an attempt to maintain the maximum degree of flexibility and mobility. Joint replacement surgery, particularly for the knee and the hip joints, is sometimes recommended when these joints have been severely damaged.

Alternative treatment

A variety of alternative therapies has been recommended for patients with RA. Meditation, hypnosis, guided imagery, and relaxation techniques have been used effectively to control pain. Acupressure and acupuncture have also been used for pain. Bodywork can be soothing, decreasing stress and tension, and is thought to improve/restore chemical balance within the body.

A multitude of nutritional supplements can be useful for RA. Fish oils, the enzymes bromelain and pancreatin, and the antioxidants (vitamins A, C, and E, selenium, and zinc) are the primary supplements to consider.

Many herbs also are useful in the treatment of RA. Anti-inflammatory herbs may be very helpful, including tumeric (Curcuma longa ), ginger (Zingiber officinale ), feverfew (Chrysanthemum parthenium ), devil's claw (Harpagophytum procumbens ), Chinese thoroughwax (Bupleuri falcatum ), and licorice (Glycyrrhiza glabra ). Lobelia (Lobelia inflata ) and cramp bark (Vibernum opulus ) can be applied topically to the affected joints.

Homeopathic practitioners recommended Rhus toxicondendron and Bryonia (Bryonia alba) for acute prescriptions, but constitutional treatment, generally used for chronic problems like RA, is more often recommended. Yoga has been used for RA patients to promote relaxation, relieve stress, and improve flexibility. Nutritionists suggest that a vegetarian diet low in animal products and sugar may help to decrease both inflammation and pain from RA. Beneficial foods for patients with RA include cold water fish (mackerel, herring, salmon, and sardines) and flavonoid-rich berries (cherries, blueberries, hawthorn berries, blackberries, etc.).

RA, considered an autoimmune disorder, is often connected with food allergies/intolerances. An elimination/challenge diet can help to decrease symptoms of RA as well as identify the foods that should be eliminated to prevent flare-ups and recurrences. Hydrotherapy can help to greatly reduce pain and inflammation. Moist heat is more effective than dry heat, and cold packs are useful during acute flare-ups.

Prognosis

About 15% of all RA patients will have symptoms for a short period of time and will ultimately get better, leaving them with no long-term problems. A number of factors are considered to suggest the likelihood of a worse prognosis. These include:

  • race and gender (female and Caucasian).
  • more than 20 joints involved.
  • extremely high erythrocyte sedimentation rate.
  • extremely high levels of rheumatoid factor.
  • consistent, lasting inflammation.
  • evidence of erosion of bone, joint, or cartilage on x rays.
  • poverty.
  • older age at diagnosis.
  • rheumatoid nodules.
  • other coexisting diseases.
  • certain genetic characteristics, diagnosable through testing.

Patients with RA have a shorter life span, averaging a decrease of three to seven years of life. Patients sometimes die when very severe disease, infection, and gastrointestinal bleeding occur. Complications due to the side effects of some of the more potent drugs used to treat RA are also factors in these deaths.

Prevention

There is no known way to prevent the development of RA. The most that can be hoped for is to prevent or slow its progress.

KEY TERMS

Articular bones Two or more bones connected to each other via a joint.

Joint Structures holding two or more bones together.

Pauciarticular juvenile RA Rheumatoid arthritis found in children that affects less than four joints.

Polyarticular juvenile RA Rheumatoid arthritis found in children that affects more than four joints.

Synovial joint A type of joint that allows articular bones to move.

Synovial membrane The membrane that lines the inside of the articular capsule of a joint and produces a lubricating fluid called synovial fluid.

Resources

BOOKS

Arthritis Foundation. The Good Living with Rheumatoid Arthritis. New York: Longstreet Press Inc., 2000.

PERIODICALS

Case, J. P. "Old and New Drugs Used in Rheumatoid Arthritis: A Historical Perspective. Part 2: The Newer Drugs and Drug Strategies." American Journal of Therapeutics May-June 2001: 163-79.

Goekoop, Y. P., et al. "Combination Therapy in Rheumatoid Arthritis." Current Opinions in Rheumatology May 2001: 177-83.

Koivuniemi, R., and M. Leirisalo-Repo. "Juvenile Chronic Arthritis in Adult Life: A Study of Long-term Outcome in Patients with Juvenile Chronic Arthritis or Adult Rhuematoid Arthritis." Clinical Rheumatology 1999: 220-6.

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Rheumatoid Arthritis

Rheumatoid arthritis

Definition

Rheumatoid arthritis (RA) is a chronic disease causing inflammation and deformity of the joints. Other systemic problems throughout the body may also develop, including inflammation of blood vessels (vasculitis), the development of bumps (rheumatoid nodules) in various parts of the body, lung disease, blood disorders, and weakening of the bones (osteoporosis ).

Description

The skeletal system of the body is made up of different types of strong, fibrous tissue called connective tissue. Bone, cartilage, ligaments, and tendons are all forms

of connective tissue that have different compositions and characteristics.

The joints are structures that hold two or more bones together. Synovial joints allow for movement between the bones being joined, the articulating bones. The simplest synovial joint involves two bones, separated by a slight gap called the joint cavity. The ends of each articular bone are covered by a layer of cartilage. Both articular bones and the joint cavity are surrounded by a tough tissue called the articular capsule. The articular capsule has two components: the fibrous membrane on the outside and the synovial membrane, or synovium, on the inside. The fibrous membrane may include tough bands of tissue called ligaments, which are responsible for providing support to the joints. The synovial membrane has special cells and many tiny blood vessels called capillaries. This membrane produces a supply of synovial fluid that fills the joint cavity, lubricates it, and helps the articular bones move smoothly about the joint.

In rheumatoid arthritis, the synovial membrane becomes severely inflamed. Usually thin and delicate, the synovium becomes thick and stiff, with numerous infoldings on its surface. The membrane is invaded by white blood cells, which produce a variety of destructive chemicals. The cartilage along the articular surfaces of the bones may be attacked and destroyed, and the bone, articular capsule, and ligaments may begin to erode. These processes severely interfere with movement in the joint.

RA exists all over the world and affects men and women of all races. In the United States alone, about two million people suffer from the disease. Women are three times more likely than men to have RA. About 80% of people with RA are diagnosed between the ages of 35 and 50. RA appears to run in families, although certain factors in the environment may also influence the development of the disease.

Causes & symptoms

The underlying event that promotes RA in a person is unknown. Given the known genetic factors involved in RA, some researchers have suggested that an outside event occurs and triggers the disease cycle in a person with a particular genetic makeup. In late 2001, researchers announced discovery of the genetic markers that predict increased risk of RA. The discovery should soon aid research into diagnosis and treatment of the disease. Recent research has also shown that several autoimmune diseases, including RA, share a common genetic link. In other words, patients with RA might share common genes with family members who have other autoimmune diseases like systemic lupus, multiple sclerosis , and others.

Many researchers are examining the possibility that exposure to an organism (a bacteria or virus) may be the first event in the development of RA. The body's normal response is to produce cells that can attack and kill the organism, protecting the body from the foreign invader. In an autoimmune disease like RA, this immune cycle spins out of control. The body produces misdirected immune antibodies, which accidentally identify parts of the person's body as foreign. These immune cells then produce a variety of chemicals that injure and destroy parts of the body.

Reports in late 2001 suggest that certain stress hormones released during pregnancy may affect development of RA and other autoimmune diseases in women. Researchers have observed that women with autoimmune disorders will often show lessened symptoms during the third trimester of pregnancy. The symptoms then worsen in the year after pregnancy. Further, women appear to be at higher risk of developing new autoimmune disorders following pregnancy.

RA can begin very gradually or it can strike without warning. The first symptoms are pain , swelling, and stiffness in the joints. The most commonly involved joints include hands, feet, wrists, elbows, and ankles. The joints are typically affected in a symmetrical fashion. This means that if the right wrist is involved, the left wrist is also involved. Patients frequently experience painful joint stiffness when they first get up in the morning, lasting perhaps an hour. Over time, the joints become deformed. The joints may be difficult to straighten, and affected fingers and toes may be permanently bent. The hands and feet may also curve outward in an abnormal way.

Many patients also notice increased fatigue , loss of appetite, weight loss, and sometimes fever . Rheumatoid nodules are bumps that appear under the skin around the joints and on the top of the arms and legs. These nodules can also occur in the tissue covering the outside of the lungs and lining the chest cavity (pleura), and in the tissue covering the brain and spinal cord (meninges). Lung involvement may cause shortness of breath and is seen more in men. Vasculitis, an inflammation of the blood vessels, may interfere with blood circulation. This can result in irritated pits (ulcers) in the skin, gangrene , and interference with nerve functioning that causes numbness and tingling.

Diagnosis

There are no tests available that can absolutely diagnose RA. Instead, a number of tests exist that can suggest the diagnosis of RA. Blood tests include a special test of red blood cells, the erythrocyte sedimentation rate, which is positive in nearly 100% of patients with RA. However, this test is also positive in a variety of other diseases. Tests for anemia are usually positive in patients with RA, but can also be positive in many other unrelated diseases. Rheumatoid factor is an autoantibody found in about 66% of patients with RA. However, it is also found in about 5% of all healthy people and in 1020% of healthy people over the age of 65. Rheumatoid factor is also positive in a large number of other autoimmune diseases and other infectious diseases.

A long, thin needle can be inserted into a synovial joint to withdraw a sample of the synovial fluid for examination. In RA, this fluid has certain characteristics that indicate active inflammation. The fluid will be cloudy, relatively thinner than usual, with increased protein and decreased or normal glucose. It will also contain a higher than normal number of white blood cells. While these findings suggest inflammatory arthritis, they are not specific to RA.

Treatment

There is no cure available for RA. However, treatment is available to combat the inflammation in order to prevent destruction of the joints and other complications of the disease. Efforts are also made to provide relief from the symptoms and to maintain maximum flexibility and mobility of the joints.

A variety of alternative therapies have been recommended for patients with RA. Meditation , hypnosis, guided imagery, relaxation , and reflexology techniques have been used effectively to control pain. Acupressure and acupuncture have also been used for pain; work on the pressure points should be done daily in combination with other therapies. Bodywork can be soothing and is thought to improve and restore chemical balance within the body. A massage with rosemary and chamomile , or soaking in a warm bath with these essential oils , can provide extra relief. Stiff joints may also be loosened up with a warm sesame oil massage, followed by a hot shower to further heat the oil and allow entry into the pores. Movement therapies like yoga, t'ai chi , and qigong also help to loosen up the joints.

A multitude of nutritional supplements can be useful for RA. Fish oils, the enzymes bromelain and pancreatin, and the antioxidants (vitamins A, C, and E, selenium , and zinc ) are the primary supplements to consider.

Many herbs also are useful in the treatment of RA. Anti-inflammatory herbs may be helpful, including turmeric (Curcuma longa ), ginger (Zingiber officinale ), feverfew (Chrysanthemum parthenium ), devil's claw (Harpagophytum procumbens ), Chinese thoroughwax (Bupleuri falcatum ), and licorice (Glycyrrhiza glabra ). Lobelia (Lobelia inflata ) and cramp bark (Vibernum opulus ) can be applied topically to the affected joints.

Homeopathic practitioners recommend Rhus toxicondendron and bryonia (Bryonia alba ) for acute prescriptions, but constitutional treatment, generally used for chronic problems like RA, is more often recommended. Yoga has been used for RA patients to promote relaxation, relieve stress, and improve flexibility. Nutritionists suggest that a vegetarian diet low in animal products and sugar may help to decrease both inflammation and pain from RA. Beneficial foods for patients with RA include cold water fish (mackerel, herring, salmon, and sardines) and flavonoid-rich berries (cherries, blueberries, hawthorn berries, blackberries, etc.). The enzyme bromelain, found in pineapple juice has also been found to have significant anti-inflammatory effects.

RA, considered an autoimmune disorder, is often connected with food allergies or intolerances. An elimination/challenge diet can help to decrease symptoms of RA as well as identify the foods that should be eliminated to prevent flare-ups and recurrences.

Hydrotherapy can help to greatly reduce pain and inflammation. Moist heat is more effective than dry heat, and cold packs are useful during acute flare-ups. Various yoga exercises done once a day can also assist in maintaining joint flexibility.

Allopathic treatment

Nonsteroidal anti-inflammatory agents and aspirin are used to decrease inflammation and to treat pain. While these medications can be helpful, they do not interrupt the progress of the disease. Low-dose steroid medications can be helpful at both managing symptoms and slowing the progress of RA, as well as other drugs called disease-modifying antirheumatic drugs. These include gold compounds, D-penicillamine, antimalarial drugs, and sulfasalazine. Methotrexate, azathioprine, and cyclophosphamide are all drugs that suppress the immune system and can decrease inflammation. All of the drugs listed have significant toxic side effects, which require healthcare professionals to carefully compare the risks associated with these medications to the benefits.

Total bed rest is sometimes prescribed during the very active, painful phases of RA. Splints may be used to support and rest painful joints. Later, after inflammation has somewhat subsided, physical therapists may provide a careful exercise regimen in an attempt to maintain the maximum degree of flexibility and mobility. Joint replacement surgery, particularly for the knee and the hip joints, is sometimes recommended when these joints have been severely damaged. Another surgery used to stop pain in a stiff joint, such as the ankle, is the fusion of the affected bones together (arthrodesis, or artificial anklylosis).

Prognosis

About 15% of all RA patients will have symptoms for a short period of time and will ultimately get better, leaving them with no long-term problems. A number of factors are considered to suggest the likelihood of a worse prognosis. These include:

  • race and gender (female and Caucasian)
  • more than 20 joints involved
  • extremely high erythrocyte sedimentation rate
  • extremely high levels of rheumatoid factor
  • consistent, lasting inflammation
  • evidence of erosion of bone, joint, or cartilage on x rays
  • poverty
  • older age at diagnosis
  • rheumatoid nodules
  • other coexisting diseases
  • certain genetic characteristics, diagnosable through testing

Patients with RA have a shorter life span, averaging a decrease of three to seven years of life. Patients sometimes die when very severe disease, infection, and gastrointestinal bleeding occur. Complications due to the side effects of some of the more potent drugs used to treat RA are also factors in these deaths.

Prevention

There is no known way to prevent the development of RA. The most that can be hoped for is to prevent or slow its progress.

Resources

BOOKS

Aaseng, Nathan. Autoimmune Diseases. New York: F. Watts, 1995.

Lipsky, Peter E. "Rheumatoid Arthritis." Harrison's Principles of Internal Medicine. 14th ed. edited by Anthony S. Fauci, et al. New York: McGraw-Hill, 1998.

Schlotzhauer, M. Living with Rheumatoid Arthritis. Baltimore: Johns Hopkins University Press, 1993.

PERIODICALS

Akil, M., and R. S. Amos. "Rheumatoid Arthritis: Clinical Features and Diagnosis." British Medical Journal. 310 (March 4, 1995): 587+.

Gremillion, Richard B. and Ronald F. Van Vollenhoven. "Rheumatoid Arthritis: Designing and Implementing a Treatment Plan." Postgraduate Medicine. 103 (February 1998): 103+.

Moran, M. "Autoimmune Diseases Could Share Common Genetic Etiology." American Medical News. 44; no. 38: (October 8, 2001):38.

"Suspect Gene Mapped, May Lead to New Diagnostic Markers and Drug Targets." Immunotherapy Weekly. (December 26, 2001):24.

Vastag, Brian. "Autoimmune Disorders and Hormones." JAMA, Journal of the American Medical Association. 286, no. 19 (November 21, 2001):1.

Ross, Clare. "A Comparison of Osteoarthritis and Rheumatoid Arthritis: Diagnosis and Treatment." The Nurse Practitioner. 22 (September 1997): 20+.

ORGANIZATIONS

American College of Rheumatology. 60 Executive Park South, Suite 150, Atlanta, GA 30329. (404)6331870. http://www.rheumatology.org. acr@rheumatology.org.

Arthritis Foundation. 1330 West Peachtree St., Atlanta, GA 30309. (404)8727100. http://www.arthritis.org. help@arthritis.org.

Kathleen Wright

Teresa G. Odle

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Wright, Kathleen; Odle, Teresa. "Rheumatoid Arthritis." Gale Encyclopedia of Alternative Medicine. 2005. Encyclopedia.com. 30 Jun. 2016 <http://www.encyclopedia.com>.

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Wright, Kathleen; Odle, Teresa. "Rheumatoid Arthritis." Gale Encyclopedia of Alternative Medicine. 2005. Retrieved June 30, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1G2-3435100666.html

Rheumatoid Arthritis

RHEUMATOID ARTHRITIS

Rheumatoid arthritis (RA) is an inflammatory disease of the joints, the cause of which is still unknown. Infectious factors are being studied, including bacterial and viral organisms, but no definite involvement of any agent has been proven. There are indications that some genetic patterns are present in higher frequencies in patients with rheumatoid arthritis. This seems related to an increased frequency in some families, but not beyond a fairly weak association.

The disease can start at any age, with the childhood type of inflammatory arthritis peaking at around age two. In adults it predominates in women (the prevalence being 2.5 times greater in women) and appears more often during the childbearing years. Studies done around the world show a frequency of 1 to 5 percent in most populations. Historically, some recognizable forms of arthritis have been found in Egyptian mummies, though rheumatoid arthritis is not one of them. Its major descriptions in the medical literature roughly coincide with the start of the industrial revolution.

The main feature of the disease is an inflammation of the synovial tissues inside the joints. Synovium is usually present as a thin specialized tissue responsible for the production of the fluid that lubricates the joint. In RA, the synovium becomes swollen and shows the presence of many inflammatory cells. There is an excessive production of fluid and joints become swollen, warm, painful, and difficult to moveboth because of the pain and because of the presence of the fluid, whose volume in the confined space of the joint restricts motion. RA mainly involves peripheral joints and does not usually involve the spine. The small joints of the fingers (except for the terminal joints) and the bones of the wrist are typically involved.

Inflammation in the joints causes the release of destructive enzymes from the inflammatory cells that have been attracted to the synovial tissue. The enzymes also collect in the fluid. These enzymes, which are usually part of the body's defense against bacteria, find the tissues in the joint to be grist for their destructive activity, and they also attack the cartilage covering the joint surfaces. This destruction can continue into the bone, and the joint can be so damaged as to render it incapable of normal function.

In about 85 percent of patients with RA a protein is found in the blood called rheumatoid factor. Although it is present in high frequency and concentration in RA, it can be found in other diseases, and even occasionally in normal individuals. RA is not simply a joint disease but can involve many other organs and tissues, including the eye, skin, lungs, heart, and blood vessels throughout the body.

Although some children, mostly girls in their teens, can have RA, the disease in the very young usually involves only a few large joints (knees and ankles). There is, however, an unusual form that afflicts children with high intermittent fevers and an extensive rash.

Treatment of RA has changed drastically (for the good) in the past few years. Aspirin was the original analgesic, anti-inflammatory drug, and it has been used for RA for over one hundred years. Aspirin is a versatile drug, but the high doses required for inflammatory arthritis frequently lead to gastric irritation. Gold compounds were the initial disease-modifying anti-rheumatic drugs (DMARDs) and have been in use for about seventy years.

The next development, starting in the early 1960s, was a rapid surge of nonsteroidal anti-inflammatory analgesic drugs (NSAIDs), which provided more prolonged activity and less gastric irritation than aspirin. The latest type of NSAIDs have even fewer gastric irritating properties but are still potent. The DMARDs that came after gold were hydroxychloroquine, an antimalarial agent that is mildly anti-inflammatory, and sulfasalazine, also mildly anti-inflammatory.

More recently, the drug methotrexate, which has been used in cancer chemotherapy, was found to be anti-inflammatory, and it has been successfully used in the treatment of RA. A major advance came with the development of biologic compounds that specifically block a link in the inflammatory "cascade" of cell-stimulating proteins. One of these is an antibody to an early product in this cascade. It is given intravenously and is effective when given at six- to eight-week intervals. Another is a "blocking" agent given by subcutaneous injection twice a week. An antibody to the B-lymphocyte involved in inflammation is also being developed. These new therapies are based on a new understanding of inflammation, even though the cause of RA still eludes researchers.

John Baum

(see also: Osteoarthritis )

Bibliography

Klippel, J. H., ed. (1997). Primer on the Rheumatic Diseases, 11th edition. Atlanta, GA: Arthritis Foundation.

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Baum, John. "Rheumatoid Arthritis." Encyclopedia of Public Health. 2002. Retrieved June 30, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1G2-3404000736.html

rheumatoid arthritis

rheumatoid arthritis (room-ă-toid) n. a form of arthritis that is a disease of the synovial lining of joints. It involves the joints of the fingers, wrists, feet, and ankles, with later involvement of the hips, knees, shoulders, and neck. Diagnosis is supported by a blood test and by X-rays revealing typical changes around the affected joints. Treatment is with a variety of drugs, including anti-inflammatory analgesics, steroids, immunosuppressants, and gold salts, and some diseased joints can be replaced by prosthetic surgery (see arthroplasty).
www.arthritiscare.org.uk/AboutArthritis/Conditions/Rheumatoidarthritis Explanation of rheumatoid arthritis from Arthritis Care

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rheumatoid arthritis

rheu·ma·toid ar·thri·tis • n. a chronic progressive disease causing inflammation in the joints and resulting in painful deformity and immobility, esp. in the fingers, wrists, feet, and ankles. Compare with osteoarthritis.

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Felty's syndrome

Felty's syndrome (fel-tiz) n. enlargement of the spleen (see hypersplenism) associated with rheumatoid arthritis, characterized by a decrease in the numbers of white blood cells and frequent infections. [ A. R. Felty (1895–1964), US physician]

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