Rheumatoid Arthritis

Definition

Rheumatoid arthritis is an autoimmune disease that primarily damages the lining of joints.

Description

Rheumatoid arthritis (RA) is a disease mainly characterized by chronic inflammation of the tissue lining the joints (synovium). A joint is a point of connection between two bones that allows motion. For example, an elbow joint connects an arm to the forearm allowing motion of the arm, and a knee joint connects a thigh to the lower leg, allowing the straightening and bending of the knee. RA can affect almost any joint of the body, including those of the fingers, wrists, shoulders, elbows, hips, knees, ankles, feet, and neck. It can lead to long-term joint damage, resulting in chronic pain and disability. RA does not only affect joints. It is a systemic disease, because it can affect other organs in the body, such as the heart, muscles, blood vessels, nervous system, and eyes.

RA is also a progressive disease. The first stage of the disease is inflammation of the synovium of the affected joint, which causes pain, warmth, stiffness, redness and swelling around the joint that can last for hours. The arthritis usually begins in the small joints of the hands and the feet, spreading later to the larger joints. In the second stage, there is an overgrowth of connective tissue on the articular surface of the affected joint resulting in a thickening of the affected synovium (pannus). Finally, as part of the automimmune response, the inflamed cells release substances that start destroying bone and cartilage, causing joint deformity, more pain, and loss of function.

Demographics

According to the World Health Organization (WHO), RA is the most common chronic inflammatory joint disease. The incidence and prevalence of RA appear to have fallen in Europe, North America and Japan in the last 50 years. The prevalence of RA is estimated as relatively constant in many populations, at 0.5–1.0%, with low occurrences reported in populations from China and Japan. According to the Arthritis Foundation, approximately 1.3 million Americans are afflicted by RA. The disease can affect anyone, including children, but 70% of people with RA are women. RA onset usually occurs between 30 and 50 years of age. A high prevalence of RA has been reported in the Pima (5.3%) and in the Chippewa (6.8%) Indians. Older age and female gender are risk factors both for the development of RA and for a poor outcome.

Causes and symptoms

The cause of RA remains unknown, but most medical researchers believe that it is an autoimmune disease, meaning a disease characterized by the involvement of an inappropriate immune response that leads the body to attack the lining of its own joints. How this autoimmune response develops is not known, but it causes the inflammation that produces the pain, swelling, and stiffness associated with RA. Other research has proposed that susceptibility to RA may be genetic or environmental.

The symptoms of RA are the same as for all forms of arthritis and usually include morning stiffness, lasting joint pain, joint swelling, joint stiffness, tenderness or pain when touching a joint, difficulty using or moving a joint normally, and warmth and redness in a joint.

Diagnosis

The RA diagnosis may be difficult to establish, because there is no single test that can be performed to confirm RA. The diagnosis is based upon an individual's history of clinical symptoms and a complete physical examination. A specialized physician, often a rheumatologist , reviews all signs and symptoms experienced by a person, so as to rule out other joint diseases. This often requires various tests, which may include:

• Rheumatoid factor (RF) test: This test looks for distinctive antibodies released in the blood by people with RA to distinguish it from other forms of arthritis and other conditions that cause similar symptoms of joint pain, inflammation, and stiffness. In the early stages of RA, however, only one in five persons tests positive for rheumatoid factor.
• Antinuclear antibody (ANA) test: This test is performed to help screen for autoimmune disorders.A small percentage of healthy people, however, have a positive ANA.
• C-Reactive protein (CRP) test: The CRP test is used to evaluate how active the inflammation is. CRP tests are not specific enough to diagnose RA, but provide a general marker of infection and inflammation levels.

QUESTIONS TO ASK YOUR DOCTOR

• What kind of arthritis is RA?
• What causes RA?
• Are there any treatments for RA?
• What does the treatment involve?
• How effective is it?
• What are the risks?
• What are the side effects associated with RA medications?

Other tests, including x rays and magnetic resonance imaging (MRI), may be used to determine the cause of chronic back pain or examine internal organs that may be affected by RA.

Treatment

There is presently no cure for rheumatoid arthritis. In addition to pain and anti-inflammatory medicines, RA is treated with antirheumatic drugs, called “disease-modifying antirheumatic drugs”(DMARDs) that can slow the damage caused by RA. Rest is prescribed for severely inflamed joints, as using them can aggravate the inflammation. Regular rest periods can often relieve pain, with short periods of bed rest considered helpful to relieve a severe flare-up in its most painful stage.

Nutrition/Dietetic concerns

There is presently no scientific evidence showing conclusively that any particular foods may have a beneficial effect on joint inflammation, although some reports have proposed that oranges and some fish oils may reduce joint inflammation in some people with RA. A healthy, balanced diet aimed at maintaining a normal weight is important for people afflicted with RA, because excess weight increases stress on the weight-bearing joints, contributing to joint pain, stiffness and inflammation.

Therapy

Drug therapy prescribes medications that can help with the pain and swelling. Acetaminophen (Tylenol) is commonly used to ease RA pain. Some nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Motrin) and naproxen, are available over-the-counter. Stronger NSAIDs must be obtained by prescription. However, in 2005, the Food and Drug Administration (FDA) issued a warning about possible side effects of some NSAIDs. Disease modifying antirheumatic drugs (DMARDs) are a group of medications commonly prescribed to RA patients with more severe RA. They act by suppressing the body's autoimmune response, decreasing pain and inflammation, reducing joint damage, and preserving the structure and function of the joints. The type of DMARD prescribed depends on the stage and severity of RA. The possible side effects and expected benefits must also be weighed. Some common DMARDs include methotrexate (Rheumatrex), sulfasalazine (Azulfidine), hydroxychloroquine (Plaquenil), leflunomide (Arava) and cyclosporine (Sandimmune, Neoral). Corticosteroid medicines such as prednisone are among the most effective drugs for relieving inflammation quickly. They are used as a temporary measure to reduce dangerous flares of inflammation, until other drugs, such as DMARDs, take effect. Generally, the stronger medications have important side effects that must be taken into account when planning treatment.

RA patients can also undergo occupational therapy, where they are instructed on how to protect affected joints, and how to reduce strain on the joints during daily activities. For instance, special shoes and the use of a cane can help alleviate pain in the feet, knees, and hips when walking. Occupational therapy also seeks to restore abilities that may have been lost, and to suggest approaches to maintain independence and fitness.

The National Arthritis Foundation provides information on alternative and complementary therapies to RA treatment programs. People with RA may benefit from massage, acupuncture , acupressure , and various herbs and supplements.

KEY TERMS

Anorexia —An eating disorder characterized by markedly reduced appetite or total aversion to food.

Antibody —A protein produced by the body's immune system in response to a foreign substance.

Autoimmune disease —Disease characterized by the involvement of an inappropriate immune response that leads the body to attack its own cells and tissues.

Autoimmune response —A condition in which a person's immune system fails to recognize its own cells as being “self” and attacks its own body.

Disease-modifying antirheumatic drug (DMARD) —Medication belonging to a group of medications commonly used in patients with rheumatoid arthritis that acts by lowering the autoimmune response.

Immune system —The organs and cells that defends the body against infections and other diseases.

Immunosuppressant —Medication that can block the body's immune response.

Joint —The point of connection between two bones that allows motion.

Nonsteroidal anti-inflammatory drug (NSAID) —Medication that does not contain cortisone used to reduce the symptoms of the pain and inflammation of arthritis.

Pannus —Overgrowth of connective tissue on the articular surface of a joint.

Rheumatoid factor (RF) —An antibody present in the blood serum of many individuals affected by rheumatoid arthritis.

Synovial fluid —A lubricating fluid secreted by the synovial membrane.

Synovial membrane —A layer of connective tissue that lines the cavities of joints.

Synovium —A fibrous envelope that produces a fluid to help to reduce friction and wear in a joint.

Systemic disease —A disease that affects the entire body instead of a specific organ.

Prognosis

The course of RA varies from one individual to another, but in general, the long-term prognosis is poor. The irreversible destruction of joints usually begins within the first 2 years of disease onset in the majority of people with RA. Treatment can manage the pain and swelling caused by RA, and joint damage may even slow down or stop. Treatment can bring relief of symptoms to 75% of those afflicted. However, at least 1 of 10 people eventually becomes severely disabled, and the average life expectancy for a patient with RA may be shortened by 3–7 years.

Prevention

Because its cause is unknown, RA cannot be prevented. However, it is often possible to prevent further damage of the joints with early treatment and therapy.

Caregiver concerns

The prevalence of RA increases up to age 80 and represents an important cause of disability in elderly persons. In many senior patients, RA first starts during middle age. Some of these patients have secondary joint deformities and deterioration even though the inflammation may be inactive. In most patients of this age group, the arthritis is accompanied by mild or moderate generalized feelings of discomfort (malaise) and anorexia. Fever and night sweats are also occasionally reported. Elderly-onset rheumatoid arthritis (EORA), defined as RA with onset at age 60 years or over, differs slightly from RA. It is characterized by a more equal gender distribution, a higher frequency of acute systemic symptoms with involvement of the shoulder, a higher rate of disease progression, and, in later stages, more joint damage and functional disability. The efficacy and tolerability of medications is similar in both older and younger patient groups, but in the elderly, caution is required with the use of NSAIDs.

Resources

BOOKS

Felstiner, Mary. Out of Joint: A Private and Public Story of Arthritis. Winnipeg, MAN: Bison Books, 2007.

Foltz-Gray, Dorothy. The Arthritis Foundation's Guide to Good Living with Rheumatoid Arthritis. 3rd ed., Atlanta, GA: Arthritis Foundation, 2006.

McNeil, M. E. A. The First Year: Rheumatoid Arthritis: An Essential Guide for the Newly Diagnosed. Washington, DC: Marlowe & Company, 2005.

Shlotzhauer, Tammi L., and James L. McGuire. Living with Rheumatoid Arthritis. Baltimore, MD: Johns Hopkins University Press, 2003.

Yu, Winnie, and Harry D. Fisher. What To Do When The Doctor Says It's Rheumatoid Arthritis: Stop Your Pain, Become More Active, and Learn How to Talk to Your Doctors. Beverley, MA: Fair Winds Press, 2005.

PERIODICALS

Kerr, L. D. “Inflammatory arthropathy: a review of rheumatoid arthritis in older patients.” Geriatrics 59, no. 10 (October 2004): 32–35.

Lyyra, T. M., and R. L. Heikkinen. “Experienced health in older women with rheumatoid arthritis.” Journal of Women & Aging 18, no. 4 (2006): 67–81.

Schmajuk, G., et al. “Treatment of older adult patients diagnosed with rheumatoid arthritis: improved but not optimal.” Arthritis and Rheumatism 57, no. 6 (August 2007): 928–934.

Semanik, P., et al. “Physical activity behavior in older women with rheumatoid arthritis.” Arthritis and Rheumatism 51, no. 2 (April 2004): 246–252.

Tutuncu, Z., et al. Hedderwick. “Do patients with older-onset rheumatoid arthritis receive less aggressive treatment?” Annals of the Rheumatic Diseases 65, no. 9 (2006): 1226–1229.

OTHER

Arthritis Advice. National Institute on Aging, Age Page. (March 08, 2008) http://www.niapublications.org/agepages/arthritis.asp

Arthritis Drug Guide. Arthritis Foundation, Arthritis Today Health Magazine. (March 08, 2008) http://www.arthritis.org/drug-guide.php

Common Therapies to Consider. Arthritis Foundation, Alternatives Overview. (March 08, 2008) http://www.arthritis.org/common-therapies-to-consider.php

Do I have Arthritis? NIAMS, Health Information Page. http://www.niams.nih.gov/Health_Info/Arthritis/tengo_artritis.asp

51 Ways to Be Good to Your Joints—Lose Weight. Arthritis Foundation, Information Page. (March 08, 2008) http://www.arthritis.org/joints-weight.php

Living Well with a Rheumatic Disease. American College of Rheumatology, Information Page. (March 08, 2008) http://www.rheumatology.org/public/factsheets/livingwell.asp

Rheumatoid Arthritis. American Academy of Family Physicians, FamilyDoctor.org Information Page (March 08, 2008) http://familydoctor.org/online/famdocen/home/articles/876.printerview.html

Rheumatoid Arthritis. Arthritis Foundation, Disease Center Information Page. (March 08, 2008) http://www.arthritis.org/disease-center.php?disease_id=31

What Is Rheumatoid Arthritis? NIAMS, Health Information Page. (March 08, 2008) http://www.niams.nih.gov/Health_Info/Rheumatic_Disease/rheumatoid_arthritis_ff.asp

ORGANIZATIONS

American College of Rheumatology, 1800 Century Place, Suite 250, Atlanta, GA, 30345-4300, (404)633-3777, (404)633-1870, http://www.rheumatology.org.

Arthritis Foundation, P.O. Box 7669, Atlanta, GA, 30357-0669, (800)283-7800, http://www.arthritis.org.

National Institute of Arthritis and Musculoskeletal Diseases (NIAMS), 1 AMS Circle, Bethesda, MD, 20892-3675, (301)495-4484, (877)22-NIAMS, (301)718-6366, [email protected], http://www.niams.nih.gov.

Monique Laberge Ph.D.