Rheumatoid arthritis

Rheumatoid arthritis is a chronic disease, mainly characterized by inflammation of the lining, or synovium, of the joints. It can lead to long-term joint damage, resulting in chronic pain, loss of function and disability.




Rheumatoid arthritis (RA) progresses in three stages. The first stage is the swelling of the synovial lining, causing pain, warmth, stiffness, redness and swelling around the joint. Second is the rapid division and growth of cells, or pannus, which causes the synovium to thicken. In the third stage, the inflamed cells release enzymes that may digest bone and cartilage, often causing the involved joint to lose its shape and alignment, more pain, and loss of movement.

Because it is a chronic disease, RA continues indefinitely and may not go away. Frequent flares in disease activity can occur. RA is a systemic disease, which means it can affect other organs in the body. Early diagnosis and treatment of RA is critical if you want to continue living a productive lifestyle. Studies have shown that early aggressive treatment of RA can limit joint damage, which in turn limits loss of movement, decreased ability to work, higher medical costs and potential surgery.

Rheumatoid Arthritis

Causes

The exact cause of rheumatoid arthritis (RA) currently is unknown. In fact, there probably isn’t an exact cause for RA. Researchers now are debating whether RA is one disease or several different diseases with common features.

Immune System
We do know that the body’s immune system plays an important role in rheumatoid arthritis. In fact, RA is referred to as an autoimmune disease because people with RA have an abnormal immune system response.

In a healthy immune system, white blood cells produce antibodies that protect the body against foreign substances. People who have RA have an immune system that mistakes the body’s healthy tissue for a foreign invader and attacks it.

Rheumatoid factor is an antibody that is directed to regulate normal antibodies made by the body. It works well in people with small quantities of rheumatoid factor. People with high levels of rheumatoid factor, however, may have a malfunctioning immune system. This is why the doctor often request a test measuring rheumatoid factor when trying to diagnose RA. In general, the higher the level of rheumatoid factor present in the body, the more severe the disease activity is.

It is important to note that not all people with RA have an elevated rheumatoid factor and not all people with an elevated rheumatoid factor have RA. The test also can come out negative if it is done too early in the course of the disease. Approximately 20 percent of people with RA will have a negative rheumatoid factor test and some people who don’t have RA will test positive.

Deformities in RA

 



Gender
Women get rheumatoid arthritis two to three times more often then men and their RA typically goes into remission when they get pregnant. Women develop RA more often than expected in the year after pregnancy and symptoms can increase after a baby is born. These facts lead researchers to believe that gender might play a role in the development and progression of RA. Many are trying to understand the effects female hormones might have in the development of RA.

Genetics
Most researchers believe there are genes involved in the cause of RA. The specific genetic marker associated with RA, HLA-DR4, is found in more than two-thirds of Caucasians with RA while it is only found in 20 percent of the general population. While people with this marker have an increased risk of developing RA, it is not a diagnostic tool. Many people who have the marker either don’t have or will never get RA. While this marker can be passed from parent to child, it is not definite that if you have RA, your child will too.

Infection
Some physicians and scientists believe that RA is triggered by a kind of infection. There is currently no proof of this. Rheumatoid arthritis is not contagious, although it is possible that a germ to which almost everyone is exposed may cause an abnormal reaction from the immune system in people who already carry a susceptibility for RA.


What are the effects?

Rheumatoid arthritis can start in any joint, but it most commonly begins in the smaller joints of the fingers, hands and wrists. Joint involvement is usually symmetrical, meaning that if a joint hurts on the left hand, the same joint will hurt on the right hand. In general, more joint erosion indicates more severe disease activity.


Other common physical symptoms include:

Fatigue
Stiffness, particularly in the morning and when sitting for long periods of time. Typically, the longer the morning stiffness lasts, the more active your disease is.

Weakness
Flu-like symptoms, including a low-grade fever
Pain associated with prolonged sitting
The occurrence of flares of disease activity followed by remission or disease inactivity
Rheumatoid nodules, or lumps of tissue under the skin, appear in about one-fifth of people with RA. Typically found on the elbows, they can indicate more severe disease activity.

Muscle pain
Loss of appetite, depression, weight loss, anemia, cold and/or sweaty hands and feet

Involvement of the glands around the eyes and mouth, causing decreased production of tears and saliva
Advanced changes to look out for include damage to cartilage, tendons, ligaments and bone, which causes deformity and instability in the joints. The damage can lead to limited range of motion, resulting in daily tasks (grasping a fork, combing hair, buttoning a shirt) becoming more difficult. You also may see skin ulcers and a general decline in health. People with severe RA are more susceptible to infection.

The effects of rheumatoid arthritis can vary from person to person. In fact, there is some growing belief that RA isn’t one disease, but it may be several different diseases that share commonalities.
Diagnosis

Diagnosing rheumatoid arthritis is a process. There isn’t a sure-fire test that can tell you positively that you have RA. Instead your doctor relies on a number of tools to help him determine the best treatment for your symptoms.

A diagnosis will be made from a medical history, a physical exam, lab tests and X-rays.

Medical History
Medical history probably is your doctor’s best tool for diagnosing rheumatoid arthritis. The more your doctor knows about you, the faster and better he will be able to diagnose your condition and determine the best treatment for you. Taking a medical history is the first line to finding out if you have rheumatoid arthritis. What you tell him will allow him to determine if RA should be considered a possible diagnosis or if he should look in another direction.

Following is a list of questions your doctor might ask in a medical history:

Do you have joint pain in many joints?
Does the pain occur symmetrically – that is, do the same joints on both sides of your body hurt at the same time? Or is the pain one-sided?
Do you have stiffness in the morning?
When is the pain most severe?
Do you have pain in your hands, wrists and/or feet?
If you have pain in your hands, which joints hurt the most?
Have you had periods of feeling weak and uncomfortable all over? Do you feel fatigued?


Physical Examination
The doctor will perform a physical exam to determine diagnosis. He will be looking for common features reported in RA, including:

Joint swelling
Joint tenderness
Loss of motion in your joints
Joint mal-alignment
Signs of rheumatoid arthritis in other organs, including your skin, lungs and eyes.

Lab Tests
While there is no one test to confirm whether or not you have rheumatoid arthritis, your doctor at A+ clinic may use several different tests and imaging studies to help make a diagnosis. The most commonly used tests are listed below, but not all doctors will use every test and some may use tests not described. You should feel free to fully question your doctor for any tests he or she orders so you understand what it is measuring and why. Most tests ordered to help with diagnosis will only have to be taken once. Tests designed to measure improvement or to check for drug side effects may need to be repeated regularly.

Complete Blood Count
There are three types of cells in your blood: red blood cells, which carry oxygen to tissues; white blood cells, which help fight infections; and platelets, which help the blood clot. Each may be tested to check for abnormalities that might exist or to monitor side effects of drugs and check progress.

People with rheumatoid arthritis often have a low red blood count, signally anemia, a common problem for people with RA. Anemia can contribute to feelings of fatigue. People with more aggressive disease tend to have more severe anemia.

White blood cells may be high, signaling that infection is present in your body. A low white blood cell count could suggest Felty’s syndrome, a complication of RA, or may be caused by some medications.

Your platelet count is elevated when you have inflammation present in the body. It can also be lowered by certain drugs.

If you take nonsteroidal anti-inflammatory drugs (NSAIDs), your platelet and white blood cell count will be monitored every six months. People taking disease-modifying antirhuematic drugs (DMARDs), will be checked every two to 12 weeks.

Erythrocyte Sedimentation Rate (ESR)
The erythrocyte sedimentation rate (ESR) measures the speed at which red blood cells fall to the bottom of a test tube. The more rapidly your red blood cells drop, the more inflammation is present in the body. A high sed rate indicates inflammation and the higher it is, the more severe the RA is. Your sed rate will be checked frequently to see if treatment is working successfully.

C-Reactive Protein
C-reactive protein (CRP) is found in the body and is elevated when inflammation is found in the body. The higher the level of CRP the more disease activity is involved. Although ESR and CRP reflect similar degrees of inflammation, sometimes one will be raised when the other isn’t. This test may be repeated regularly to monitor your inflammation and your response to medication.



Rheumatoid Factor
Approximately 70 to 80 percent of people with rheumatoid factor (RF) also have rheumatoid arthritis. It is tested by measuring the amount of RF in your body. The higher the amount of RH present in the body, the more active and severe your disease is.

Some people with RA do not have RF in their blood. They are called “seronegative.” People with RF in there blood are called “seropositive.”

Antinuclear Antibodies (ANA)
This test detects a group of autoantibodies (antibodies against self), which is seen in about 30 to 40 percent of people with RA. Although it commonly is used as a screening tool, ANA testing isn't used as a diagnostic tool because many people without RA or with other diseases can have ANAs.

Imaging Studies

Radiographs (X-rays)
Your doctor may take X-rays of your bones and joints upon diagnosis with RA to provide a valuable baseline for comparison with later X-rays. They show the swelling of the soft tissues and the loss of bone density around the joints – the result of your reduced activity and inflammation. As your disease progresses, your X-rays can show small holes or erosions near the ends of bone s and narrowing of the joint space due to loss of cartilage. Doctors used to wait until the appearance of erosion before beginning aggressive treatment of RA. Now it is widely believed that it is better to treat aggressively before the development of erosion.


Magnetic Resonance Imaging (MRI)
A MRI can detect early inflammation before it is visible on an X-ray, and are particularly good at pinpointing synovitis (inflammation of the lining of the joint)

Joint Ultrasound
Joint ultrasound is a much less expensive way to look for joint inflammation before X-rays show damage. Although not currently used often, this procedure may gain wider use over the next few years as doctors increase their efforts to document early evidence of the disease.

Bone Densitometry (DEXA)
Bone densitometry is an important imaging study for measuring bone density, used primarily to detect osteoporosis. Osteoporosis may be especially severe in people with RA due to joint immobilization, the inflammatory response itself and the use of certain therapies (such as glucocorticoids) that may hasten bone loss. Some doctors suggest that a bone density test should be part of the evaluation and monitoring of all people with RA, particularly for women after menopause.

Treatment options

Because rheumatoid arthritis presents itself on many different fronts and in many different ways, treatment must be tailored to the individual, taking into account the severity of your arthritis, other medical conditions you may have and your individual lifestyle. Current treatment methods focus on relieving pain, reducing inflammation, stopping or slowing joint damage and improving your functioning and sense of well-being.

Rheumatoid arthritis is a serious disease. It is crucial that you get an early diagnosis and work with your doctor to find the best treatment for you so that you can live well with it. Just a few years ago, your doctor might have only prescribed an over-the-counter pain reliever, like an analgesic or non-steroidal, anti-inflammatory drug (NSAID), until you experienced increased disease progression. Now, with the improvement of available medications, doctors know that they have to be more aggressive early on in order to prevent severe deformity and joint erosion.

Medications
The proper medication regimen is important in controlling your RA. You must help your doctor determine the best combination for you. The main categories of drugs used to treat RA are:

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) – These drugs are used to reduce inflammation and relieve pain. These are medications such as aspirin, ibuprofen, indomethacin and aceclofenac/diclofenac.
Analgesic Drugs – These drugs relieve pain, but don’t necessarily have an effect on inflammation. Examples of these medications are acetaminophen, propoxyphene, mepeidine and morphine.
Glucocorticoids or Prednisone – These are prescribed in low maintenance doses to slow joint damage caused by inflammation.
Disease Modifying Antirheumatic Drugs (DMARDs) – These are used with NSAIDs and/or prednisone to slow joint destruction caused by RA over time. Examples of these drugs are methotrexate, injectable gold, penicillamine, azathioprine, chloroquine, hydroxychloroquine, sulfasalazine and oral gold.
Biologic Response Modifiers – These drugs directly modify the immune system by inhibiting proteins called cytokines, which contribute to inflammation. Examples of these are etanercept, infliximab, adaliumumab and anakinra.
Protein-A Immuoadsorption Therapy – This is not a drug, but a therapy that filters your blood to remove antibodies and immune complexes that promote inflammation.
DMARDs, particularly methotrexate, have been the standard for aggressively treating RA. Recently, studies have shown that the most aggressive treatment for controlling RA may be the combination of methotrexate and another drug, particularly biologic response modifiers. The dual drug treatment seems to create a more effective treatment, especially for people who may not have success with or who have built up a resistance to, methotrexate or another drug alone. Doctors now are prescribing combination drug therapy more often and studies continue. It appears that these combination drug therapies might become the new road to follow in treating RA. Here are some medications your doctor may suggest you combine with methotrexate: lefluonomide (Arava), etanercept (Enbrel), adalimumab (Humira) and infliximab (Remicade).


Surgery
Many people with rheumatoid arthritis might consider surgery as part of their treatment plan. The surgical options available today can contribute greatly to improving your quality of life with RA. The following are different surgical options available to people with RA.

Synovectomy – When one or two joints are affected more severely than others, this procedure is used to reduce the amount of inflammatory tissue by removing the diseased synovium or lining of the joint. It may result in less swelling and pain and the slowing or prevention of further joint damage.

Arthroscopic Surgery – In this procedure, the surgeon inserts a very thin tube with a light at the end into the joint through a small incision. It is connected to a closed-circuit television and allows the surgeon to see the extent of the damage in the joint. Once there, the doctor can take tissue samples, remove loose cartilage, repair tears, smooth a rough surface or remove diseased synovial tissue. It is most commonly performed on the knee and shoulder.

Joint Replacement Surgery or Arthroplasty - This is the surgical reconstruction or replacement of a joint. Successfully used to help people who otherwise might be in a wheelchair, joint replacement surgery involves the removal of the joint, resurfacing and relining of the ends of bones and replacing the joint with a man-made component. This procedure is usually recommended for people over 50 or who have severe disease progression. Typically a new joint will last between 20 and 30 years.

Arthrodesis or fusion – This procedure fuses two bones together. While it limits movement, it does decrease pain and increase stability of the joints in the ankles, wrists, fingers, toes and spine.


RA can affect anyone, including children, but 70 percent of people with RA are women. Onset usually occurs between 30 and 50 years of age.

RA often goes into remission in pregnant women, although symptoms tend to increase in intensity after the baby is born. RA develops more often than expected the year after giving birth.

While women are two to three times more likely to get RA than men, men tend to be more severely affected when they get it.

People with the genetic marker HLA-DR4 may have an increased risk of developing RA. This marker is found in white blood cells and plays a role in helping your body distinguish between its own cells and foreign invaders.