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Rheumatoid Arthritis

Rheumatoid Arthritis

Introduction - What Is Rheumatoid Arthritis?

Rheumatoid arthritis is a chronic inflammatory disease that causes pain, stiffness, and swelling around the joints. In the United States, rheumatoid arthritis affects more than 2 million people and is twice as common in women as men.8092  Rheumatoid arthritis can develop at any age, but it typically begins between the ages of 30 and 50.8092 

Rheumatoid arthritis is not a condition that occurs because of aging or injury, but is an autoimmune disease. An autoimmune disease is a disease in which a person’s immune system, which normally acts to defend the body against disease, mistakenly attacks that person’s healthy tissues. In rheumatoid arthritis, the body’s immune system attacks the joints. 8092  If not treated, this inflammation can lead to permanent bone and joint damage. One key feature of rheumatoid arthritis is inflammation (swelling and warmth) of certain joints.8092  This inflammation frequently causes pain and restricts movement. Rheumatoid arthritis most commonly affects the joints of the hands, wrists, feet, ankles, elbows, and shoulders, though any joint may be involved.8092  Rheumatoid arthritis tends to affect joints symmetrically, that is, if the left elbow is affected the right elbow is also affected.6612 

Rheumatoid arthritis can sometimes be accompanied by other symptoms, such as rheumatoid nodules (hard lumps under the skin), 6601  Sjögren’s syndrome (dry eyes and mouth),6601  and vasculitis (an inflammation of the blood vessels). 6602  As rheumatoid arthritis progresses, it can lead to joint damage, wearing down of the ends of bones and a decrease in the necessary gap between bones and joints. This damage to the end of the bones worsens joint pain and stiffness and worsens joint function.

Causes of Rheumatoid Arthritis

The exact cause of rheumatoid arthritis is unknown. Recent scientific findings suggest that rheumatoid arthritis may be caused by a combination of genetic and environmental factors.

Genetics

Rheumatoid arthritis tends to run in families. If someone in your family, particularly a close relative has rheumatoid arthritis, you are at an increased risk for developing the condition.10508,  6604,  6605  Studies have shown that smokers with a family history of rheumatoid arthritis are at an even greater risk of developing rheumatoid arthritis. Furthermore, smoking can also increase the severity of rheumatoid arthritis.6606,  6607 

Environment

One theory suggests that rheumatoid arthritis may be caused by other environmental factors, such as exposure to certain bacteria or viruses. However, this theory has not been completely proven. 6608 

Symptoms of Rheumatoid Arthritis

The main symptoms of rheumatoid arthritis are:

  • Joint pain

  • Joint stiffness after immobility (after sitting or sleeping)

  • Joint swelling

  • Soft-tissue swelling

  • Bone loss (that may lead to brittle bones that fracture easily) near the joints

  • Fatigue or tiredness

  • Loss of appetite

Any of these symptoms can lead to an inability to function normally in daily activities. People with rheumatoid arthritis tend to have joints that are swollen and tender. This occurs in a symmetrical pattern. This means that symptoms such as joint pain, stiffness, and swelling can be seen on both the left- and right-hand sides of the body.6612  If rheumatoid arthritis is left untreated, it can lead to permanent joint and bone damage as well as disability.6613,  6601,  6611,  6614,  6615 

Diagnosis of Rheumatoid Arthritis

Physicians who specialize in diagnosing, detecting, and treating rheumatoid arthritis and other diseases of the joints are called rheumatologists. There is no single test that rheumatologists can use to diagnose a person with rheumatoid arthritis. Therefore, to accurately diagnosis the disease, a rheumatologist relies on a combination of factors, including patient’s symptoms, physical examination, blood tests, and x-rays of selected joints.10705,  6601  During a physical examination of the patient, the rheumatologist will examine swollen and tender joints to determine the extent of arthritis, which will help determine the potential risk of further joint damage. Additionally, the rheumatologist may order a blood test to determine whether the patient has high levels of rheumatoid factor, an antibody found in 80% of people with rheumatoid arthritis.6601 

Fig.1667 depicts a normal joint and a joint affected by rheumatoid arthritis.

Figure 1667 – A Normal Joint and a Joint Affected by Rheumatoid Arthritis


Centocor. Data on file.

11688

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How Does Rheumatoid Arthritis Differ From Osteoarthritis?

Rheumatoid arthritis and osteoarthritis are the 2 most common forms of arthritis. Some people have both diseases. The table below compares rheumatoid arthritis with osteoarthritis.

Figure 2578 – Rheumatoid Arthritis vs. Osteoarthritis


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Complications of Rheumatoid Arthritis

For most patients, rheumatoid arthritis worsens as time passes, and therapies for rheumatoid arthritis are often not effective in controlling the symptoms of the disease for extended periods.11113  Most rheumatoid arthritis patients experience joint damage and severe declines in function within 10 years of the onset of rheumatoid arthritis. Approximately 60% of patients become too ill to work after 10 years of disease.6938 

Rheumatoid arthritis can directly or indirectly affect every organ in the body. One of the most common complications of rheumatoid arthritis is the development of rheumatoid nodules, or hard lumps under the skin. These nodules occur on areas of the body exposed to physical strain, particularly the elbows, the outside edge of the lower arm, and areas where tendons are attached to the bones.6619,  6620,  6621 

Vasculitis, or the inflammation of blood vessels, can occur in some rheumatoid arthritis patients. However, this complication tends to occur in patients with more severe rheumatoid arthritis. 6622,  6601 

Treatment of Rheumatoid Arthritis

There is no cure for rheumatoid arthritis. Treatment is directed toward reducing inflammation and managing the symptoms of disease. If left untreated, rheumatoid arthritis usually worsens over time. Therefore, rheumatologists recommend that once patients have been diagnosed with rheumatoid arthritis, they begin treatment as soon as possible.6660 

Patients may experience a dramatic reduction in their personal activity levels within the first few years of diagnosis, due to the rapid progression of the disease.6623  Those diagnosed before age 45 are more likely to have severe disease. Even if you have had the disease for many years, it’s still very important to start effective treatment as soon as possible.

Although rheumatoid arthritis is a chronic condition, early treatment can help to slow joint damage in patients with moderate to severe rheumatoid arthritis. Treatment should include education about the disease and medications. It is important to remember that all treatment options have potential side effects. Take the time to discuss the potential benefits and risks of the available treatment options with your doctor before deciding which treatment is right for you.

Medications for Rheumatoid Arthritis

There are several drugs that may be prescribed by your doctor for the treatment of rheumatoid arthritis symptoms. Some may act to lessen pain and reduce inflammation while others work to slow the progression of joint damage. Any drug chosen by your doctor is based upon your individual situation, including your symptoms, other medicines you may be taking, your response to previous treatments, and other factors. Only your doctor can help you decide when a treatment is right for you. Listed below are examples of categories of drug therapies used in the treatment of rheumatoid arthritis.

  • Nonsteroidal anti-inflammatory drugs (NSAIDs)

  • COX-2 inhibitors (a subcategory of NSAIDs)

  • Disease-modifying antirheumatic drugs (known as DMARDs)

  • Biologics (used in patients who have not responded well to other drugs)

Lifestyle Changes

Patients with rheumatoid arthritis benefit from moderate exercise, which can keep joints moving, maintain flexibility, and potentially improve their rheumatoid arthritis symptoms. A safe exercise program can help improve stamina and the ability to perform daily tasks, such as walking and dressing.

Before starting any new exercise program, patients should talk with their doctors to make sure that they choose the appropriate exercises. Gentle, low-impact exercise, such as walking, water aerobics, and yoga, are forms of exercise that allow patients to keep moving with minimum physical strain and avoiding painful movements. Other types of exercise, such as golf or biking, are more intense and require patients to prepare with the appropriate stretches and warm-up exercises. This will help to avoid undue stress on joints and decrease the risk of injury.

A good diet is closely linked to good overall health and helps control your weight. A balanced diet should contain fruits, vegetables, and whole grains, while sugar, salt, and fat intake should be limited .

Research suggests that rheumatoid arthritis may be affected by certain types of food. Foods containing omega-3 fatty acids, such as fish, are thought to help reduce inflammation. Bones can be strengthened by eating calcium-rich foods, including dark green vegetables, low-fat cheeses, and skim milk.

Your doctor may suggest a weight-reduction program if you are overweight. Excess weight puts stress on your hips, back, hands, feet, and joints and can make arthritis symptoms worse.

Discussing Rheumatoid Arthritis With Your Doctor

Your rheumatologist will need to know about the effectiveness of your past treatments as well as how rheumatoid arthritis is affecting your quality of life. It’s often a good idea to write down any questions you want to ask your rheumatologist before your appointment so you won’t forget to ask them during your visit. Your rheumatologist will ask questions to help determine the most effective rheumatoid arthritis treatment for you. If you don’t understand your doctor’s answers, don’t be afraid to ask for further explanation.

Questions Your Doctor May Ask You About Your Rheumatoid Arthritis

  • Do you have pain in your joints?

  • Do you have stiffness in your joints for at least 1 hour after waking up?

  • Do you have any swelling or fluid around your joints?

  • Are these symptoms the same on the left- and right-hand sides of your body?

  • Do you have any family members with rheumatoid arthritis?

  • How does your joint problem affect your daily tasks?

Questions You May Want to Ask Your Rheumatoid Arthritis Doctor

  • Do I have any joint damage?

  • Can rheumatoid arthritis continue to damage my joints even if I am taking medical therapies?

  • How will I know if my rheumatoid arthritis is controlled?

Additional Information and Resources for Rheumatoid Arthritis

This concludes the discussion of Rheumatoid Arthritis. We encourage you to read other topics on the MEDVERSATION™ website.

Content on this page was last changed on November 19, 2009.

References:

6601.  Lipsky PE. Rheumatoid arthritis. In: Fauci AS, ed. Harrison’s Rheumatology. 16th ed. New York, NY: McGraw Hill; 2006:85-104.
6602.  Voskuyl AE, Zwinderman AH, Westedt ML, Vandenbroucke JP, Breedveld FC, Hazes JM. Factors associated with the development of vasculitis in rheumatoid arthritis: results of a case-control study. Ann Rheum Dis. 1996;55(3):190-192.
6604.  Silman AJ, MacGregor AJ, Thomson W, et al. Twin concordance rates for rheumatoid arthritis: results from a nationwide study. Br J Rheumatol. 1993;32(10):903-907.
6605.  Seldin MF, Amos CI, Ward R, Gregersen PK. The genetics revolution and the assault on rheumatoid arthritis. Arthritis Rheum. 1999;42(6):1071-1079.
6606.  Costenbader KH, Feskanich D, Mandl LA, Karlson EW. Smoking intensity, duration, and cessation, and the risk of rheumatoid arthritis in women. Am J Med. 2006;119(6):503-511.
6607.  Gorman JD. Smoking and rheumatoid arthritis: another reason to just say no. Arthritis Rheum. 2006;54(1):10-13.
6608.  Schumacher HR Jr, Gérard HC, Arayssi TK, et al. Lower prevalence of Chlamydia pneumoniae DNA compared with Chlamydia trachomatis DNA in synovial tissue of arthritis patients. Arthritis Rheum. 1999;42(9):1889-1893.
6611.  Harris ED Jr. Clinical features of rheumatoid arthritis. In: Harris ED Jr, Budd RC, Firestein GS, et al. Kelley’s Textbook of Rheumatology. 7th ed. Philadelphia, PA: WB Saunders; 2005:1043-1054.
6612.  Blumberg SN, Fox DA. Rheumatoid arthritis: guidelines for emerging therapies. Am J Manag Care. 2001;7(6):617-626.
6613.  O’Dell J. Rheumatoid arthritis: the clinical picture. In: Koopman WJ, Moreland LW, eds. Arthritis and Allied Conditions. 15th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2000:1165-1175.
6614.  Haugeberg G, Orstavik RE, Kvien TK. Effects of rheumatoid arthritis on bone. Curr Opin Rheumatol. 2003;15(4):469-475.
6615.  Scott DL, Pugner K, Kaarela K, et al. The links between joint damage and disability in rheumatoid arthritis. Rheumatology (Oxford). 2000;39(2):122-132.
6619.  Maldyk H, Slotwinska L. Clinical pattern of rheumatoid arthritis in patients with rheumatoid nodules. Polish Med J. 1971;10(1):24-30.
6620.  Hollingsworth JW, Saykaly RJ. Systemic complications of rheumatoid arthritis. Med Clin North Am. 1977;61(2):217-228.
6621.  Hurd ER. Extraarticular manifestations of rheumatoid arthritis. Semin Arthritis Rheum. 1979;8(3):151-176.
6622.  Wilkinson M, Torrance WN. Clinical background of rheumatoid vascular disease. Ann Rheum Dis. 1967;26(6):475-480.
6623.  Breedveld FC, Han C, Bala M, et al. Association between baseline radiographic damage and improvement in physical function after treatment of patients with rheumatoid arthritis. Ann Rheum Dis. 2005;64(1):52-55.
6660.  Arthritis Disease Center: rheumatoid arthritis. Arthritis Foundation website http://www.arthritis.org/disease-center.php?disease_id=31. Published 2007. Accessed March 10, 2008.
6938.  Pincus T, Callahan LF. What is the natural history of rheumatoid arthritis? Rheum Dis Clin North Am. 1993;19(1):123-151.
8092.  The American College of Rheumatology. Rheumatoid Arthritis. The American College of Rheumatology website. http://www.rheumatology.org/public/factsheets/ra_new.asp#1 . Accessed May 6, 2008.
10508.  Aho K, Koskenvuo M, Tuominen J, Kaprio J. Occurrence of rheumatoid arthritis in a nationwide series of twins. J Rheumatol . 1986 Oct;13(5):899-902.
10705.  American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines. Guidelines for the management of rheumatoid arthritis: 2002 update. Arthritis Rheum. 2002;46(2):328-346.
11113.  Brook A, Corbett M. Radiographic changes in early rheumatoid disease. Ann Rheum Dis. 1977;36(1):71-73.
11688.  Centocor. Data on file.
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