Rheumatoid arthritis

Rheumatoid arthritis (RA) is a long-term disease that leads to inflammation of the joints and surrounding tissues. It can also affect other organs.

RA; Arthritis - rheumatoid

The cause of RA is unknown. It is considered an autoimmune disease. The body's immune system normally fights off foreign substances, like viruses. But in an autoimmune disease, the immune system confuses healthy tissue for foreign substances. As a result, the body attacks itself.

RA can occur at any age. Women are affected more often than men.

RA usually affects joints on both sides of the body equally. Wrists, fingers, knees, feet, and ankles are the most commonly affected. The course and the severity of the illness can vary considerably. Infection, genes, and hormones may contribute to the disease.

The disease often begins slowly, with symptoms that are seen in many other illnesses:

• Fatigue
• Loss of appetite
• Low fever
• Swollen glands
• Weakness

Eventually, joint pain appears.

• Morning stiffness, which lasts more than 1 hour, is common. Joints can even become warm, tender, and stiff when not used for as little as an hour.
• Joint pain is often felt on both sides of the body.
• The fingers (but not the fingertips), wrists, elbows, shoulders, hips, knees, ankles, toes, jaw, and neck may be affected.
• The joints are often swollen and feel warm and boggy (or spongy) to the touch.
• Over time, joints lose their range of motion and may become deformed.

Other symptoms include:

• Chest pains when taking a breath (pleurisy)
• 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

Joint destruction may occur within 1-2 years after the disease appears.

A specific blood test is available for diagnosing RA and distinguishing it from other types of arthritis. It is called the 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
• Rheumatoid factor test (positive in about 75% of people with symptoms)
• Synovial fluid analysis

Regular blood or urine tests should be done to determine how well medications are working and whether drugs are causing any side effects.

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 current standard of care for RA, in addition to rest, strengthening exercises, and anti-inflammatory drugs.

• Methotrexate (Rheumatrex) is the most commonly used DMARD for rheumatoid arthritis. Leflunomide (Arava) may be substituted for methotrexate.
• 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.

• 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 sulfasalazine (Azulfidine), 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:

• Infections from bacteria, viruses, and fungi
• Leukemia
• Possibly psoriasis

SURGERY

Occasionally, surgery is needed to correct severely affected joints. Surgeries can relieve joint pain and deformities.

The first surgical treatment may be a synovectomy, which is the removal of the joint lining (synovium).

At some point, total joint replacement is needed. In extreme cases, total knee, hip replacement, ankle replacement, shoulder replacement, and others may be done. These surgeries can mean the difference between being totally dependent on others and having an independent life at home.

PHYSICAL THERAPY

Range-of-motion exercises and exercise programs prescribed by a physical therapist can delay the loss of joint function.

Joint protection techniques, heat and cold treatments, and splints or orthotic devices to support and align joints may be very helpful.

Sometimes therapists will use special machines to apply deep heat or electrical stimulation to reduce pain and improve joint mobility.

Occupational therapists can create splints for the hand and wrist, and teach how to best protect and use joints when they are affected by arthritis. They also show people how to better cope with day-to-day tasks at work and at home, despite limitations caused by RA.

Frequent rest periods between activities, as well as 8 to 10 hours of sleep per night, are recommended.

For additional information and resources, see arthritis support group.

The course of rheumatoid arthritis differs from person to person. For some patients, the disease becomes less aggressive over time and symptoms may improve.

Other people develop a more severe form of the disease.

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.

Treatment for rheumatoid arthritis has improved. Many people with RA work full-time. However, after many years, about 10% of those with RA are severely disabled, and unable to do simple daily living tasks such as washing, dressing, and eating.

Rheumatoid arthritis is not only a disease of joint destruction. It can involve almost all organs.

Problems that may occur include:

• Anemia due to failure of the bone marrow to produce enough new red blood cells
• Damage to the lung tissue (rheumatoid lung)
• Injury to the spinal cord when the cervical spine (neck bones) becomes unstable as a result of RA
• Rheumatoid vasculitis (inflammation of the blood vessels), which can lead to skin ulcers and infections, bleeding stomach ulcers, and nerve problems that cause pain, numbness, or tingling. Vasculitis may also affect the brain, nerves, and heart, which can cause stroke, heart attack, or heart failure.
• Swelling and inflammation of the outer lining of the heart (pericarditis) and of the heart muscle (myocarditis). Both of these conditions can lead to congestive heart failure.
• Sjogren syndrome

The treatments for RA can also cause serious side effects. If you experience any side effects, immediately tell your health care provider.

Call your health care provider if you think you have symptoms of rheumatoid arthritis.

Rheumatoid arthritis has no known prevention. However, it is often possible to prevent further damage to the joints with proper early treatment.

Yazici Y. Treatment of rheumatoid arthritis: we are getting there. Lancet. 2009;374:178-180. Epub 2009 Jun 26.

Deighton C, O'Mahony R, Tosh J, Turner C, Rudolf M; Guideline Development Group. Management of rheumatoid arthritis: summary of NICE guidelines. BMJ. 2009;338:b702. doi: 10.1136/bmj/b702.

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.

Rheumatoid arthritis (RA) is a long-term disease that leads to inflammation of the joints and surrounding tissues. It can also affect other organs.

RA; Arthritis - rheumatoid

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.

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

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

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:

• Infections from bacteria, viruses, and fungi
• Leukemia or lymphoma
• Psoriasis

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).

See: Arthritis support group

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.

Rheumatoid arthritis can affect nearly every part of the body. Complications may include:

• Damage to the lung tissue (rheumatoid lung)
• Increased risk of hardenign 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.

Call your health care provider if you think you have symptoms of rheumatoid arthritis.

There is no known prevention. Proper early treatment can help prevent further joint damage.

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.

Review Date: 02/02/2012

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.