Rheumatoid Arthritis

By Sandhya K. Adusumilli, M.D.

Rheumatoid arthritis (RA) affects 2.1 million Americans. RA is a chronic, progressive illness characterized by periods of disease flares and remissions. It mainly causes inflammation of the lining of the joints (synovium). It is an autoimmune disease in that the immune system produces antibodies that attack the bodies’ healthy tissue mistaking it as a foreign invader. It is a systemic disease, with involvement of other organs like lungs, heart, eyes, blood vessels or skin.

RA is 2-3 times more common in women than men, but men are more severely affected. It can affect persons of all ages including children (Juvenile Rheumatoid Arthritis), but more commonly involves persons between 40-60 years age. If untreated, it results in chronic pain, loss of function and disability. It can lead to long-term and permanent damage, which in turn limits loss of movement, decreases ability to work, incurs higher medical costs, and need for potential surgery.

Exact cause of RA is not known, but various theories indicate that environmental factors trigger or precipitate the illness in persons prone to develop RA. In some families, other members can be affected, suggesting a genetic basis for the disorder. When the disease is active, symptoms can include fatigue, lack of appetite, low grade fever, muscle and joint aches, joint swelling, and stiffness, usually most notable in the morning and after periods of inactivity. The disease usually presents with symmetric involvement of the joints of fingers, hands, wrists, ankles and feet. It may affect few joints initially and then progress to involve multiple joints within weeks to months. Simple tasks of daily living, such as turning door knobs and opening jars can become difficult during flares. If untreated, it eventually leads to loss of motion, joint malalignment and deformities in the joints.

Diagnosis is made based on a combination of obtaining of clinical history and physical examination by your physician, blood work and imaging studies. Blood work may reveal elevation of erythrocyte sedimentation rate (ESR or sed rate), presence of rheumatoid factor (in 80% patients), anti-cyclic citrullinated peptide antibody (in 90% patients), anemia, low or high white cell count, and high platelet counts. X-ray studies may be normal or reveal soft tissue swelling and loss of bone density around the joints in early stages. Later stages reveal narrowing of joint space due to loss of cartilage and erosions near the ends of bones, all due to inflammation. Joint x-rays can also be helpful in monitoring the progression of disease and joint damage over time.

Although there is no absolute cure for rheumatoid arthritis, early medical treatment presently has better outcomes. Aggressive management can improve function, stop damage to joints as seen on x-rays, and prevent work disability. Also, the goal of treatment in rheumatoid arthritis is to reduce joint inflammation and pain, maximize joint function, and prevent joint destruction and deformity. The optimal treatment of rheumatoid arthritis involves a combination of patient (and family) education, rest, joint protection and strengthening exercises, and additional combination of medications. Surgery is done to restore function to damaged joints as well as to reduce pain. Total joint replacement of shoulders, hips and knees has been quite successful when indicated.

Physical and occupational therapists are trained to provide specific exercise instructions and can offer splinting supports. For example, wrist and finger splints can be helpful in reducing inflammation and maintaining joint alignment. Devices, such as canes, toilet seat raisers, and jar grippers can assist daily living. Heat and cold applications are modalities that can ease symptoms before and after exercise.

Listed below are the main categories of medications used to treat RA. Usually a combination of medications is recommended.

Nonsteroidal anti-inflammatory medications: Include ibuprofen, naproxen, nabumetone, indomethacin, etc., Reduce inflammation to a mild extent and relieve pain.

Glucocorticoids or prednisone: Low doses of the medications reduce inflammation, relieve pain and slow joint damage.

Disease modifying anti-rheumatic drugs (DMARDs): Include methotrexate, leflunomide, sulfasalazine, hydroxychloroquine, azathioprine, and oral or injectable gold. Improve physical function, decrease joint inflammation, and slow or prevent joint destruction caused by RA.

Biologic response modifiers: Include etanercept, infliximab, adalimumab and anakinra. These drugs modify immune system by inhibiting proteins that cause inflammation and thereby improve physical function, decrease joint inflammation, and slow or prevent joint destruction caused by RA.

Future Treatments: Scientists throughout the world are studying many promising areas of new treatment approaches for rheumatoid arthritis. Rituxan, abatacept are some of the medications that were studied recently and showed preliminary results indicating benefit in treating patients who have failed biologic medications.

RA is a serious disease, especially if not treated. Working with your physician is crucial to figure out the best treatment plan tailored to the severity of your arthritis, and to the other medical conditions that you may have. It is much easier now than ever to control rheumatoid arthritis through the use of current treatment approaches. Increased life span, improved quality of life and lesser amount of pain or no pain is now realized by most patients.