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The outlook has dramatically improved for many people newly diagnosed
with rheumatoid arthritis (RA), long feared as one of the most disabling
types of arthritis. RA remains a serious disease, and one that can vary
widely in symptoms and outcomes. Even so, recent advances in treatment
have made it possible to stop or at least slow the progression of joint
damage. Many of these new treatments have emerged in the last 10 years
because of exciting and rapidly advancing research into the fundamentals
of inflammation. Some new therapies target inflammation; others involve
combinations of existing medications to increase benefit.
Fast Facts
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RA is the most common type of arthritis triggered by
the immune system.
-
Treatments have improved dramatically
and help many of those affected.
-
Rheumatologists have the expertise necessary to
diagnose this disease correctly and offer patients the most advanced
treatments.
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The normal joint structure is pictured on the left. On the
right is
the joint affected by rheumatoid arthritis which has swelling
of the
synovium that can lead to damage to cartilage and bone. |
|
What rheumatoid arthritis is
RA is a chronic disease that causes pain, stiffness, swelling, and limitation
in the motion and function of multiple joints. Though joints are the principal
body parts affected by RA, inflammation can develop in other organs as
well.
The stiffness seen in active RA is typically worst in the morning and
may last anywhere from one to two hours to the entire day. This long period
of morning stiffness is an important diagnostic clue, as not many other
arthritic diseases behave this way. For example, osteoarthritis does not
generally cause prolonged morning stiffness. While RA can affect any joint,
the small joints in the hands and feet tend be involved more frequently
than others. This produces a pattern of joint disease that rheumatologists
regard as characteristic of RA.
Other symptoms that can occur in RA include:
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loss of energy
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low-grade fevers
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loss of appetite
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dry eyes and mouth from an associated condition known
as Sjogren's syndrome
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firm lumps called rheumatoid nodules beneath the skin
in areas such as the elbow and hands
What causes rheumatoid arthritis
RA is classified as an autoimmune disease, which develops because certain
cells of the immune system malfunction and attack healthy joints. While
the cause of RA remains unknown, exciting and rapidly advancing research
is revealing the factors that are important in producing inflammation.
The primary focus of the inflammation is in the synovium, which is the
lining tissue of the joint. Inflammatory
chemicals released by the immune cells cause swelling and damage to cartilage
and bone. This research is giving us a better understanding of the immune
and genetic factors that may be involved in the disease. As a result of
this work, new medications have been developed that specifically block
certain signals in the body from the immune system that are important
in causing RA symptoms and joint damage.
Who gets rheumatoid arthritis
RA is the most common form of inflammatory arthritis. More than 2 million
Americans suffer from RA. About 75 percent of those affected are women,
and 1–3% of women may develop rheumatoid arthritis is their lifetime. The
disease most often begins between the fourth and sixth decades of life;
however, RA can develop at any age.
How rheumatoid arthritis is diagnosed
RA can be difficult to diagnose because it may begin gradually with subtle
symptoms. Many diseases, especially early on, behave in a manner similar
to RA. For this reason, patients suspected of having RA should be evaluated
by a rheumatologist, a physician with the necessary skill and experience
to reach a precise diagnosis and develop the most appropriate treatment
plan.
The diagnosis of RA is based on the symptoms described and physical examination
findings such as warmth, swelling and pain in the joints. Certain laboratory
abnormalities commonly found in RA can help in establishing a diagnosis.
Tell-tale abnormalities include:
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anemia (a low red blood cell count);
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rheumatoid factor (an antibody eventually found in approximately
80% of patients with RA, but in only 30% at the start of the arthritis);
and
-
an elevated erythrocyte sedimentation rate or “sed rate” (a
blood test that in most patients with RA tends to correlate with
the amount of inflammation in the joints).
X-rays can be very helpful in diagnosing RA but may not show any abnormalities
in the first 3–6 months of arthritis. X rays are useful in determining
if the disease is progressing.
It is important to remember that for most patients with this disease
(especially those who have had symptoms for less than six months), there
is no single test that “confirms” a diagnosis of RA. Rather, diagnosis
is established by skillfully evaluating the appropriate symptoms, physical
examination findings, laboratory tests and X-rays.
How rheumatoid arthritis is treated
Therapy for patients with RA has improved dramatically over the past
25 years. Current treatments offer most patients good to excellent relief
of symptoms and the ability to continue to function at or near normal
levels. Since there is no cure for RA, the goal of treatment is to minimize
patients' symptoms and disability by introducing appropriate medical therapy
early on, before the joints are permanently damaged. No single therapy
is effective for all patients, and many patients will need to change treatment
strategies during the course of their disease.
Successful management of RA requires early diagnosis and, at times, aggressive
treatment. To quickly reduce joint inflammation and symptoms, first-line
treatment usually consists of non-steroidal anti-inflammatory drugs (NSAIDs)
such as ibuprofen (Motrin and others), naproxen (Naprosyn,
Aleve), celecoxib (Celebrex)
and many others. In addition, corticosteroids such as prednisone (Deltasone and
others) may be given orally at low doses or via injection into the joints.
However, all RA patients with persistent swelling in the joints are candidates
for treatment with disease-modifying anti-rheumatic drugs (DMARDs), often
used in conjunction with NSAIDs and/or low dose corticosteroids. DMARDs
have greatly improved the symptoms and function as well as the quality
of life for the vast majority of patients with RA. DMARDs include methotrexate (Rheumatrex and Folex), leflunomide (Arava), hydroxychloroquine (Plaquenil), sulfasalazine (Azulfidine), gold given
orally (Auranofin) or intramuscularly (Myochrisine), minocycline (Minocin,
Dynacin and Vectrin), azathiaprine (Imuran),
and cyclosporine (Sandimmune and Neoral).
A new class of medications, referred to as biologic response modifiers
or “biologic agents” can specifically target parts of the immune system
that lead to inflammation as well as joint and tissue damage in RA. These
medications are also DMARDs, because they slow the progression of the
disease. FDA-approved treatments include adalimumab (Humira),
anakinra (Kineret), etanercept (Enbrel), infliximab
(Remicade), abatacept (Orencia), and rituximab (Rituxan). In some cases these medications are used alone;
in many cases, they are combined with methotrexate for added efficacy.
The optimal treatment of RA often requires more than medication alone.
Proper treatment requires comprehensive, coordinated care, patient education
and the expertise of a number of providers, including rheumatologists,
primary care physicians, and physical and occupational therapists .
Broader health impact of rheumatoid arthritis
Recent research indicates that people with RA, particularly those whose
disease is not well controlled, may have a higher risk for heart disease
and stroke. Talk with your physician about your own risk and ways that you
can minimize it.
Living with rheumatoid arthritis
It is important for people with RA to remain physically active, while occasionally
scaling back activities when the disease flares. A consultation with a physical
or occupational therapist may help to determine what level and types of activities
are appropriate. In general, rest when a joint is swollen and inflamed, or
when feeling fatigued. At these times, gentle range-of-motion exercises will
keep the joint flexible. When feeling better, low-impact aerobic exercises
such as walking and exercises to boost muscle strength will improve overall
health and reduce pressure on joints.
The diagnosis of a chronic illness is a life-changing event that can cause anxiety
and occasionally feelings of isolation or depression. Because the treatments
for rheumatoid arthritis have improved dramatically, these feelings usually decrease
with time as energy improves and pain and limitation decrease. It is important
to discuss there normal reactions to illness with your physician and health care
providers, who can provide you with the information and resources you need for
support during your treatment.
 |
|
Rheumatoid arthritis affects the wrist and the small joints
of the hand including the knuckles and the middle joints of the
fingers. |
Points to Remember
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RA has been a primary focus of rheumatologic research and
the treatments now available have dramatically improved outcomes
for patients. Joint pain and swelling can usually be well controlled
and joint damage can be minimized by early treatment.
-
Expertise is particularly needed to establish a diagnosis
of RA early, to rule out diseases that mimic RA (thereby avoiding
unnecessary testing, drug therapy and costs) and to design a treatment
plan that is best suited and customized for the patient and addresses
the need for and the risks and benefits of DMARD therapy. Accordingly,
the rheumatologist, working with the primary care physician and other
health care providers, should play the major role in outlining, implementing
and supervising the management of the patient with RA.
-
Studies have shown that people who receive early treatment
of RA feel better, are more likely to be able to be lead an active
life, and are less likely to experience the type of joint damage that
leads to joint replacement.
The rheumatologist's role in the treatment of
rheumatoid arthritis
RA is a complex disease, but many advances in treatment have been made
recently. Rheumatologists are specialists in musculoskeletal disorders
and therefore are more likely to make a proper diagnosis. They can also
advise patients about the best treatment options available.
To find a rheumatologist
For more information about rheumatologists, click
here.
For a listing of rheumatologists in your area, click
here.
For more information
The American College of Rheumatology has compiled this list to give you
a starting point for your own additional research. The ACR does not endorse
or maintain these Web sites, and is not responsible for any information
or claims provided on them. It is always best to talk with your rheumatologist
for more information and before making any decisions about your care.
The Arthritis Foundation
www.arthritis.org
National Institute of Arthritis and Musculoskeletal and Skin Diseases
Information Clearinghouse
www.niams.nih.gov
Updated May 2004
Written by Eric Ruderman and reviewed by the American College of Rheumatology
Communications and Marketing Committee.
