Rheumatoid Arthritis

RA is the most common form of autoimmune arthritis. It affects more than 1.3 million Americans. About 75% of RA patients are women. In fact, 1 – 3% of women may get rheumatoid arthritis in their lifetime. The disease most often begins between the ages of 30 and 50. However, RA can start at any age.

RA is a chronic disease that causes joint pain, stiffness, swelling and decreased movement of the joints. Small joints in the hands and feet are most commonly affected. Sometimes RA can affect your organs, such as eyes, skin or lungs.

The joint stiffness in active RA is often the worst in the morning. It may last one to two hours (or even the whole day). It generally improves with movement of the joints. Stiffness for a long time in the morning is a clue that you may have RA, as this is not common in other conditions. For instance, osteoarthritis most often does not cause prolonged morning stiffness.

Other signs and symptoms that can occur in RA include:

• Loss of energy
• Low fevers
• Loss of appetite
• Dry eyes and mouth from a related health problem, Sjogren's syndrome
• Firm lumps, called rheumatoid nodules, which grow beneath the skin in places such as the elbow and hands

RA is an autoimmune disease. Your immune system is supposed to attack foreigners in your body, like bacteria and viruses, by creating inflammation. In an autoimmune disease, the immune system mistakenly sends inflammation to your own healthy tissue. The immune system creates a lot of inflammation that is sent to your joints causing joint pain and swelling. If the inflammation remains present for a long period of time, it can cause damage to the joint. This damage typically cannot be reversed once it occurs. The cause of RA is not known. There is evidence that autoimmune conditions run in families. For instance, certain genes that you are born with may make you more likely to get RA.

RA is diagnosed by examining blood test results, examining the joints and organs, and reviewing x-ray or ultrasound images. There is no one test to diagnose RA. Blood tests are run to look for antibodies in the blood that can been seen in RA. Antibodies are small proteins in the bloodstream that help fight against foreign substances called antigens. Sometimes these antibodies are found in people without RA. This is called a false positive result. Blood tests are also run to look for high levels of inflammation. The symptoms of RA can be very mild making the diagnosis more difficult. Some viral infections can cause symptoms that can be mistaken for RA. A rheumatologist is a physician with the skill and knowledge to reach a correct diagnosis of RA and to recommend a treatment plan.

Abnormal blood tests commonly seen in RA include:

• Anemia (a low red blood cell count)
• Rheumatoid factor (an antibody, or blood protein, found in about 80% of patients with RA in time, but in as few as 30% at the start of arthritis)
• Antibodies to cyclic citrullinated peptides (pieces of proteins), or anti-CCP for short (found in 60 - 70% of patients with RA)
• Elevated erythrocyte sedimentation rate (a blood test that, in most patients with RA, confirms the amount of inflammation in the joints)

X-rays can help in detecting RA, but may be normal in early arthritis. Even if normal, initial X-rays may be useful later to show if the disease is progressing. MRI and ultrasound scanning can be done to help confirm or judge the severity of RA.

RA is a chronic arthritis. Generally the symptoms will need to be present for more than three months to consider this diagnosis. However there are patients who are diagnosed sooner.

Therapy for RA has improved greatly in the past 30 years. Current treatments give most patients good or excellent relief of symptoms and let them keep functioning at, or near, normal levels. With the right medications, many patients can have no signs of active disease. When the symptoms are completely controlled, the disease is in “remission”.

There is no cure for RA. The goal of treatment is to improve your joint pain and swelling and to improve your ability to perform day-to-day activities. Starting medication as soon as possible helps prevent your joints from having lasting or possibly permanent damage. No single treatment works for all patients. Many people with RA must change their treatment at least once during their lifetime.

RA patients should begin their treatment with disease-modifying antirheumatic drugs — referred to as DMARDs. These drugs not only relieve symptoms but also slow progression of the joint damage. Often, doctors prescribe DMARDs along with nonsteroidal anti-inflammatory drugs or NSAIDs and/or low-dose corticosteroids, to lower swelling and pain. DMARDs have greatly improved the pain, swelling, and quality of life for nearly all patients with RA. Ask your rheumatologist about the need for DMARD therapy and the risks and benefits of these drugs.

Common DMARDs include methotrexate (Rheumatrex, Trexall, Otrexup, Rasuvo), leflunomide (Arava), hydroxychloroquine (Plaquenil) and sulfasalazine (Azulfidine).

Gold is an older DMARD that is often given as an injection into a muscle (such as Myochrysine), but can also be given as a pill — auranofin (Ridaura). The antibiotic minocycline (Minocin) also is a DMARD, as well as azathioprine (Imuran) and cyclosporine (Neoral, Sandimmune, Gengraf). These three drugs and gold are rarely prescribed for RA these days, because other drugs work better or have fewer side effects.

Patients with more serious disease may need medications called biologic response modifiers or “biologic agents.” They can block immune system chemical signals that lead to inflammation and joint/tissue damage. FDA-approved drugs of this type include abatacept (Orencia), adalimumab (Humira), anakinra (Kineret), certolizumab (Cimzia), etanercept (Enbrel), golimumab (Simponi) infliximab (Remicade), rituximab (Rituxan, MabThera) and tocilizumab (Actemra). Most often, patients take these drugs with methotrexate, as the mix of medicines is more helpful.

Janus kinase (JAK) inhibitors are another type of DMARD. People who cannot be treated with methotrexate alone may be prescribed a JAK inhibitor such as tofacitinib (Xeljanz).

The best treatment of RA needs more than medicines alone. Patient education, such as how to cope with RA, also is important. Proper care often requires a team of providers, including rheumatologists, primary care physicians, and physical and occupational therapists. You will need frequent visits through the year with your rheumatologist. These checkups let your doctor track the course of your disease and check for any side effects of your medications. Also, you likely will need to repeat blood tests and X-rays or ultrasounds from time to time.

Sarilumab (Kevzara, Sanofi/Regeneron) was approved May 2017 by the FDA to treat adults with moderate to severe active RA who do not respond well to or have intolerance to disease-modifying antirheumatic drugs (DMARDs), such as methotrexate.

It is important to be physically active most of the time, but to sometimes scale back activities when the disease flares. In general, rest is helpful when a joint is inflamed, or when you feel tired. At these times, do gentle range-of-motion exercises, such as stretching. This will keep the joint flexible.

When you feel better, RA patients are encouraged to do low-impact aerobic exercises, such as walking, and exercises to boost muscle strength. This will improve your overall health and lower the pressure on your joints. A physical or occupational therapist can help you find which types of activities are best for you, and at what level or pace you should do them.

Finding that you have a chronic illness is a life-changing event. It can cause worry and sometimes feelings of isolation or depression. Thanks to greatly improved treatments, these feelings tend to decrease with time as energy improves, and pain and stiffness decrease. Discuss these normal feelings with your health care providers. They can provide helpful information and resources.

RA is a complex disease, but many advances in treatment have occurred recently. Rheumatologists are doctors who are experts in diagnosing and treating arthritis and other diseases of the joints, muscles and bones. Thus, they are best qualified to make a proper diagnosis of RA. They can also advise patients about the best treatment options.