Rheumatoid Arthritis (113)

Inflammatory Arthritis

The Facts

Rheumatoid arthritis (RA) is a chronic condition that causes the lining of your joints or other body areas to become inflamed. As it progresses, it further damages the tendons, ligaments, cartilage, and bone in your joints. It may also damage other areas of the body, including the lungs or blood vessels.

About 1% of the Canadian population has RA, with women about 3 times more likely than men to get it. Although it can occur at all ages, people most often develop RA between the ages of 40 and 60 years.

It was thought that children get RA (called juvenile rheumatoid arthritis or JRA), but it is now recognized to be a different set of diseases, collectively called juvenile idiopathic arthritis (JIA).

RA is a serious, usually progressive disease that can lead to severe disability, reduced quality of life, and shorter lifespan. Fortunately, treatment and management strategies developed over the years have led to much improved lives, longevity, and outcomes for many RA patients.

There is currently no cure for RA.

Causes

Rheumatoid arthritis (RA) is an autoimmune disease. This means that the body's immune system fails to recognize its own tissue, and views it as a foreign invader. In the case of RA, the immune system attacks mostly the joints, but it can affect other tissues as well.

It's hard to determine who will develop RA. It is believed that RA may be caused by a combination of factors, including genetic risk and environmental factors.  If someone has a close relative that has RA, they have a 2 to 3 times higher risk of developing RA. It is also possible that being exposed to certain viral infections or cigarette smoke may also trigger or worsen inflammation.

Symptoms and Complications

Rheumatoid arthritis (RA) usually develops gradually, but occasionally it can begin without warning as a sudden, painful episode. The first signs often include muscle and joint pain, fatigue, and stiffness. Just after getting up in the morning, or following a period of inactivity, the joints may feel stiff. This can last for under an hour but, as the RA gets worse, the discomfort will last for longer periods. The disease begins by attacking joints in the hands, wrists, and feet, and can later spread to the elbows, shoulders, neck, jaw, hips, knees, and ankles. As a result of being painfully inflamed, joints can become deformed as the tissue in them is destroyed. Up to 30% of people develop hard lumps (nodules) under their skin, around bony areas such as the knees and elbows. If tear and saliva glands are affected, it can result in dry eyes and a dry mouth, a condition called Sjögren's syndrome. Because RA is a systemic disease, it can also affect the heart, lungs, and eyes.

A hallmark of RA is that it is usually symmetrical, while most other types of arthritis are not. Symmetrical means that if a joint on one side becomes affected, within a relatively short time (i.e., days, weeks, a month or two), the corresponding joint on the other side of the body will also become involved.

RA also commonly accelerates and worsens atherosclerosis (hardening of the arteries), so your doctor may monitor for risk factors like high blood pressure, cholesterol, and diabetes. Your doctor may also advise you to not smoke. Treatment for atherosclerosis is very important.

One-third of sufferers have a mild form of RA with very few flare-ups of their symptoms. 10% might only have one painful episode and then go for a long period with no other signs of the disease. For many, though, symptoms only get worse over time.

Making the Diagnosis

If you have symptoms like those described above, see your doctor as soon as possible; an early diagnosis means faster treatment and less damage to your joints. Your doctor will first do a physical examination and ask about your medical history and signs or symptoms such as morning stiffness that may alert your doctor to the diagnosis. Unfortunately, there are no tests that definitively confirm the diagnosis of RA. But as with many diseases, a doctor can make a firm diagnosis based on carefully examining a person's medical history, performing a physical exam, and analyzing tests to see how the disease develops over time.

Laboratory tests can be helpful, but they can sometimes turn up negative even with very active disease. Some tests your doctor may perform that are particularly helpful include those that test for the rheumatoid factor, CCP antibodies, erythrocyte sedimentation rate (ESR), and C-reactive protein.

X-rays are helpful to detect more advanced changes, and ultrasound and MRI are important to evaluate how the disease is progressing.

Treatment and Prevention

Rheumatoid arthritis (RA) can't be prevented or cured. However, it is possible to treat the symptoms and, with certain medications, to slow down the progress of the disease.
A key factor, developed from careful studies over time, is to start treatment very early on before joint damage has occurred. If successful, this strategy can preserve joint health, something not often accomplished in the past.

Diagnosis, treatment, and management of RA requires very experienced and skilled care by doctors who are familiar with RA therapy. Rheumatologists specialize in severe arthritis such as RA. Before starting any medication, it is important to discuss the risks and benefits with your doctor.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective for reducing pain and reducing inflammation of the joints, but they do not slow the progression of the disease. Examples of NSAIDs include celebrex*, diclofenac, ibuprofen, indomethacin, meloxicam, and naproxen. The side effects of NSAIDs – including upset stomach or ulcers – can be minimized by other medications. Ask your doctor about these medications if you feel you need them. Some NSAIDs cause less stomach upset than others. If you find you can't tolerate the NSAID you're taking, talk to your doctor.

Corticosteroids (e.g., prednisone, triamcinolone) are also effective medications for reducing inflammation and relieving pain and stiffness. They can be taken as pills or injected directly into the joints. They are used sparingly as they don't actually slow down the damage done by the RA. They may be useful during the period before DMARDs begin to work or for managing flare-ups. Corticosteroids can be taken as pills or as injections directly into the joints. Corticosteroids have long-term side effects including thinning of the skin and bones (increasing the risk of osteoporosis), higher blood pressure and blood sugar levels, fluid retention, weight gain, and lowered immunity against infection.

Disease-modifying antirheumatic drugs (DMARDs) can slow RA and prevent joint damage. Although medications such as hydroxychloroquine, methotrexate, sulfasalazine and leflunomide require time (weeks to months) to work, they are important in combating the autoimmune component of the disease. They slow the damage by fighting immune system cells that attack the joints.

These medications can be taken together with NSAIDs for inflammation and pain, or with corticosteroids when treatment is first started.

A group of medications called biologics or biologic response modifiers are also used in the treatment of RA. These medications are produced using molecular biology and they generally target cells in the immune system which are responsible for inflammation. Examples of these medications in Canada include abatacept, adalimumab, anakinra, etanercept, infliximab, rituximab, and tofacitinib. These medications improve physical symptoms and slow down joint destruction. They are frequently used along with other DMARDs such as methotrexate. They also have their own sets of potentially serious, even life-threatening side effects. It is very important that you discuss the benefits and risks of all these treatments with your doctor.

All these medications have potential serious side effects. They must be used very carefully, monitored closely, and some require special strategies.

Physical therapy, exercise, and orthopedic intervention are often important in the management of the disease.

In spite of good medical treatment and lifestyle changes, RA may progress, increasing damage to your joints. When there is advanced disease or strong pain, surgery may be required to restore more regular movement. Surgery may help lessen pain, improve movement and function of joints, and, in some circumstances, improve physical appearance.

There are certain daily lifestyle adjustments you can make to help cope with the RA:

• Apply cold packs to numb a sore joint and reduce inflammation.
• Use hot compresses to reduce pain and stiffness by relaxing muscles and increasing circulation.
• Seek physical therapy - a health care professional can help you manage pain and teach you ways to strengthen muscles and restore motion in your joints.
• Aim for at least 150 minutes of moderate physical activity each week. Low-impact exercises such as swimming and walking may also help prevent flare-ups.
• Protect your joints by learning which positions are less stressful on your joints when doing various activities. Pace yourself and use canes, bath bars, shower seats, and reaching aids to make daily tasks easier.
• Follow a healthy diet and lifestyle to maintain a normal weight. Excess body mass is a "mechanical stress" on the joints, especially the hips and knees.
• Do not smoke.

For many people, having an effective treatment and management plan can restore their quality of life. It is important to learn all you can about your condition and the treatments that are available to you, and to work closely with your rheumatologist and the rest of your health care team. Arthritis Society Canada and The Arthritis Foundation are valuable resources.

Learning to manage RA will give you a feeling of control over the disease. With medical and lifestyle intervention, it's possible to remain active and productive in all aspects of daily life.

*All medications have both common (generic) and brand names. The brand name is what a specific manufacturer calls the product (e.g., Tylenol®). The common name is the medical name for the medication (e.g., acetaminophen). A medication may have many brand names, but only one common name. This article lists medications by their common names. For information on a given medication, check our Drug Information database. For more information on brand names, speak with your doctor or pharmacist.