Rheumatoid Arthritis

What is rheumatoid arthritis?

Arthritis has many forms and can affect people of any age, including children and adolescents. Arthritis can be broken down broadly into degenerative and inflammatory forms. The most commonly known type of degenerative arthritis is osteoarthritis, which is manifested by progressive wear and tear on the joints. The most common form of inflammatory arthritis is rheumatoid arthritis, which is manifested by swelling, warmth, and pain in the joints.

Rheumatoid Arthritis (RA) is a chronic, autoimmune disorder and is the most debilitating form of inflammatory arthritis. In RA, the body’s immune system attacks its own healthy cells and tissues, specifically the synovial (joint lining) membrane, causing pain, swelling, stiffness, and limited joint mobility. The joints most commonly affected by RA are in the hands, wrists, feet, ankles, knees, shoulders, and elbows. Over time, damage can occur in the joints if the inflammation is not effectively controlled with medications. Damage in other organs, such as the heart and lungs or even the skin, eyes, and blood vessels, may also occur although much less commonly than in the joints.

RA symptoms typically begin between the ages of 30 and 60; however, RA can develop at any age. RA affects over 1.2 million Americans. 75 percent of people with RA are women. If treatment is not started early, 60 percent of people with RA may be unable to work and on disability within 10 years of the onset of the disease. Over time, the joint swelling and damage of RA can result in bone erosion and deformity. Without proper treatment, pain and disability increase and RA patients are at greater risk of developing cardiovascular disease, lymphoma, anemia, osteoporosis, and depression.

  • Fewer than 10 percent of RA patients experience a spontaneous remission of symptoms.
  • In the early phases of the disease, some patients may experience recurrent explosive attacks of RA symptoms followed by periods of remission (called palindromic RA). However, over time the joint pain and swelling almost always become chronic, and patients experience daily stiffness and pain in the joints.

What causes rheumatoid arthritis?

RA is caused by the immune system attacking healthy joint tissue. What triggers or causes this autoimmune condition is unknown. However, there are some known risk factors that increase your risk of developing RA:

  • Age: RA most commonly occurs between the ages of 30 and 60.
  • Cigarettes: People who smoke cigarettes have a higher chance of developing RA compared to people who don't smoke, and their RA is more severe.
  • Gender: RA is 3 times more common in women compared to men.
  • Genetics: If you have a family member with RA or another autoimmune disease, you are at a greater risk of developing RA.
  • Obesity: You are at a higher risk of developing RA if you are overweight or obese.

What are the symptoms of rheumatoid arthritis?

Joint stiffness is usually the earliest symptom. Patients report that it is difficult to move the joints when they arise from bed or after sitting for a prolonged period of time. They report improvement after one to two hours, or after taking a warm shower or running their hands in warm water. In the early phase of RA, these symptoms may come and go. Other symptoms may include:

  • Fatigue
  • Weakness
  • Low-grade fever
  • Malaise
  • Loss of appetite
  • Weight loss

Joint pain and swelling usually occurs symmetrically, meaning the same joints are affected on both sides of the body simultaneously.

  • Inflamed painful joints, which lead to enlarged or deformed joints, are the most identifiable symptom of RA. Joints can be painful to the touch and have a limited range of motion. The number of joints can vary but will usually involve at least two joints and often quite a few more. The pain is usually reported as a deep ache but sometimes can persent as an explosive attack that lasts 24-48 hours.
  • Morning stiffness can persist for one to several hours and is a hallmark of RA. Similar stiffness can occur after extended periods of inactivity (called gelling). The duration of stiffness in the morning or following inactivity helps to gauge how extensive the disease inflammation is.
  • Rheumatoid nodules form below the skin and occur in 20 to 30 percent of RA cases. The nodules are firm, painless bumps of tissue most commonly on the elbows and hands but can develop at pressure points on the feet and knees.
  • Dry eye and dry mouth or sicca, is the most common way the eye is affected by RA. In some cases, the eye can become red and inflamed and painful and requires the attention of an ophthalmologist (eye doctor).
  • Shortness of breath when climbing stairs or walking some distance can occur when there is lung involvement. Since there are many causes of shortness of breath, these symptoms require evaluation by a treating rheumatologist and possibly by a lung specialist.
  • Heart attack, stroke, or heart failure can occur in individuals with RA due, in part, to the chronic inflammation. "Tight" control of the RA inflammation with medications is recommended, which will hopefully reduce this risk of heart disease.

How is rheumatoid arthritis diagnosed?

There is no one blood test or exam question your rheumatologist can use to definitively diagnose RA. However, there are patterns of joint involvement and several blood tests that help make the diagnosis. In its early stages, RA symptoms may mimic those of other types of inflammatory arthritis, so it is important to rule them out. To confirm the diagnosis, your doctor will conduct a thorough physical exam with blood tests, and may take radiographic images.

The physical exam involves checking your joints for swelling, redness and warmth and for pain with movement. Be prepared to answer a comprehensive list of questions about your medical history as well as the medical history of immediate family members. Tell your doctor when you first began experiencing RA symptoms, if there is any pattern to the symptoms, and what treatments you have attempted.

Your doctor will take blood samples at your first appointment to look for chemical markers of RA. People with rheumatoid arthritis often have an elevated erythrocyte sedimentation rate (ESR, or sed rate) or C-reactive protein (CRP), which indicate inflammation. Other common blood tests obtained by your doctor look for antibodies associated with RA. These are called rheumatoid factor and anti-CCP antibody. About 95 percent of individuals with RA have one or both of these antibodies. RA patients also tend to show mild anemia (low red blood cell count) but otherwise have fairly normal blood tests. The blood tests are informative also for assessing your baseline level of health and deciding the best course of treatment. For example, your doctor will want to make sure your liver and kidney tests are normal, as some of the RA treatments could affect these organs. Your doctor will also ask you if you have every had exposure to tuberculosis, and whether you have had a prior "PPD" (skin prick) test for tuberculosis. Finally, your doctor may get additional blood tests to rule out lupus, gout, certain viral infections, and other conditions that can mimic RA.

Your doctor also may recommend imaging tests such as X-rays to track how RA is affecting your joints over time. MRI and ultrasound tests can also be used. Bone and cartilage damage can occur quickly and images provide the best assessment of change.

How is rheumatoid arthritis treated?

Although there is no known cure for RA, the treatment of RA has undergone an enormous and successful explosion over the past 15 years. There are now many highly effective treatments for RA that not only reduce or eliminate the painful symptoms of RA, but will also stop or significantly slow damage to the joints. Some of these medications are taken by the mouth. Others must be taken by injection or infusion (through a line put into your vein); these types of medication are called biologics. Whether taken by mouth or injections, these treatments are all referred to as disease-modifying agents because they stop or slow the normal process of joint destruction. Your doctor may recommend a combination of these disease modifying agents if your RA inflammation is not controlled by one medication alone. Some patients may want to supplement their RA treatments with "complementary" therapies such as fish oil, acupuncture, and other strategies; these are less well studied and should not be used as the sole treatments for RA. Emotional and social support can help minimize stress.

An occupational therapist will suggest products and techniques that can help you with daily tasks like buttoning a blouse, which is difficult to do with joints stiff from RA. A physical therapist can teach you exercises to help keep your muscles strong and joints flexible.

If, despite treatment, a joint becomes severely damaged, your rheumatologist may consider surgery to repair damaged joints. Surgery can correct deformities, thereby reducing pain and restoring your ability to use your joint.

Complications of Rheumatoid Arthritis

  • Cardiopulmonary disease resulting from RA can take different forms. Your breathing may be affected either with pleurisy (lung inflammation and pain) or intrapulmonary nodules (masses on the lungs). Pericarditis (inflammation of the pericardium or lining of the heart) and atherosclerosis (thickening of the arteries in the heart) can both cause chest pain. Atherosclerosis is the leading cause of death in RA so be sure to tell your doctor if you experience any chest pain symptoms.
  • Sjögren’s syndrome develops in 10-15 percent of RA patients. Sjögren's is characterized by dry eyes and/or a dry mouth.
  • Peripheral neuropathy or nerve damage is an occasional complication of the nervous system in RA patients. It is typically a mild numbing feeling in the lower extremities like your legs and feet that can cause poor coordination. Other neuropathies (e.g., carpal tunnel syndrome) can occur because RA causes joint tissue swelling that compresses the nerve tissue. Carpal tunnel symptoms can often be relieved by a cortisone shot to the wrist. If this is not successful, surgery may be required to open the tunnel and relieve pressure on the nerve.