WHAT IS RHEUMATOID ARTHRITIS (RA)?
There are more than 100 forms of arthritis, a group of musculoskeletal disorders and conditions that destroy joints, bones, muscles, cartilage and other connective tissues, making movement painful and sometimes impossible. Osteoarthritis is the most common and well-known form:nearly 27 million Americans have been diagnosed with it, and it is expected that there are many more undiagnosed cases. Unlike osteoarthritis, an inflammatory disease, rheumatoid arthritis is an autoimmune disease in which the immune system, which normally produces antibodies that attack foreign substances (called antigens) such as bacteria, viruses and toxins, instead attacks the body’s own healthy cells and tissues, specifically synovium, the thin membrane that lines the joints. When the synovium is damaged or destroyed, liquid builds up in the joints and causes pain and inflammation.
An estimated 1.3 million people in the U.S. have RA – almost 1 percent of the nation’s adult population. There are nearly three times as many women as men with the disease. In women, RA most commonly begins between the ages of 30 and 60. For men it usually occurs later in life. It is estimated that over 300,000 children have the juvenile form of RA.
It is important for people with rheumatoid arthritis to be under the care of a rheumatologist. There are new, highly effective – and highly complex – treatments and medications for RA that can not only reduce pain, but also arrest the progression of the disease.
What causes RA?
The cause of rheumatoid arthritis is not yet known. Most scientists agree that genetics play a key role and have identified genetic markers that increase by 10 the probability of developing the disease. Not surprisingly, these genes are associated with the immune system and chronic inflammation, though not all people with these genes develop rheumatoid arthritis and not all people with the disease have these genes.
Infectious agents, such as bacteria or viruses, may trigger the disease in someone with a genetic propensity for it. In addition, female hormones are suspect (70 percent of people with RA are women), as well as the body’s response to stressful events such as physical or emotional trauma. Smoking also increases the risk of developing RA among people with the specific gene, and it can increase the disease’s severity and reduce the effectiveness of treatment.
Rheumatoid arthritis is an incurable, chronic disease. It tends to come on gradually. Most people with RA experience acute bouts of intense pain and inflammation, called flares , which come and go. In some people the disease is continuously active and gets worse over time. Others enjoy long periods of remission – no disease activity or symptoms at all. Early diagnosis and early and aggressive treatment to put the disease into remission are the best means of avoiding joint destruction, organ damage and disability.
The symptoms and course of rheumatoid arthritis vary from person to person and can change on a daily basis. Rheumatoid arthritis is symmetrical, meaning if a joint on one side of the body is affected, the corresponding joint on the other side of the body is also involved.
Joint symptoms may include:
- Morning stiffness lasting more than an hour
- Joints may feel warm, tender and stiff when not used for an hour
- Loss of range of motion
- Joint may become deformed.
- Inflammation and swelling in the joints
- Inflammation and swelling in the areas surrounding the joints
- Chest pain when taking a breath (pleurisy)
- Dry eyes and mouth (Sjogren syndrome)
- Eye burning, itching and discharge
- Nodules , or lumps of tissue under the skin over bony areas exposed to pressure (elbows, fingers, spine or heels
- Numbness, tingling or burning in the hands and feet
- Sleep difficulties
- Loss of appetite
- Low-grade fever
- Systemic (throughout the body) inflammation, affecting organs such as the skin, heart and lungs
There is no single laboratory test that instantly confirms a diagnosis of RA. Patients should be treated by a rheumatologist. A medical history should be taken and physical exam performed. The physician is looking for certain features of RA, including swelling, warmth and limited motion in joints throughout the body, as well as nodules or lumps under the skin. The doctor will ask about fatigue or an overall feeling of stiffness. The pattern of joints affected by arthritis (e.g., symmetrically located) can help distinguish rheumatoid arthritis from other conditions. Certain blood tests to identify antibodies, levels of inflammation and other markers that aid diagnosis and assessments should be performed, although the presence of these antibodies does not indicate a definitive diagnosis. A newer, more specific test measures the presence of anti-cyclic citrullinated peptides (anti-CCP) – proteins found in tissue damaged by RA. People with a positive anti-CCP test are 90 to 95 percent likely to have RA.
Additional blood tests may be performed, such as for anemia (a low red blood cell count) or an elevated erythrocyte sedimentation rate (ESR) – how fast the red blood cells cling together, fall and settle at the bottom of a test tube. The higher the rate, the greater the inflammation. Testing for c-reactive protein (CRP) also indicates the extent of inflammation. Doctors frequently take X-rays to assess joint damage – typically bone loss at the edges of joints, called erosions – combined with loss of joint cartilage.
Although there is no cure for RA, highly effective treatments exist. Once RA is diagnosed, aggressive treatment should begin right away to slow disease progression and lower chances of joint damage.
There are two groups of medications used to treat rheumatoid arthritis:those for symptom relief and reduction of inflammation (nonsteroidal anti-inflammatory drugs – NSAIDS – and corticosteroids), and those that can modify the disease or put it in remission (antirheumatic drugs and biologic agents). Two or more of these drugs may be used in combination. Some may affect the immune system and require close monitoring. Others may produce side effects, which must also be monitored. Research on new medications is ongoing, with an influx of new drugs into the pipeline.
Pain relief and inflammation reduction:
- ibuprofen (Advil, Motrin)
- ketoprofen (Actron, Orudis KT)
- naproxen sodium (Aleve
- celecoxib (Celebrex), a type of NSAID called a COX-2 inhibitor, which is designed to be safer for the stomach.
Cortisterioid drugs are potent and fast-acting anti-inflammatories. Because of possible side effects, they are usually used for as short a period of time as possible and in as low a dose as possible.
DMARDS: Disease-modifying antirheumatic drugs
- hydroxycholorquine (Plaquenil)
- sulfasalazine (Azulfidine, Azulfidine EN-Tabs)
- leflunomide (Arava)
- azathioprine (Imuran)
DMARDs actually modify the course of the disease. Because of this they will commonly be prescribed early on after diagnosis in order to prevent irreparable joint damage.
Biologic agents: Biologic response modifiers, or biologics, is newest category of medications used for RA and is a subset of DMARDs. There are currently nine of these medications approved for treatment of rheumatoid arthritis. These new agents have truly revolutionized the treatment of rheumatoid arthritis. They work for two out of three patients and often slow or halt the progression of the disease, sometimes even pushing it into remission. They are expensive:about $1000 to $3000 per month, and though they are usually covered by health insurance, the member will typically be responsible for some percentage of the cost. It is wise to research coverage by talking with the insurance carrier. In addition, many drug companies offer some sort of financial assistance for biologics.
Biologics are administered either by injection or intravenously. Biologics are used when methotrexate has failed. It may take several trials of different biologics to see which one will work for any given patient. Biologics do increase the risk of infection.
- abatacept (Orencia)
- adalimumab (Humira)
- anakinra (Kineret)
- certolizumab pegol (Cimzia)
- etanercept (Enbrel)
- infliximab (Remicade)
- golimumab (Simponi)
- rituximab (Rituxan).
Each of the biologics blocks a specific step in the inflammation process. Cimzia, Enbrel, Humira, Remicade and Simponi block a cytokine called tumor necrosis factor-alpha (TNF), and therefore often are called TNF inhibitors. Kineret blocks a cytokine called interleukin-1 (IL-1). Orencia blocks the activation of T cells. Rituxan blocks B cells. Actemra blocks a cytokine called interleukin-6 (IL-6).
Because biologics target specific steps in the process, they don’t wipe out the entire immune response as some other RA treatments do, and in many people a biologic agent can slow, modify or stop the disease – even when other treatments have not produced results.
JAK inhibitors: A new drug, tofacitinib (Xeljanz) is being compared to biologics. However, it is part of a new subcategory of DMARDs known as “JAK inhibitors” that block Janus kinase, or JAK, pathways, which are involved in the body’s immune response. Unlike biologics, it can be taken orally.
In general, there is not enough scientific evidence to prove that any complementary health approaches are beneficial for RA, and there are safety concerns about some of them. Some mind and body practices and dietary supplements may be beneficial additions to conventional RA treatments, but there is not enough evidence to draw conclusions. The therapies below can be beneficial to some people and can add to quality of life and a positive outlook. As always, these treatments should be approved and monitored by one’s physician.
- Mindfulness training
- Cognitive-behavioral therapy emphasizing pain management
- Dealing with depression
- Heat and cold treatments
- Deep abdominal breathing
- Progressive muscle relaxation
- Visualization and guided imagery
- Tai chi
- Assistive devices
As with all forms of arthritis, reducing inflammation is key. A diet rich in omega-3 fatty acids and low in inflammation-producing foods is recommended. But no specific diet has been shown to reduce RA symptoms.
Avoid alcohol, especially if taking methotrexate, as liver damage can be a serious side effect.
Supplements:even natural supplements can interact with other medications, so communicate with your rheumatologist before introducing any new substance into your treatment plan. These supplements have the most medical research to back them up:
- Borage seed oil
- Fish oil
- Thunder god vine
- Folic acid:if you take the drug methotrexate, folic acid may help to relieve some of the drug’s side effects.
- Calcium and vitamin D are important as bone-boosting agents, especially if corticosteroids, which can cause bone loss, are being taken
Best Exercise Regime
- Moderate physical exercise
- Physical therapy
- Strength training for joint support
- Weight control
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