Rheumatoid Arthritis
What is Rheumatoid Arthritis (RA)?
It is an auto-immune, chronic systemic inflammatory disease in which the body’s immune system which normally protects itself produce antibodies which mistakenly attacks the joints. This causes inflammation of the synovium that lines the inside of joints resulting in swelling and painful joints. The synovium makes a fluid that lubricates joints and helps them move smoothly. If inflammation continues, it can damage the cartilage as well as the bones. Over time, with loss of cartilage, the joint spacing between bones narrows resulting in painful unstable joints and joint deformity can occur. Patients will have reduced movement of that joint due to the pain and swelling. Thus early diagnosis and aggressive treatment to control RA is recommended before the joint is deformed.
It affects women about three times more than males and 1 – 3% of women may get rheumatoid arthritis in their lifetime. The disease most often begins between the ages of 30 and 50. Having a family history of rheumatoid arthritis will increase the risk of getting RA.
In short, Rheumatoid Arthritis is a chronic disease that causes joint pain, stiffness, swelling and decreased movement of the joints. Small joints like the hands and feet are most commonly affected although other joints can also be involved. The joints are usually symmetrically involved i.e. both hands instead of just one. RA can also affect your other organs, such as eyes, skin or lungs.
It is an auto-immune, chronic systemic inflammatory disease in which the body’s immune system which normally protects itself produce antibodies which mistakenly attacks the joints. This causes inflammation of the synovium that lines the inside of joints resulting in swelling and painful joints. The synovium makes a fluid that lubricates joints and helps them move smoothly. If inflammation continues, it can damage the cartilage as well as the bones. Over time, with loss of cartilage, the joint spacing between bones narrows resulting in painful unstable joints and joint deformity can occur. Patients will have reduced movement of that joint due to the pain and swelling. Thus early diagnosis and aggressive treatment to control RA is recommended before the joint is deformed.
It affects women about three times more than males and 1 – 3% of women may get rheumatoid arthritis in their lifetime. The disease most often begins between the ages of 30 and 50. Having a family history of rheumatoid arthritis will increase the risk of getting RA.
In short, Rheumatoid Arthritis is a chronic disease that causes joint pain, stiffness, swelling and decreased movement of the joints. Small joints like the hands and feet are most commonly affected although other joints can also be involved. The joints are usually symmetrically involved i.e. both hands instead of just one. RA can also affect your other organs, such as eyes, skin or lungs.
What causes Rheumatoid Arthritis?
The exact pathophysiology of Rheumatoid Arthritis is unknown. It is an auto immune disease whereby the body attacks the joint's synovium as mentioned earlier. Ongoing research is conducted to find the exact cause and link. There's hypothesis that people that carries the gene HLA has a higher tendency to develop RA. Other possible external factors include smoking, occupational exposures to mineral oil and silica, infection and trauma.
The exact pathophysiology of Rheumatoid Arthritis is unknown. It is an auto immune disease whereby the body attacks the joint's synovium as mentioned earlier. Ongoing research is conducted to find the exact cause and link. There's hypothesis that people that carries the gene HLA has a higher tendency to develop RA. Other possible external factors include smoking, occupational exposures to mineral oil and silica, infection and trauma.
Symptoms of Rheumatoid Arthritis
Initially, patients may just experience some joint pain without swelling or deformity.
The symptoms experienced by patients are:
Other organs involvement:
Initially, patients may just experience some joint pain without swelling or deformity.
The symptoms experienced by patients are:
- Joint pain, swelling and stiffness for 6 weeks or more
- Morning stiffness lasting 1-2 hours or even longer in some people which improves with movement of joints
- Small joints like hand, wrist and feet are more commonly involved
- symmetrical involvement of joints: same joints on both sides of body
- Usually more than one joint involved (polyarthritis)
- Joint deformities: Boutonniere deformity, Swan neck deformity of fingers
- Arthritis mutilans (also known as opera glass hands) results if destruction is severe and extensive, with dissolution of bone.
- systemic symptoms: lethargy, low grade fever and loss of appetite
Other organs involvement:
- Mouth: dry mouth (Sjogren's syndrome), gum infection
- Eyes: dry eyes (Sjogren's syndrome), redness, pain, sensitivity to light and blur vision
- Lungs: Pulmonary Inflammation and scarring of lungs (fibrosis) resulting in shortness of breath
- Skin : Rheumatoid nodules which grow beneath the skin in places such as the elbow and hands
- Anemia
- Blood vessels: Inflammation of blood vessels that can lead to damage in the nerves, skin and other organs (heart diseases)
- Felty syndrome – This condition is characterized by splenomegaly, leukopenia, and recurrent bacterial infections; it may respond to disease-modifying antirheumatic drugs (DMARDs)
Diagnosis of Rheumatoid Arthritis
To make the diagnosis of RA, the rheumatologist will ask ask you questions on your history, conduct a physical examination, run some diagnostic tests and imaging.
Abnormal blood tests result sen in patients with RA are:
X-rays can help in detecting RA but may be normal in early stages. Follow up X-rays may be useful later to show if the disease is progressing. MRI and ultrasound scanning can be done to help confirm or gauge the severity of RA. These imaging studies are done to look for joint damage due to erosions, loss of bone within the joint and narrowing of joint space.
To make the diagnosis of RA, the rheumatologist will ask ask you questions on your history, conduct a physical examination, run some diagnostic tests and imaging.
Abnormal blood tests result sen in patients with RA are:
- Rheumatoid factor (an antibody found in 80 percent of people with RA during the course of their disease)
- Antibodies to cyclic citrullinated peptides (anti-CCP) found in 60 - 70% of patients with RA
- Anemia (low red cell count)
- Raised inflammation markers i.e. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)
X-rays can help in detecting RA but may be normal in early stages. Follow up X-rays may be useful later to show if the disease is progressing. MRI and ultrasound scanning can be done to help confirm or gauge the severity of RA. These imaging studies are done to look for joint damage due to erosions, loss of bone within the joint and narrowing of joint space.
Diagnostic Classification Criteria for RA
Classification criteria for RA (score-based algorithm: add score of categories A through D; a score of ≥ 6 out of 10 is needed for classification of a patient as having definite Rheumatoid Arthritis)
A. Joint involvements
B. Serology (at least one test result is needed for classification)
C. Acute phase reactants (at least one test result is needed for classification)
D. Duration of symptoms
Classification criteria for RA (score-based algorithm: add score of categories A through D; a score of ≥ 6 out of 10 is needed for classification of a patient as having definite Rheumatoid Arthritis)
A. Joint involvements
- One large joint = 0
- Two to 10 large joints = 1
- One to three small joints (with or without involvement of large joints) = 2
- Four to 10 small joints (with or without involvement of large joints) = 3
- > 10 joints (at least one small joint) =5
B. Serology (at least one test result is needed for classification)
- Negative Rheumatoid Factor and negative Anti-CCP = 0
- Low positive Rheumatoid Factor or low positive Anti-CCP = 2
- High positive Rheumatoid Factor or high positive Anti-CCP =3
C. Acute phase reactants (at least one test result is needed for classification)
- Normal CRP and normal ESR =0
- Abnormal CRP or normal ESR =1
D. Duration of symptoms
- < six weeks =0
- ≥ six weeks =1
Differential diagnosis of RA
As RA symptoms may mimic some other diseases. The differential diagnosis to think of include :
- If there are other skin findings may suggest systemic lupus erythematosus (SLE), systemic sclerosis, or psoriatic arthritis.
- Polymyalgia rheumatica should be considered in elderly especially with symptoms primarily in the shoulder and hip
- Patients with a history of inflammatory bowel disease or inflammatory eye disease and also with inflammatory back symptoms may have spondyloarthropathy.
- Parvovirus: Persons with less than six weeks of symptoms may have a viral infection instead
- Fibromyalgia: the presence of numerous myofascial trigger points and somatic symptoms may point to fibromyalgia, which can also coexist with Rheumatoid Arthritis.
As RA symptoms may mimic some other diseases. The differential diagnosis to think of include :
- If there are other skin findings may suggest systemic lupus erythematosus (SLE), systemic sclerosis, or psoriatic arthritis.
- Polymyalgia rheumatica should be considered in elderly especially with symptoms primarily in the shoulder and hip
- Patients with a history of inflammatory bowel disease or inflammatory eye disease and also with inflammatory back symptoms may have spondyloarthropathy.
- Parvovirus: Persons with less than six weeks of symptoms may have a viral infection instead
- Fibromyalgia: the presence of numerous myofascial trigger points and somatic symptoms may point to fibromyalgia, which can also coexist with Rheumatoid Arthritis.
Treatment of Rheumatoid Arthritis (RA)
There is no cure for RA. The goal of treatment is to improve symptoms, stop inflammation of the joints, prevent joint and organ damage, improve physical and quality of life and to reduce long term complications. Starting medication as soon as possible helps prevent your joints from deteriorating and deter permanent damage. No single treatment works for the patients and some patients need to change their treatment at least once during their lifetime to keep the disease in remission. There are different drugs used in the treatment of rheumatoid arthritis. Some are used to ease the symptoms of RA (reduce pain and inflammation) and others are used to slow or stop the course of the disease so as to inhibit structural damage.
Medications to relieve symptoms:
- Nonsteroidal anti-inflammatory drugs (NSAIDS): help to reduce pain and inflammation. However long term use may result in gastric ulcer and harms the kidneys.
- Corticosteroids : to reduce inflammation and join swelling
Medications to retard the disease:
- Disease-modifying antirheumatic drugs (DMARDs) : oral medications include methotrexate, hydroxycholorquine, sulfasalazine, leflunomide and cyclophosphamide. Gold, minocycline, azathioprine and cyclosporin are rarely prescribed nowadays because of its side effects. These drugs not only relieve symptoms but also slow progression of the joint damage. They are usually combined with NSAIDS for better symptoms control.
JAK inhibitors
- Another type of DMARD which block the Janus kinase, or JAK, pathways, which are involved in the body’s immune response.
Biologics for more serious disease
- Biologic response modifiers or “biologic agents.” FDA-approved drugs are Orencia, adalimumab (Humira), Kineret, certolizumab (Cimzia), etanercept, golimumab, infliximab (Remicade), Rituxan, MabThera and Actemra. They are given as injections or as infusion form.
- They can block specific immune system chemical signals that lead to inflammation and joint/tissue damage without affecting the entire immune response as some other RA treatments do.
- Biologic can slow, modify or stop the disease
Exercise and physiotherapy
- Being physically active helps improve quality of life and muscle strength in patients
- They should also do stretching so as to improve joint mobility and flexibility
- During flare periods, they should reduce the activities
- Occupational and physiotherapists will be able to guide patients on the range of activities they can do
Surgery
- only reserved for those with joint deformity and severe joint damage; joint replacement surgery may be done to improve symptoms and deformity
Remission is possible in about 10 to 50% of patients with RA. It is more likely in males, nonsmokers, persons younger than 40 years and in those with late-onset disease (older than 65 years), with shorter duration of disease, with milder disease activity, without elevated acute phase reactants and without positive rheumatoid factor or anti-CCP.
When the disease is better controlled, medication dosages may be slowly decreased to the minimum amount necessary. Patients will require frequent follow ups to make sure they are stable and prompt increase in medication is recommended with disease flare-ups.
There is no cure for RA. The goal of treatment is to improve symptoms, stop inflammation of the joints, prevent joint and organ damage, improve physical and quality of life and to reduce long term complications. Starting medication as soon as possible helps prevent your joints from deteriorating and deter permanent damage. No single treatment works for the patients and some patients need to change their treatment at least once during their lifetime to keep the disease in remission. There are different drugs used in the treatment of rheumatoid arthritis. Some are used to ease the symptoms of RA (reduce pain and inflammation) and others are used to slow or stop the course of the disease so as to inhibit structural damage.
Medications to relieve symptoms:
- Nonsteroidal anti-inflammatory drugs (NSAIDS): help to reduce pain and inflammation. However long term use may result in gastric ulcer and harms the kidneys.
- Corticosteroids : to reduce inflammation and join swelling
Medications to retard the disease:
- Disease-modifying antirheumatic drugs (DMARDs) : oral medications include methotrexate, hydroxycholorquine, sulfasalazine, leflunomide and cyclophosphamide. Gold, minocycline, azathioprine and cyclosporin are rarely prescribed nowadays because of its side effects. These drugs not only relieve symptoms but also slow progression of the joint damage. They are usually combined with NSAIDS for better symptoms control.
JAK inhibitors
- Another type of DMARD which block the Janus kinase, or JAK, pathways, which are involved in the body’s immune response.
Biologics for more serious disease
- Biologic response modifiers or “biologic agents.” FDA-approved drugs are Orencia, adalimumab (Humira), Kineret, certolizumab (Cimzia), etanercept, golimumab, infliximab (Remicade), Rituxan, MabThera and Actemra. They are given as injections or as infusion form.
- They can block specific immune system chemical signals that lead to inflammation and joint/tissue damage without affecting the entire immune response as some other RA treatments do.
- Biologic can slow, modify or stop the disease
Exercise and physiotherapy
- Being physically active helps improve quality of life and muscle strength in patients
- They should also do stretching so as to improve joint mobility and flexibility
- During flare periods, they should reduce the activities
- Occupational and physiotherapists will be able to guide patients on the range of activities they can do
Surgery
- only reserved for those with joint deformity and severe joint damage; joint replacement surgery may be done to improve symptoms and deformity
Remission is possible in about 10 to 50% of patients with RA. It is more likely in males, nonsmokers, persons younger than 40 years and in those with late-onset disease (older than 65 years), with shorter duration of disease, with milder disease activity, without elevated acute phase reactants and without positive rheumatoid factor or anti-CCP.
When the disease is better controlled, medication dosages may be slowly decreased to the minimum amount necessary. Patients will require frequent follow ups to make sure they are stable and prompt increase in medication is recommended with disease flare-ups.