Rheumatoid arthritis

Dr. Vic Weatherall

Rheumatoid arthritis (RA) is a chronic widespread inflammatory disease of unknown cause. It is an autoimmune disease in which joints, usually those of the hands and feet, are inflamed resulting in swelling, pain, and often the eventual destruction of the joint’s interior.

Rheumatoid arthritis
Rheumatoid arthritis1

Watch the rheumatoid arthritis video. This disease can also cause a variety of symptoms throughout the body, for example, it may cause nodules under the skin, lymph node enlargement, inflammation around the heart and lungs, and inflammation of the blood vessels.

In RA, the immune system attacks the tissues that line and cushion the joints, eventually causing the cartilage, bone, and ligaments of the joint to erode, and causing scarring within the joint. The rate of joint deterioration is highly variable. The autoimmune reaction can also affect other tissues, as described above.

The cause of RA is unknown, but many factors, including genetic predisposition, may influence onset. Many researchers suspect that it could be triggered by an infection with a common germ causing the immune systems of susceptible people to react abnormally.

This article discusses

Who gets it?

An estimated 293,000 people in Canada suffer from rheumatoid arthritis. It develops in about 1% of the population, affecting women 2-3 times more than men. This disease usually appears between the ages of 25-50, but can occur at any age.

What are the signs and symptoms?

Rheumatoid arthritis may start gradually or with a sudden, severe attack with flu-like symptoms. Common signs and symptoms include:

  • pain and swelling in three or more joints, primarily in the hands, wrists, or fingers (for at least 6 weeks)
  • usually symmetrical (on both sides)
  • morning stiffness of joints and muscles lasting for more than 1 hour (for at least 6 weeks)
  • general weakness and fatigue
  • fever and weight loss

Symptoms vary from person to person. In some, the disease may be mild with periods of activity or joint inflammation (flare-ups) and inactivity (remissions), in others it may be continuously active and get worse as time goes on.

How is it diagnosed?

Many arthritic diseases can mimic rheumatoid arthritis, therefore, if RA is suspected it is vital to have the appropriate tests to confirm the diagnosis. The diagnosis is generally made based on

  • signs and symptoms as above
  • increased rheumatoid factor (RF) and increased sedimentation rate (ESR) in the blood
  • characteristic changes on x-rays
  • abnormal findings on joint fluid analysis or tissue biopsy (not commonly performed)

Early diagnosis is very important to help avoid disability or deformity.

How is it treated?

Although there is no cure for RA today, much can be done to manage the condition. A variety of treatments exist to treat the symptoms resulting in less pain, stiffness, and easier movement. There are four major treatment approaches for RA: physical management, lifestyle management, medication, and surgery. Active patient involvement during treatment plan is essential.

Treatment should start with the least aggressive measures moving to more aggressive ones if required.

Physical management

There are a variety ways to help manage the pain of RA and regain optimal function in the affected joints without using drugs, or in combination with them.

Heat and cold

Heat reduces pain by relaxing tight tissues surrounding the joint and by improving blood flow in the area. Cold blocks pain signals from the area and decreases inflammation. Note that during periods of increased inflammation, heat may exacerbate the situation.

Therapy

Chiropractors, physical therapists, and occupational therapists teach techniques to reduce the pain and restore joint motion and muscle strength to increase comfort throughout daily life.

Contact Dr. Weatherall if you have any questions or to see if he can help you with a problem.

Home exercise

Exercise helps lessen symptoms of RA and make the patient feel better overall. Appropriate and moderate stretching and strengthening helps relieve pain and keeps the muscles and tendons around the affected joint flexible and strong.

Low impact exercises like swimming, walking, water aerobics, and stationary bicycling can all reduce pain while maintaining strength, flexibility, and cardiovascular function. Patients should always check with their health care provider before beginning an exercise program.

Lifestyle management

Patient must protect their joints by avoiding excess stress from daily tasks. For example, alternate heavy tasks with lighter ones, avoiding stressful joint positions and support them where necessary, using assistive devices such as canes and grab bars. They must strive to stay at their recommended weight to avoid increased stress on their joints. Note that most RA sufferers are not obese.

A basic principle of RA treatment is resting the joints. Regular rest periods often help relieve pain and complete rest may be needed during severe flare-ups. Splints can be helpful to help immobilize and rest the joints; however, some overall movement is needed to prevent the joints from stiffening.

A regular healthy diet is generally appropriate. Some people have flare-ups after eating certain foods. A diet rich in fish and plant oils but low in red meat may help reduce the inflammation. Calcium supplementation may also be helpful. Food allergy testing may be considered as well.

Developing good relaxation and coping skills gives the a patient a greater feeling of control over their arthritis and a more positive outlook.

Medication

Nonsteroidal anti-inflammatories (NSAIDs): NSAIDs reduce pain when taken at a low dose and relieve inflammation when taken at a higher dose. Non-prescription drugs include ASA (Aspirin, Anacin) and ibuprofen (Motrin IB, Advil). Prescription NSAIDs include Naprosyn, Relafen, Indocid, Voltaren, Feldene, and Clinoril. Taking more than one NSAID at a time increases the possibility of side effects, particularly stomach problems such as heartburn, ulcers and bleeding. People taking these medications should consider a stomach protectant such as misoprostol (Cytotec). COX-2 selective inhibitor NSAIDs directly target COX-2, an enzyme responsible for inflammation and pain. They reduce the risk of peptic ulceration, the main feature of drugs such as celecoxib (Celebrex). However, this class of NSAID can pose a risk to other organs.

Disease modifying anti-rheumatic drugs (DMARDs): DMARDs may be prescribed when inflammation continues for more than 6 weeks or when RA strikes many joints at once. These drugs target the cells in the immune system causing the inflammation, but do not reverse permanent joint damage. The most common medications are gold salts, methotrexate, sulfasalazine, hydroxychloroquine, chloroquine, and azathioprine. A DMARD is usually prescribed in addition to an NSAID or corticosteroid. Side effects may include mouth sores, diarrhea and nausea. More serious side effects, monitored through regular blood and urine tests, include liver damage, and excessive lowering of white blood cell count (increasing susceptibility to certain infections), and platelet count (affecting blood clotting).

Corticosteroids: Corticosteroids are man-made drugs that closely resemble cortisone, a hormone natural produced by the body. In RA, these drugs are used to treat extreme inflammation accompanied by severe pain and stiffness. They are also used to treat systemic RA which may affect the lining of the lungs and blood vessels. The most common form of corticosteroid is prednisone, taken in pill form. Side effects from long term use may include cataracts, high blood pressure, sleep problems, muscle loss, bruising, thinning of the bones (osteoporosis), weight gain, and susceptibility to infections. The goal with this and most drugs is to find the lowest effective dose that will avoid as many of the side effects as possible.

Corticosteroids sometimes injected into one or more joints or other areas of inflammation. While eliminating the serious side effects, injections may harm joints if given more than a few times a year.

Surgery

Severe cases that have not responded to treatment may benefit from surgery. There are a number of different kinds of surgery for RA ranging from minor procedures to complete joint reconstruction.

What is the outcome?

The course of RA is variable and the results of various types of treatment differ from person to person. Most people can maintain an active lifestyle and manage very well with the combined benefits of balanced exercise, rest, modified lifestyle, and medication.

Image citation

  1. Wouterstomp at en.wikipedia [Public domain], from Wikimedia Commons.