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Rheumatoid Arthritis

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The outlook has dramatically improved for many people newly diagnosed with rheumatoid arthritis (RA), long feared as one of the most disabling types of arthritis.

Hand with Rheumatoid Arthritis

RA remains a serious disease, and one that can vary widely in symptoms and outcomes. Even so, recent advances in treatment have made it possible to stop or at least slow the progression of joint damage. Many of these new treatments have emerged in the last 10 years because of exciting and rapidly advancing research into the fundamentals of inflammation. Some new therapies target inflammation; others involve combinations of existing medications to increase benefit.

Fast Facts on Rheumatoid Arthritis

Joint with rheumatoid arthritis inflammation

  • RA is the most common type of arthritis triggered by the immune system.
  • Treatments have improved dramatically and help many of those affected.
  • Rheumatologists have the expertise necessary to diagnose this disease correctly and offer patients the most advanced treatments.

What Rheumatoid Arthritis Is

RA is a chronic disease that causes pain, stiffness, swelling, and limitation in the motion and function of multiple joints. Though joints are the principal body parts affected by RA, inflammation can develop in other organs as well.

The stiffness seen in active RA is typically worst in the morning and may last anywhere from one to two hours to the entire day. This long period of morning stiffness is an important diagnostic clue, as not many other arthritic diseases behave this way. For example, osteoarthritis does not generally cause prolonged morning stiffness. While RA can affect any joint, the small joints in the hands and feet tend be involved more frequently than others. This produces a pattern of joint disease that rheumatologists regard as characteristic of RA.

Other symptoms that can occur in RA include:

  • loss of energy
  • low-grade fevers
  • loss of appetite
  • dry eyes and mouth from an associated condition known as Sjogren's syndrome
  • firm lumps called rheumatoid nodules beneath the skin in areas such as the elbow and hands

What causes rheumatoid arthritis

RA is classified as an autoimmune disease, which develops because certain cells of the immune system malfunction and attack healthy joints. While the cause of RA remains unknown, exciting and rapidly advancing research is revealing the factors that are important in producing inflammation. The primary focus of the inflammation is in the synovium, which is the lining tissue of the joint. Inflammatory chemicals released by the immune cells cause swelling and damage to cartilage and bone. This research is giving us a better understanding of the immune and genetic factors that may be involved in the disease. As a result of this work, new medications have been developed that specifically block certain signals in the body from the immune system that are important in causing RA symptoms and joint damage.

Who gets rheumatoid arthritis

RA is the most common form of inflammatory arthritis. More than 2 million Americans suffer from RA. About 75 percent of those affected are women, and 1 to 3 percent of women may develop rheumatoid arthritis in their lifetime. The disease most often begins between the fourth and sixth decades of life; however, RA can develop at any age.

How rheumatoid arthritis is diagnosed

Rheumatoid arthritis joint inflammation

RA can be difficult to diagnose because it may begin gradually with subtle symptoms. Many diseases, especially early on, behave in a manner similar to RA. For this reason, patients suspected of having RA should be evaluated by a rheumatologist, a physician with the necessary skill and experience to reach a precise diagnosis and develop the most appropriate treatment plan.

The diagnosis of RA is based on the symptoms described and physical examination findings such as warmth, swelling and pain in the joints. Certain laboratory abnormalities commonly found in RA can help in establishing a diagnosis. Tell-tale abnormalities include:

  • anemia (a low red blood cell count)
  • rheumatoid factor (an antibody eventually found in approximately 80 percent of patients with RA, but in only 30 percent at the start of the arthritis); and
  • an elevated erythrocyte sedimentation rate or "sed rate" (a blood test that in most patients with RA tends to correlate with the amount of inflammation in the joints)

X-rays can be very helpful in diagnosing RA but may not show any abnormalities in the first 3 to 6 months of arthritis. X rays are useful in determining if the disease is progressing.

It is important to remember that for most patients with this disease (especially those who have had symptoms for less than six months), there is no single test that "confirms" a diagnosis of RA. Rather, diagnosis is established by skillfully evaluating the appropriate symptoms, physical examination findings, laboratory tests and X-rays.

How rheumatoid arthritis is treated

Therapy for patients with RA has improved dramatically over the past 25 years. Current treatments offer most patients good to excellent relief of symptoms and the ability to continue to function at or near normal levels. Since there is no cure for RA, the goal of treatment is to minimize patients' symptoms and disability by introducing appropriate medical therapy early on, before the joints are permanently damaged. No single therapy is effective for all patients, and many patients will need to change treatment strategies during the course of their disease.

Rx for treatment

Successful management of RA requires early diagnosis and, at times, aggressive treatment. To quickly reduce joint inflammation and symptoms, first-line treatment usually consists of non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Motrin and others), naproxen (Naprosyn, Aleve), celecoxib (Celebrex) and many others. In addition, corticosteroids such as prednisone (Deltasone and others) may be given orally at low doses or via injection into the joints.

However, all RA patients with persistent swelling in the joints are candidates for treatment with disease-modifying anti-rheumatic drugs (DMARDs), often used in conjunction with NSAIDs and/or low dose corticosteroids.

DMARDs have greatly improved the symptoms and function as well as the quality of life for the vast majority of patients with RA. DMARDs include methotrexate (Rheumatrex and Folex), leflunomide (Arava), hydroxychloroquine (Plaquenil), sulfasalazine (Azulfidine), gold given orally (Auranofin) or intramuscularly (Myochrisine), minocycline (Minocin, Dynacin and Vectrin), azathiaprine (Imuran), and cyclosporine (Sandimmune and Neoral).

A new class of medications, referred to as biologic response modifiers or "biologic agents" can specifically target parts of the immune system that lead to inflammation as well as joint and tissue damage in RA. These medications are also DMARDs, because they slow the progression of the disease.

FDA-approved treatments include adalimumab (Humira), anakinra (Kineret), etanercept (Enbrel), infliximab (Remicade), abatacept (Orencia), and rituximab (Rituxan). In some cases these medications are used alone; in many cases, they are combined with methotrexate.

The optimal treatment of RA often requires more than medication alone.

Broader health impact of rheumatoid arthritis

Recent research indicates that people with RA, particularly those whose disease is not well controlled, may have a higher risk for heart disease and stroke. Talk with your physician about your own risk and ways that you can minimize it.

Living with rheumatoid arthritis

Older couple walking

It is important for people with RA to remain physically active, while occasionally scaling back activities when the disease flares. A consultation with a physical or occupational therapist may help to determine what level and types of activities are appropriate. In general, rest when a joint is swollen and inflamed, or when feeling fatigued. At these times, gentle range of motion exercises will keep the joint flexible. When feeling better, low impact aerobic exercises such as walking and exercises to boost muscle strength will improve overall health and reduce pressure on joints.

The diagnosis of a chronic illness is a life-changing event that can cause anxiety and occasionally feelings of isolation or depression. Because the treatments for rheumatoid arthritis have improved dramatically, these feelings usually decrease with time as energy improves and pain and limitation decrease. It is important to discuss there normal reactions to illness with your physician and health care providers, who can provide you with the information and resources you need for support during your treatment.

Many of those who suffer from inflammation due to their arthritis, asthma, allergies or a number of other diseases have reaped the benefit of Omega-3 fatty acids, a known anti-inflammatory. This supplement fills in where foods can't. Omega-3 supplementation is a supplement that offers all the Omega-3 your body needs and takes the guess work out of what to eat and what not to eat.

Oil the Joints?

A daily dose of monounsaturated fatty acids - found in olive oil, avocados and nuts - could help you overcome rheumatoid arthritis. In a recent study, MUFA consumption was a predictor of remission in patients with RA. Your best bet: Substitute anti-inflammatory MUFAs or omega-3s for saturated fats, which have been linked to joint cartilage damage. Source: EULAR 2014

Points to Remember

  • RA has been a primary focus of rheumatologic research and the treatments now available have dramatically improved outcomes for patients. Joint pain and swelling can usually be well controlled and joint damage can be minimized by early treatment.
  • Expertise is particularly needed to establish a diagnosis of RA early, to rule out diseases that mimic RA (thereby avoiding unnecessary testing, drug therapy and costs) and to design a treatment plan that is best suited and customized for the patient and addresses the need for and the risks and benefits of DMARD therapy. Accordingly, the rheumatologist, working with the primary care physician and other health care providers, should play the major role in outlining, implementing and supervising the management of the patient with RA.
  • Studies have shown that people who receive early treatment of RA feel better, are more likely to be able to be lead an active life, and are less likely to experience the type of joint damage that leads to joint replacement.

Resource: American College of Rheumatology -- Written by Eric Ruderman and reviewed by the American College of Rheumatology Communications and Marketing Committee.

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