Rheumatoid arthritis (RA) is an autoimmune disease that causes chronic inflammation of the joints. Autoimmune diseases are illnesses that occur when the body’s tissues are mistakenly attacked by their own immune system.
The immune system contains a complex organization of cells and antibodies designed normally to “seek and destroy” invaders of the body, particularly infections.
Patients with autoimmune diseases have antibodies and immune cells in their blood that target their own body tissues, where they can be associated with inflammation.
While inflammation of the tissue around the joints and inflammatory arthritis are characteristic features of rheumatoid arthritis, the disease can also cause inflammation and injury in other organs in the body.
Because it can affect multiple other organs of the body, rheumatoid arthritis is referred to as a systemic illness and is sometimes called rheumatoid disease.
Rheumatoid arthritis that begins in people under 16 years of age is referred to as juvenile idiopathic arthritis (formerly juvenile rheumatoid arthritis).
While rheumatoid arthritis is a chronic illness, meaning it can last for years, patients may experience long periods without symptoms.
However, rheumatoid arthritis is typically a progressive illness that has the potential to cause significant joint destruction and functional disability.
A joint is where two bones meet to allow movement of body parts. Arthritis means joint inflammation. The joint inflammation of rheumatoid arthritis causes swelling, pain, stiffness, and redness in the joints.
The inflammation of rheumatoid disease can also occur in tissues around the joints, such as the tendons, ligaments, and muscles.
In some people with rheumatoid arthritis, chronic inflammation leads to the destruction of the cartilage, bone, and ligaments, causing deformity of the joints.
Damage to the joints can occur early in the disease and be progressive.
Moreover, studies have shown that the progressive damage to the joints does not necessarily correlate with the degree of pain, stiffness, or swelling present in the joints.
Rheumatoid Arthritis Causes
The cause of RA is not yet fully understood, although doctors do know that an abnormal response of the immune system plays a leading role in the inflammation and joint damage that occurs.
No one knows for sure why the immune system goes awry, but there is scientific evidence that genes, hormones and environmental factors are involved.
Researchers have shown that people with a specific genetic marker called the HLA shared epitope have a fivefold greater chance of developing rheumatoid arthritis than do people without the marker.
The HLA genetic site controls immune responses.
Other genes connected to RA include: STAT4, a gene that plays important roles in the regulation and activation of the immune system; TRAF1 and C5, two genes relevant to chronic inflammation; and PTPN22, a gene associated with both the development and progression of rheumatoid arthritis.
Yet not all people with these genes develop RA and not all people with the condition have these genes.
Researchers continue to investigate other factors that may play a role.
These factors include infectious agents such as bacteria or viruses, which may trigger development of the disease in a person whose genes make them more likely to get it; female hormones (70 percent of people with RA are women); obesity; and the body’s response to stressful events such as physical or emotional trauma.
Research also has indicated that environmental factors may play a role in one’s risk for rheumatoid arthritis. Some include exposure to cigarette smoke, air pollution, insecticides and occupational exposures to mineral oil and silica.
Rheumatoid Arthritis Symptoms
In the early stages, people with RA may not initially see redness or swelling in the joints, but they may experience tenderness and pain.
These following joint symptoms are clues to RA:
- Joint pain, tenderness, swelling or stiffness for six weeks or longer
- Morning stiffness for 30 minutes or longer
- More than one joint is affected
- Small joints (wrists, certain joints of the hands and feet) are affected
- The same joints on both sides of the body are affected
Along with pain, many people experience fatigue, loss of appetite and a low-grade fever.
The symptoms and effects of RA may come and go. A period of high disease activity (increases in inflammation and other symptoms) is called a flare. A flare can last for days or months.
Ongoing high levels of inflammation can cause problems throughout the body. Here of some ways RA can affect organs and body systems:
- Eyes. Dryness, pain, redness, sensitivity to light and impaired vision
- Mouth. Dryness and gum irritation or infection
- Skin. Rheumatoid nodules – small lumps under the skin over bony areas
- Lungs. Inflammation and scarring that can lead to shortness of breath
- Blood Vessels. Inflammation of blood vessels that can lead to damage in the nerves, skin and other organs
- Blood. Anemia, a lower than normal number of red blood cells
What tests do physicians use to diagnose rheumatoid arthritis?
There is no singular test for diagnosing rheumatoid arthritis. The diagnosis is based on the clinical presentation.
Ultimately, rheumatoid arthritis is diagnosed based on a combination of the presentation of the joints involved, characteristic joint swelling and stiffness in the morning, the presence of blood rheumatoid factor and citrulline antibody, as well as findings of rheumatoid nodules and radiographic changes (X-ray testing).
It is important to understand that there are many forms of joint disease that can mimic rheumatoid arthritis.
The first step in the diagnosis of rheumatoid arthritis is a meeting between the doctor and the patient.
The doctor reviews the history of symptoms, examines the joints for inflammation, tenderness, swelling, and deformity, the skin for rheumatoid nodules (firm bumps under the skin, most commonly over the elbows or fingers), and other parts of the body for inflammation.
Certain blood and X-ray tests are often obtained. The diagnosis will be based on the pattern of symptoms, the distribution of the inflamed joints, and the blood and X-ray findings.
Several visits may be necessary before the doctor can be certain of the diagnosis.
A doctor with special training in arthritis and related diseases is called a rheumatologist.
Rheumatoid Arthritis Treatment
The goals of rheumatoid arthritis (RA) treatment are to:
- Stop inflammation (put disease in remission)
- Relieve symptoms
- Prevent joint and organ damage
- Improve physical function and overall well-being
- Reduce long-term complications
To meet these goals, the doctor will follow these strategies:
Early, aggressive treatment. The first strategy is to reduce or stop inflammation as quickly as possible – the earlier, the better.
Targeting remission. Doctors refer to inflammation in RA as disease activity. The ultimate goal is to stop it and achieve remission, meaning minimal or no signs or symptoms of active inflammation.
One strategy to achieve this goal is called “treat to target.”
Tight control. Getting disease activity to a low level and keeping it there is what is called having “tight control of RA.” Research shows that tight control can prevent or slow the pace of joint damage.
Medications for RA
There are different drugs used in the treatment of rheumatoid arthritis. Some are used primarily to ease the symptoms of RA; others are used to slow or stop the course of the disease and to inhibit structural damage.
Drugs that ease symptoms
Nonsteroidal anti-inflammatory drugs (NSAIDs) are available over-the-counter and by prescription. They are used to help ease arthritis pain and inflammation.
NSAIDs include such drugs as ibuprofen, ketoprofen and naproxen sodium, among others. For people who have had or are at risk of stomach ulcers, the doctor may prescribe celecoxib, a type of NSAID called a COX-2 inhibitor, which is designed to be safer for the stomach.
These medicines can be taken by mouth or applied to the skin (as a patch or cream) directly to a swollen joint.
Drugs that slow disease activity
Corticosteroids. Corticosteroid medications, including prednisone, prednisolone and methyprednisolone, are potent and quick-acting anti-inflammatory medications.
They may be used in RA to get potentially damaging inflammation under control, while waiting for NSAIDs and DMARDs (below) to take effect.
Because of the risk of side effects with these drugs, doctors prefer to use them for as short a time as possible and in doses as low as possible.
DMARDs. An acronym for disease-modifying antirheumatic drugs, DMARDs are drugs that work to modify the course of the disease.
Traditional DMARDs include methotrexate, hydroxycholorquine, sulfasalazine, leflunomide, cyclophosphamide and azathioprine.
These medicines can be taken by mouth, be self-injected or given as an infusion in a doctor’s office.
Biologics. These drugs are a subset of DMARDs. They may work more quickly than traditional DMARDs. They include abatacept, adalimumab, anakinra, certolizumab pegol, etanercept, infliximab, golimumab and rituximab.
Each biologic blocks a specific step in the inflammation process. Certolizumab pegol, etanercept, adalimumab, infliximab, and golimumab block a cytokine called tumor necrosis factor-alpha (TNF), and therefore often are called TNF inhibitors. Anakinra blocks a cytokine called interleukin-1 (IL-1).
Abatacept blocks the activation of T cells. Rituximab blocks B cells. Tocilizumab blocks a cytokine called interleukin-6 (IL-6).
These medicines are injected or given by infusion in a doctor’s office. Because they target specific steps in the process, they don’t wipe out the entire immune response as some other RA treatments do.
In many people with RA, a biologic can slow, modify or stop the disease – even when other treatments haven’t helped much.
JAK inhibitors. A new subcategory of DMARDs known as “JAK inhibitors” block the Janus kinase, or JAK, pathways, which are involved in the body’s immune response.
Tofacitinib belongs to this class. Unlike biologics, it can be taken by mouth.
Surgery for RA may never be needed, but it can be an important option for people with permanent damage that limits daily function, mobility and independence.
Joint replacement surgery can relieve pain and restore function in joints badly damaged by RA. The procedure involves replacing damaged parts of a joint with metal and plastic parts. Hip and knee replacements are most common.
However, ankles, shoulders, wrists, elbows, and other joints may be considered for replacement.
Rheumatoid Arthritis Self Care
Self care, or self management, means taking a proactive role in treatment and maintaining a good quality of life. Here are some ways you can manage RA symptoms (along with recommended medication) and promote overall health.
Anti-inflammatory Diet and Healthy Eating
While there is no specific “diet” for RA, researchers have identified certain foods that are rich in antioxidants and can help control and reduce inflammation.
Many of them are part of the so-called Mediterranean diet, which emphasizes fish, vegetables, fruits and olive oil, among other healthy foods.
It’s also important to eliminate or significantly reduce processed and fast foods that fuel inflammation.
Balancing Activity with Rest
Rest is important when RA is active and joints feel painful, swollen or stiff. Rest helps reduce inflammation and fatigue that can come with a flare. Taking breaks throughout the day conserves energy and protects joints.
For people with RA, exercise is so beneficial it’s considered a main part of RA treatment. The exercise program should emphasize low-impact aerobics, muscle strengthening and flexibility.
The program should be tailored to fitness level and capabilities, and take into account any joint damage that exists. A physical therapist can help to design an exercise program.
Heat and Cold Therapies
Heat treatments, such as heat pads or warm baths, tend to work best for soothing stiff joints and tired muscles. Cold is best for acute pain. It can numb painful areas and reduce inflammation.
These treatments are applied directly to the skin over the painful muscle or joint. They may be creams or patches. Depending on the type used, it may contain nonsteroidal anti-inflammatory drugs (NSAIDs), salicylates or capsaicin, which help reduce pain.
Natural and Alternative Therapies
Relaxation techniques, such as deep breathing, guided imagery and visualization can help train painful muscles to relax.
Research shows massage can help reduce arthritis pain, improve joint function and ease stress and anxiety. Acupuncture may also be helpful.
This involves inserting fine needles into the body along special points called “meridians” to relieve pain. Those who fear needles might consider acupressure, which involves applying pressure, instead of needles, at those points.
Studies have shown that turmeric and omega-3 fish oil supplements may help with rheumatoid arthritis pain and morning stiffness.
However, talk with a doctor before taking any supplement to discuss side effects and potential interactions.
Positive Attitude and Support System
Many studies have demonstrated that resilience, an ability to “bounce back,“ encourages a positive outlook. Having a network of friends, family members and co-workers can help provide emotional support.
It can help a patient with RA cope with life changes and pain.