Arthritis is a complex family of musculoskeletal disorders consisting of more than 100 different diseases or conditions that destroy joints, bones, muscles, cartilage and other connective tissues, hampering or halting physical movement. Rheumatoid arthritis (RA) is a form of inflammatory arthritis and an autoimmune disease. In RA, for reasons no one fully understands, the immune system – which is designed to protect our health by attacking foreign cells such as viruses and bacteria – instead attacks the body’s own tissues, specifically the synovium, a thin membrane that lines the joints. As a result of the attack, fluid builds up in the joints, causing pain in the joints and inflammation that’s systemic – meaning it can occur throughout the body.
An estimated 1.3 million people in the United States have RA—that’s 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. It often occurs later in life for men.
What causes it?
The cause of rheumatoid arthritis is not yet known. Most scientists agree that a combination of genetic and environmental factors is responsible. Researchers have identified genetic markers that cause a tenfold greater probability of developing rheumatoid arthritis. These genes are associated with the immune system, chronic inflammation or the development and progression of RA. Still, not all people with these genes develop rheumatoid arthritis and not all people with the disease have these genes.
Researchers are also investigating infectious agents, such as bacteria or viruses, which may trigger the disease in someone with a genetic propensity for it. Other suspects include female hormones (70 percent of people with RA are women) and the body’s response to stressful events such as physical or emotional trauma. Smoking may also play a role – it not only boosts the risk of developing RA among people with a specific gene, it can also increase the disease’s severity and reduce the effectiveness of treatment
What are the effects?
Rheumatoid arthritis is a chronic disease, meaning it can’t be cured. Most people with RA experience intermittent bouts of intense disease activity, called flares. 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. Evidence shows that early diagnosis, early treatment, and aggressive treatment to put the disease into remission is 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. Your joints may feel warm to the touch and you might notice a decreased range of motion, as well as inflammation, swelling and pain in the areas around the affected joints. 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. Because the inflammation is systemic, you’re likely to feel fatigued and you may become anemic, lose your appetite and run a low-grade fever.
In the long term, rheumatoid arthritis may affect many different joints and cause damage to cartilage, tendons and ligaments – it can even wear away the ends of your bones. One common outcome is joint deformity and disability. Some people with RA develop rheumatoid nodules; lumps of tissue that form under the skin, often over bony areas exposed to pressure. These occur most often around the elbows but can be found elsewhere on the body, such as on the fingers, over the spine or on the heels. Over time, the inflammation that characterizes RA can also affect numerous organs and internal systems.
How Is it diagnosed?
To diagnose rheumatoid arthritis, your physician will take a medical history and perform a physical examination. The doctor will look for certain features of RA, including swelling, warmth and limited motion in joints throughout your body, as well as nodules or lumps under the skin. Your doctor may also ask if you have experienced fatigue or an overall feeling of stiffness. The pattern of joints affected by arthritis can help distinguish rheumatoid arthritis from other conditions. Your physician should recommend certain blood tests to identify antibodies, levels of inflammation and other markers that aid diagnosis and assessments. He’ll likely call for X-rays to determine if you have 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 you have a diagnosis, you should begin treatment right away to slow disease progression and lower chances for joint damage.
What are the treatment options?
Medications used to treat rheumatoid arthritis can be divided into two groups: those that help relieve symptoms and reduce inflammation (nonsteroidal anti-inflammatory drugs and corticosteroids), and those that can modify the disease or put it in remission (disease-modifying antirheumatic drugs and biologic agents). Your physician may recommend using two or more together. Some medications affect the immune system or have other side effects, making careful monitoring very important. Research on new medications is ongoing, with an influx of new drugs into the pipeline.
Engaging in moderate physical activity on a regular basis helps decrease fatigue, strengthen muscles and bones, increases flexibility and stamina, and improves your general sense of well-being. When your symptoms are under control, work with your health-care team to develop a full exercise program that includes stretching for joint flexibility and range of motion, strength training for joint support and aerobic (cardiovascular) exercise for overall health, weight control, muscle strength and energy level.
There is no known cure for rheumatoid arthritis. To date, the goal of treatment in rheumatoid arthritis is to reduce joint inflammation and pain, maximize joint function, and prevent joint destruction and deformity. Early medical intervention has been shown to be important in improving outcomes. Aggressive management can improve function, stop damage to joints as monitored on X-rays, and prevent work disability. Optimal treatment for the disease involves a combination of medications, rest, joint-strengthening exercises, joint protection, and patient (and family) education. Treatment is customized according to many factors such as disease activity, types of joints involved, general health, age, and patient occupation. Treatment is most successful when there is close cooperation between the doctor, patient, and family members.
Two classes of medications are used in treating rheumatoid arthritis: fast-acting "first-line drugs" and slow-acting "second-line drugs" (also referred to as disease-modifying antirheumatic drugs or DMARDs). The first-line drugs, such as aspirin and cortisone (corticosteroids), are used to reduce pain and inflammation. The slow-acting second-line drugs, such asmethotrexate (Rheumatrex, Trexall), andhydroxychloroquine (Plaquenil), promote disease remission and prevent progressive joint destruction.
The degree of destructiveness of rheumatoid arthritis varies among affected individuals. Those with uncommon, less destructive forms of the disease or disease that has quieted after years of activity ("burned out" rheumatoid arthritis) can be managed with rest plus pain control and anti-inflammatory medications alone. In general, however, function is improved and disability and joint destruction are minimized when the condition is treated earlier with second-line drugs (disease-modifying antirheumatic drugs), even within months of the diagnosis. Most people require more aggressive second-line drugs, such as methotrexate, in addition to anti-inflammatory agents. Sometimes these second-line drugs are used in combination. In some cases with severe joint deformity, surgery may be necessary.