Rheumatoid Arthritis

Definition

Rheumatoid arthritis (RA) is an autoimmune disease. It causes pain, swelling, stiffness, and loss of function in the joints. RA usually affects the same joint on both sides of the body. It occurs mostly in the:

  • Fingers
  • Wrists
  • Elbows
  • Shoulders
  • Jaw
  • Hips
  • Knees
  • Toes

Rheumatoid Arthritis

rheumatoid arthritis

© 2008 Nucleus Medical Art, Inc.

Causes

RA is caused by a combination of genetic and environmental factors that trigger an abnormal immune response. Possible causes:

  • Genetic factors—Certain genes that play a role in the immune system are associated with RA development.
  • Defects in the immune system can cause ongoing inflammation.
  • Environmental factors—Certain infectious agents, such as some viruses or bacteria, may increase susceptibility to RA.
  • Other factors—Some evidence suggests that hormonal factors may promote RA development in combination with genetic factors and environmental exposure.

Risk Factors

These factors increase your chance of developing RA. Tell your doctor if you have any of these risk factors:

  • Family members with RA
  • Sex: female
  • Ethnic background: Pima Indians
  • Heavy or long-term smoking

Symptoms

When RA begins, symptoms may include:

  • Joint pain and stiffness that is:
    • Symmetrical
    • Most prominent in the morning
    • Lasts for at least half an hour
  • Red, warm, or swollen joints
  • Joint deformity
  • Mild fever, tiredness
  • Loss of appetite
  • Small lumps or nodules under the skin

As RA progresses, it may cause complications with the:

  • Heart
  • Lungs
  • Eyes
  • Skin
  • Liver
  • Kidneys
  • Blood
  • Nervous system
  • Blood vessels

It is also linked to early cardiovascular disease and death.

Diagnosis

There is no single test for RA. The doctor will ask about your symptoms and medical history. She will examine your joints, skin, reflexes, and muscle strength.

Tests:

  • Rheumatoid factor (RF) level in the blood
  • Erythrocyte sedimentation rate (ESR) of the blood—to measure inflammation in the body
  • C-reactive protein (CRP)—an indicator of active inflammation in the blood
  • White blood cell count
  • X-rays of affected joints (especially dual energy x-ray absorptiometry)

Treatment

There is no cure for RA. The goals of treatment are to:

  • Relieve pain
  • Reduce inflammation
  • Slow down joint damage
  • Improve functional ability

Medications

  • Disease-modifying anti-rheumatic drugs (DMARDS)—to slow the course of the disease
    These medications are used early in the course of the disease to prevent long-term damage:
    • Methotrexate (Rheumatrex)
    • Hydroxychloroquine (Plaquenil)
    • Sulfasalazine (Azulfidine)
    • Leflunomide (Arava)
    • Cyclosporine (Neoral)
    • Penicillamine (Cuprimine)
    • Gold (Ridaura)—Gold can also be given as an injection.
    • Minocycline (Minocin)
  • Immunosuppressive drugs (only used when other DMARDS are ineffective):
    • Azathioprine (Imuran)
    • Cyclophosphamide (Cytoxan)—rarely used
    • Chlorambucil (Leukeran)—rarely used
  • Biologic response modifiers—drugs that interfere with the autoimmune response associated with RA:
    • Etanercept (Enbrel)
    • Infliximab (Remicade)
    • Adalimumab (Humira)
    • Abatacept (Orencia)
    • Rituximab (Rituxan)
  • Adjunctive medications:
    • Acetaminophen (Tylenol)
    • Nonsteroidal anti-inflammatory drugs (NSAIDs) including ibuprofen and naproxen

    ***Please Note: On September 30, 2004, Merck & Co., Inc. announced a voluntary withdrawal of Vioxx (rofecoxib) from the US and worldwide market due to safety concerns. A study showed a small but significant increased risk of cardiovascular events (such as heart attack) in patients taking the prescription medication. Vioxx is a so-called "selective" nonsteroidal anti-inflammatory drug (NSAID) specially designed to lower the risk of stomach irritation. It is commonly used in the treatment of acute and chronic pain associated with arthritis, menstruation, and other conditions. Since Merck's withdrawal of Vioxx, evidence has come to light regarding similar dangers posed by the other popular selective NSAID, Celebrex (celecoxib), which is produced by Pfizer. Most physicians now question the wisdom of prescribing any medications from the COX-2 class, particularly in patients with known cardiovascular disease.

Steroids

Low-dose corticosteroids (prednisone 10 mg or the equivalent) are often used first. They may be tapered when other drugs start working. Avoid long-term steroid use. Corticosteroid injections to inflamed joints may also be used.

Rest and Exercise

Rest reduces active joint inflammation and pain, and fights fatigue. Exercise is important for maintaining muscle strength and flexibility. It also preserves joint mobility.

Joint Care

Splints applied to painful joints may reduce pain and swelling. Devices that help with daily activities can also reduce stress on joints. Devices include:

  • Zipper extenders
  • Long-handled shoehorns
  • Specially designed kitchen tools

Stress Reduction

Stress reduction can ease the difficulties of living with a chronic, painful disease. Exercise programs, support groups, and open communication with healthcare providers can reduce stress.

Surgery

Joint replacement and tendon reconstruction help relieve severe joint damage.

Lifestyle Measures

These may relieve stiffness and weakness and reduce inflammation:

  • Maintain a balance between rest and exercise.
  • Attempt mild strength training.
  • Participate in aerobic exercise (eg, walking, swimming, dancing).
  • Avoid heavy impact exercise.
  • Stop smoking.
  • Control weight.
  • Participate in a physical therapy program.

Prevention

There are no guidelines for preventing RA.

RESOURCES:

American College of Rheumatology
http://www.rheumatology.org/

The Arthritis Foundation
http://www.arthritis.org/

CANADIAN RESOURCES:

Canadian Orthopaedic Association
http://www.coa-aco.org/

Canadian Rheumatology Association
http://www.rheum.ca/

References:

Rheumatoid arthritis. National Institute of Arthritis and Musculoskeletal and Skin Disorders website. Available at: http://www.niams.nih.gov/Health_Info/Rheumatic_Disease/default.asp. Published January 1998. Updated May 2004. Accessed June 18, 2008.

Tanaka E, et al. Impact of shoulder, elbow, and knee joint involvement on assessment of rheumatoid arthritis using the American College of Rheumatology Core Data Set. Arthritis Rheum. 2005;53:864-871.

Verstappen SM, et al. Overview of work disability in rheumatoid arthritis patients as observed in cross-sectional and longitudinal surveys. Arthritis Rheum. 2004;51:488-497.



Last reviewed February 2008 by Jill Landis, MD

Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.

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