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Rheumatoid arthritis

Rheumatoid arthritis is a chronic disease of multiple joints on both sides of the body. When rheumatoid arthritis is present, the lining of the inside of joints (called the synovium) becomes thickened and inflamed (synovitis).

Rheumatoid arthritis is due to an abnormality in the function of the immune system. It is an example of an autoimmune disease; the body attacks itself. It may cause inflammation and damage to other parts of the body such as the skin, lungs, eyes and blood vessels.

When the joint lining becomes thickened and inflamed, damage may occur to the joint and to the surrounding tendons and ligaments. The cartilage becomes thinner, and the bones around the joints become eroded. Rheumatoid arthritis is an example of an inflammatory joint disease. Other types of joint inflammation may be due to other diseases such as gout. Some people with psoriasis develop inflammatory arthritis, called psoriatic arthritis. Permanent joint damage is a danger with all types of inflammatory joint disease.

Swelling, redness, warmth and tenderness of joints lasting longer than six weeks suggest rheumatoid arthritis might be starting. It may begin in the large and middle hand knuckles, or the wrists. Rheumatoid arthritis sometimes starts slowly in just one or two joints. Sometimes it begins in the toes, with swelling and pain felt in the balls of the feet. The elbows, shoulders, knees and ankles are frequently involved with rheumatoid arthritis. The joints feel unusually stiff, especially in the mornings. Joint stiffness lasts an hour or longer. In comparison, the extra morning stiffness from osteoarthritis (‘wear and tear arthritis’) rarely is longer than 30 minutes. Inflammation in the body causes fatigue, and sometimes mild fevers.

The cause of rheumatoid arthritis is unknown. It may be related to having particular genes, and abnormalities in the signals that immune cells send to each other. There may be something in the environment, (either in a person’s system or in the external environment) that triggers rheumatoid arthritis to start. Smoking is linked to a higher risk for developing rheumatoid arthritis.

The diagnosis of rheumatoid arthritis usually is made by or confirmed by a rheumatologist, (a specialist trained in arthritic diseases). Several joints, both large and small, often are involved on both sides of the body. Once it begins, the symptoms usually do not improve without treatment. In addition to swelling and tenderness of the joints, blood tests and x-rays help to confirm the diagnosis. Having a positive blood test called a rheumatoid factor is not enough to diagnose rheumatoid arthritis. In recent years, a newer blood test called anti-CCPhas been found more specific than rheumatoid factor in helping to diagnose rheumatoid arthritis, but by itself does not mean the disease is present. Remission is now possible, and is considered to be the target of treatment.

Most patients with inflammatory joint diseases such as rheumatoid arthritis are treated by specialists called rheumatologists. In order to prevent permanent joint damage, it is very important that the diagnosis is made promptly, and that treatment is started as soon as possible. No cure has yet been found, but there are many types of medications (often used in combination) which are very effective in treating rheumatoid arthritis.

These medications are called disease-modifying anti-rheumatic drugs (DMARDs for short). Traditionally effectiveDMARDs include methotrexate, sulfasalazine, plaquenil and leflunomide. Treatment may be started with one of these, or a combination of two or three. Several other similar medications are occasionally used.

Recent discoveries of how the immune system causes inflammation in rheumatoid arthritis has led to an increasing number of injectable medications called ‘Biologics, or biologic DMARDs’. They inhibit a protein called TNF which has been linked to inflammation in rheumatoid arthritis. Examples of these TNF inhibitors are Cimzia, Enbrel, Humira, Remicade, and Simponi.

Other new and effective medications also approved for the treatment of rheumatoid arthritis include Actemra,Orencia,Rituxan, and Xeljanz. They also effectively reduce damage caused by rheumatoid arthritis by affecting certain cells or chemical signals in the immune system.

Although both traditional DMARDs and the newer biologic medications have been thoroughly tested, they all may cause side effects, and should be prescribed by a licensed health care provider with training and experience in their use.

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