Rheumatoid Arthritis | Description | Prevention | Causes and symptoms | Treatment
Definition
Rheumatoid arthritis is a chronic inflammatory autoimmune joint disease that causes pain, stiffness, swelling, and decreased movement in joints. Unchecked, it can lead to the eventual joint destruction.
Description
Rheumatoid arthritis is a painful disease that causes joints to swell and become stiff and restricts their range of motion. People of any age, including children, can get rheumatoid arthritis, but it most commonly appears in middle age. About three times more women than men develop rheumatoid arthritis. Between .03% and 1.5% of the population in the United States, or about 2.5 million people, have rheumatoid arthritis. The disease occurs in all ethnic groups worldwide.
Causes and symptoms
Although researchers are not sure of the exact cause of rheumatoid arthritis, they do know that it is an autoimmune disease in which immune system cells function incorrectly, leading them to attack the ligaments and joints of the body.
Symptoms vary from person to person and can mimic other bone and joint diseases such as osteoarthritis. For most people, the symptoms of rheumatoid arthritis appear gradually, although about one-third of individuals develop serious symptoms within a few months. In many people, symptoms tend to change from day to day, with periods of improvement followed by periods of worsening symptoms. In more serious cases, symptoms simply worsen progressively without periods of improvement. The wrists and hand joints are affected in more than 85% of individuals with rheumatoid arthritis. Usually if a joint on one side of the body is inflammed, the same joint on the other side will also be affected.
Signs and symptoms of rheumatoid arthritis include:
· sore, stiff, swollen, and warm joints
· involvement of multiple joints
· prolonged stiffness of over an hour in the morning
· general feelings of illness and fatigue, especially when joint pain has worsened
· chronic low fever
· appetite loss and weight loss
· anemia
· formation of rheumatoid nodules or bumps under the skin often around the elbow, spine, and fingers
· inflammation of the tear and salivary glands, causing dry eyes and mouth.
Diagnosis
Although a family physician can diagnose rheumatoid arthritis, a rheumatologist who specializes in bone and joint diseases usually is consulted. Rheumatoid arthritis is difficult to diagnose because symptoms are common to many other diseases. Diagnosis is made on the basis of medical history supplemented with x rays and blood tests. Diagnosis often involves ruling out other causes of joint distress.
The American Rheumatology Association designates that at least four of the following seven criteria must be present for at least six weeks to diagnose rheumatoid arthritis.
· morning joint stiffness lasting more than one hour
· pain simultaneously in three or more joint areas
· arthritis in the wrist or hand
· joint pain in symmetrical joint areas (e.g., both wrists, both knees)
· presence of rheumatoid nodules
· presence of serum rheumatoid factor, a protein found in blood
· x rays that show typical rheumatoid arthritis changes in the affected joints
X rays often appear normal until rheumatoid arthritis is quite advanced and serious joint damage has already occurred. Rheumatoid factor is an antibody or immune system protein. It is found in 80-90% of people with rheumatoid arthritis, but it is also found in about 30% of people who have no symptoms of the disease, so its presence is not a definitive diagnosis.
Treatment
There is no cure for rheumatoid arthritis. Treatment is divided into two categories: treatment of symptoms and treatment to stop or slow joint damage. Treatment to improve symptoms includes the use of various pain medications including nonsteroidal anti-inflammatory drugs (e.g., aspirin, ibuprophen, naproxen sodium) and analgesics (acetaminophen, tramadol), either alone or in combination with narcotic pain medications. Corticosteroids such as prednisone and cortisone are also used in the lowest effective dose to control pain and stiffiness. Also beneficial is exercise and physical therapy to increase strength and flexibility.
Drugs to stop or slow joint damage are collectively called disease-modifying antirheumatic drugs (DMARDs). These drugs, especially when given early in the course of the disease, interfere with the disease process in ways that slow or stop joint damage. DMARDs are often given in combination with drugs to improve symptoms. Some common DMARDs include methotrexate (Rheumatrex, Trexall), hydroxy-chloroquinine (Plaquenil), sulfasalazine (Azulfidine), leflunomide (Arava), D-pencillamine (Dpen, Cuprimine), azathioprine (Imuran), cyclosporine (Neoral, Sandimmune) and minocycline (Minocin, Dynacin). All these drugs have potentially serious side effects and may require regular blood or other tests.
Rheumatoid arthritis can also be treated with biologic response modifiers (BMRs). BMRs target specific proteins of the immune system that are involved in rheumatoid arthritis. Most BMRs are approved for use in adults only. The exception is etanercept (Enbrel), which is approved for individuals over age four. Other BMRs used to treat rheumatoid arthritis include infliximab (Remicade), anakinra (Kineret), and adalimumab (Humira). BMRs interfere with and may weaken the immune system. Individuals should not receive live-virus vaccinations while taking BMRs. Other side effects are also possible.
Many complementary and alternative cures are heavily advertised for rheumatoid arthritis. The National Center for Complementary and Alternative Medicine has investigated many of these alternative cures. Most do not provide any benefit to individuals with rheumatoid arthritis. Those complementary and alternative treatments that may have possible benefit include thunder god vine (Tripteryguim wilfordii, not available in the United States as of September 2005), gamma-linolenic acid (GLA), fish oil, glucosamine and chrondroitin (effective in animals, but unproven in humans), and mind-body stress reduction techniques. Individuals should not replace conventional treatment with alternative therapies, and before adding any herbal or other complementary treatments should consult their physician, as some complementary therapies may interfere with the conventional treatment and/or have serious side effects.
When treatment fails to control pain and joint damage, joint replacement surgery followed by guided rehabilitation may be necessary. Knee and hip replacement surgery are the most common types of surgery done on individuals with rheumatoid arthritis.
Prognosis
There is no cure for rheumatoid arthritis. The course of the disease is variable. Some people have the disease for only a year or two, and then it goes away on its own without joint damage. Many other people have periods when the disease is quiet and symptoms disappear, only to flare up again for unknown reasons. For some people the disease is continuous, chronic, and progressively worsens. It is estimated that rheumatoid arthritis reduces the lifespan of men by 7.5 years and of women by 3.5 years.
Health care team roles
A rheumatologist normally oversees the health care team treating an individual with rheumatoidarthritis. Nurses play an important role in patient education by teaching individuals with rheumatoidarthritis how to balance activity and rest. Physical therapists evaluate an individual's range of motion and teach appropriate exercises to promote joint mobility and muscle fitness and the appropriate use of heat and cold treatments. Physical therapists also have special equipment that can provide electrical stimulation to reduce pain and improve joint movement. Occupational therapists teach individuals how to move in ways that protect their joints and how to perform tasks of daily living in ways that reduce pain and stress on he joints. Both PT and OT are essential after surgery, but may also be helpful to individuals with advanced rheumatoid arthritis undergoing non-surgical treatments.
Prevention
Rheumatoid arthritis cannot be prevented. Early detection and treatment can help slow the disease. Clinical trials of new medications and complementary and alternative therapies forrheumatoid arthritis are ongoing. A list of clinical trials currently enrolling patients is available at www.clinicaltrials.gov.
KEY TERMS
Autoimmune disease— A disease in which the immune system of the body inappropriately attacks the body's own tissues.
Osteoarthritis— A noninflammatory wearing away of bone and cartilage most often associated with aging.
Resources
BOOKS
Haskell, Gretchen. Arthritis Foundation's Guide to Good Living with Rheumatoid Arthritis, 2nd ed. Atlanta, GA: Arthritis Foundation, 2005.
ORGANIZATIONS
American College of Rheumatology. 1800 Century Place, Suite 250 Atlanta, GA 30345-4300. (404) 633-3777. http://www.rheumatology.org.
Arthritis Foundation. P. O. Box 7669, Atlanta, GA 30357-0669. (800) 568-4045.http://www.arthritis.org.
National Institute of Arthritis and Musculoskeletal and Skin Disease Information Clearing House. National Institutes of Health, 1 Ames Circle, Bethesda, MD 20892-3675. (877) 226-4267 (toll free).http://www.niams.nih.gov.
OTHER
"Rheumatoid Arthritis." Arthritis Foundation. 2003. http://www.arthritis.org.
Ruderman, Eric. "Rheumatoid Arthritis." American College of Rheumatology, May 2004.
"Rheumatoid Arthritis and Complementary and Alternative Medicine." National Center for Complementary and Alternative Medicine. September 2005. http://nccam.nih.gov/health/RA.
