Unknown: Rheumatoid Arthritis

Definition
Description
Demographics
Causes and Symptoms
Diagnosis
Treatment
Prognosis
Prevention
The Future
For more information

Definition

Rheumatoid arthritis, or RA, is an autoimmune disorder characterized by inflammation of the joints, resulting in pain, swelling, and gradual loss of

function. The joints most commonly affected are the hands, wrists, elbows, knees, ankles, and feet; however, other joints may be involved as well.

Description

RA develops gradually in about 90 percent of persons diagnosed with it. The patient notices that the affected joints do not move as freely as they once did, and there may be pain, redness, and swelling as well. Patients whose hands and wrists are affected may notice nodules (small lumps) underneath the skin of the joints. Nodules also develop on the elbows of about 20 percent of patients with RA. In most cases, the joints on both sides of the body are affected; this symmetrical pattern is one significant difference between rheumatoid arthritis and osteoarthritis. The intensity of the pain varies from person to person, but it is common for patients with RA to feel that their joints are stiffest in the morning, with some improvement later in the day.

In addition to pain and stiffness in the joints, patients with RA frequently suffer from aches in the muscles, fever and flu-like symptoms, loss of appetite, cold or sweaty hands and feet, unintended weight loss, and general lack of energy.

The symptoms of RA are not constant but tend to come and go. A period of freedom from symptoms is called a remission, and the sudden return or worsening of symptoms is called a flare. Over time, however, the symptoms of joint damage become worse. One reason for diagnosing RA as quickly as possible is to slow or prevent further damage to the joints.

RA can affect other body systems, including the skin, eyes, bones, lungs, and nervous system. Patients may experience dry eyes; tingling or numbness in the hands or feet; anemia; osteoporosis; increased vulnerability to infections; and an increased risk of lymphoma (cancer of the lymphatic system).

Demographics

RA is one of the most common inflammatory joint diseases, affecting at least 2.1 million people in the United States. It strikes about three people in every 10,000 worldwide, although some countries and ethnic groups have higher rates than others. Some Native American tribes have rates of RA as high as 5 to 6 percent, while natives of the Caribbean have a lower than average rate. The reason for these differences is not yet known.

RA is primarily a disease of adults; the most common age at onset is thirty-five to fifty. Children, however, can also get rheumatoid arthritis,

as can elderly adults. As with lupus and other autoimmune disorders, women are three times as likely as men to develop RA. Men with RA, however, are more likely to have a more severe form of RA and to die earlier than women with the disease.

Although rheumatoid arthritis is not considered a genetic disease in the strict sense, it does appear to run in some families. A parent, child, or sibling of a person with RA has a 3 percent greater risk of developing the disease themselves than someone in the general population.

Causes and Symptoms

The cause of RA is not known. Some researchers think that it may be caused by a bacterium or virus because of the inflammation that weakens the patient's joints. Others think that hormones may be involved because RA affects women significantly more often than men. Still others think that genetic factors are also involved because at least four separate genes known to regulate the immune system's responses have been associated with an increased risk of RA. Some of these genetic markers, however, are also found in persons who do not have the disease. What seems clear is that there is no single gene that determines whether a person will develop RA.

What happens in rheumatoid arthritis is that the synovium, a type of tissue that lines the joints in the body, becomes inflamed, swells, and starts

to damage the bones and cartilage in the joint. The inflammation can spread to other tissues near the joint, such as the tendons, ligaments, blood vessels, and nerve endings. As the tissues inside the joint are damaged by the inflamed synovium, the person experiences the destruction as stiffness and pain when using the joint. As the tissues surrounding the joint are affected by the disease, the effects of the inflammation may spread to the blood vessels, the lungs, or other organ systems. Women with RA may also develop Sjögren syndrome, a disorder characterized by dryness of the eyes and mouth.

The symptoms of RA have already been described.

Diagnosis

Rheumatoid arthritis is not always easy to diagnose just from the patient's history because the symptoms may develop slowly over time and there are other disorders that have some of the same symptoms. In particular the doctor will need to rule out Lyme disease, osteoarthritis, and lupus. There is no single test that can be used to confirm the diagnosis of RA. The diagnosis is based on a combination of blood tests, imaging studies of the patient's joints, and a history of the patient's symptoms. The most widely accepted blood test is called the anti-CCP test; it measures the presence of an autoantibody in the patient's blood. Another autoantibody that is measured for diagnostic purposes is rheumatoid factor, or RF.

In 1987 the American College of Rheumatology drew up a list of diagnostic criteria that doctors can use to help with the diagnosis. A patient who meets four of the seven criteria is considered to have RA:

• Morning stiffness lasting longer than an hour most mornings for at least six weeks
• Arthritis in the hand joints for six weeks or longer
• Arthritis in three or more of fourteen other joints for at least six weeks
• Symmetrical arthritis for at least six weeks
• Rheumatoid factor (RF) in the blood higher than that found in 95 percent of the population
• Nodules beneath the skin
• X-ray evidence of joint damage

Treatment

There is no cure for rheumatoid arthritis. Therapy is focused on relieving the patient's pain, slowing or preventing further damage to the joints,

reducing inflammation, and improving the person's ability to function. It is critical to begin treatment as soon as possible after diagnosis. In the recent past, doctors concentrated on relieving pain and waiting for symptoms to get worse before prescribing stronger pain relievers. It is now known that joint destruction can begin within one to two years of the earliest symptoms of the disease, so that slowing down its progress is important.

The mainstay of treatment for RA is medications. These typically include several different types of drugs:

• Drugs to relieve pain and reduce inflammation. These include steroid medications and NSAIDs like aspirin and ibuprofen.
• Disease-modifying anti-rheumatic drugs (DMARDs). DMARDs are prescribed to slow down the destruction of the joint tissues. They include drugs like methotrexate, injectable gold, and penicillamine.
• Biologic response modifiers. Also known as biologics, these drugs work by blocking certain proteins that contribute to inflammation. They include drugs like Enbrel and Humira.

Most patients benefit from a combination of drugs rather than just one. Drug therapy for RA is highly individualized, and the doctor may have to try more than one drug in each group to see which works best for the patient. Combining the DMARD methotrexate with one of the biologics appears to work well for patients with moderate or severe RA.

In some cases the doctor may recommend surgery to reduce inflammation or improve range of motion in the damaged joints. The types of surgery most commonly performed to treat RA include total joint replacement; repair or reconstruction of damaged tendons and ligaments; and surgical removal of inflamed synovium.

Patients with RA are also given physical therapy or occupational therapy and an exercise program to keep their joints as flexible as possible as long as possible. Although exercise must be balanced with rest, it can help people to sleep better, improve their mood, and lose weight if needed as well as keeping joints and muscles strong.

Doctors also recommend stress reduction programs for patients with RA. Although emotional stress does not cause the disease, the anger and fear that many patients experience when they are diagnosed with RA can make the pain worse and make it more difficult to cope with the disease.

Relaxation techniques, meditation, and support groups are all beneficial ways to lower a patient's stress level.

Prognosis

RA is a disease that involves significant loss of function and shortened life spans for most patients diagnosed with it. Only a small minority—about 5 percent—of patients recover spontaneously. About a third of patients are forced to stop working within five years of being diagnosed; after ten years, about 50 percent of patients have some limitations on their activity. People with a family history of RA have worse prognoses than those without; men generally have worse prognoses than women; and those who are elderly at the time of diagnosis have worse prognoses than younger patients. Researchers estimate that patients with RA have their life expectancy shortened by five to ten years on average.

Prevention

There is no known way to prevent rheumatoid arthritis; however, early diagnosis and prompt treatment can slow the progression of the disease and reduce the patient's risk of complete disability.

WORDS TO KNOW

Autoantibody : A type of protein made by a person's immune system that attacks the body's own tissues.

Flare : A return or worsening of the symptoms of RA.

Remission : A period of freedom from the symptoms of RA.

Rheumatoid factor (RF) : An antibody that attacks the body's own tissues that is found in some patients with RA and is measured as part of the diagnostic process.

Rheumatologist : A doctor who specializes in diagnosing and treating arthritis and other diseases of the muscles and joints.

Synovium : A type of tissue lining the joints that ordinarily secretes a fluid that lubricates the joints.

The Future

Researchers are presently looking at new treatments for rheumatoid arthritis as well as trying to gain a better understanding of its causes.

There are over 600 clinical studies under way as of 2008 looking at new biologic drugs as well as various combinations of DMARDs and biologics in treating the disease. The National Institutes of Health and the Arthritis Foundation have set up ten research centers around the United States that are collecting genetic materials from families in which two or more siblings have developed rheumatoid arthritis. Other researchers are studying the role of hormones in RA to discover why the disease affects women more frequently but men more severely.

Another question researchers are investigating is why the number of new cases of RA has started to drop in the United States in recent years. Although the decline is not a sharp one, it may shed new light on the cause or causes of RA.

SEE ALSO Fibromyalgia; Lupus; Lymphoma; Osteoarthritis; Osteoporosis; Sjögren syndrome

For more information

BOOKS

Clough, John D. Arthritis. Cleveland, OH: Cleveland Clinic Press, 2006.

Klippel, John H., ed. The Arthritis Foundation's Guide to Good Living with Rheumatoid Arthritis. 2nd ed. Atlanta, GA: Arthritis Foundation, 2004.

McNeil, M. E. A. The First Year—Rheumatoid Arthritis: An Essential Guide for the Newly Diagnosed. New York: Marlowe, 2005.

PERIODICALS

Baruchin, Aliyah. “A Breakthrough in Joint Pain.” New York Times, February 2, 2008. Available online at http://health.nytimes.com/ref/health/healthguide/esn-rheumatoid-ess.html (accessed August 17, 2008).

Brody, Jane E. “Living Better with Rheumatoid Arthritis.” New York Times, August 11, 2008. Available online at http://www.nytimes.com/2008/08/12/health/12brod.html?_r=1&oref=slogin (accessed August 18, 2008).

WEB SITES

American College of Rheumatology (ACR). Rheumatoid Arthritis. Available online at http://www.rheumatology.org/public/factsheets/ra.asp?aud=pat (accessed August 17, 2008).

Arthritis Foundation. Rheumatoid Arthritis. Available online at http://www.arthritis.org/disease-center.php?disease_id=31 (accessed August 17, 2008]

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). Rheumatoid Arthritis. Available online at http://www.niams.nih.gov/Health_Info/Rheumatic_Disease/default.asp (accessed August 16, 2008).