Rheumatoid arthritis (RA) is a chronic autoimmune inflammatory disease of unknown cause. In fact, it is the most commonly diagnosed systemic (meaning “entire body”) inflammatory arthritis.
RA not only affects your joints but also affects a wide variety of body systems, including the skin, eyes, lungs, blood, nerves, and heart. RA is typically symmetrical, as it affects joints on both sides of the body (e.g., both hands and/or both knees). Autoimmune refers to the fact that RA is characterized by your immune system mistakenly attacking your own body’s tissues (in this case, your joints and their linings).
RA affects just over 1.3 million Americans — approximately 0.6 percent of the population — and approximately one percent of the world’s population. The disease generally starts between the ages of 30 and 60. RA is also a significant cause of disability and lost work productivity, as some estimate that 60 percent of people diagnosed with RA are unable to work after seven to 10 years. Plus, the disease is responsible for increased medical costs, as patients with RA are hospitalized more frequently than those patients without RA.
Risk Factors
Although the cause of RA is unknown, there are definite risk factors associated with the disease. These risk factors include:
- Age: Most RA cases are diagnosed in individuals older than 60.
- Sex: Women are up to three times more likely to develop RA than men.
- Genetics: The traits you inherited traits; they account for approximately 50 percent of the risk.
- Family History: If you have a first-degree relative (i.e., parents or sibling) diagnosed with RA, you have a roughly four times greater risk of developing the disease as compared to the general population.
- Smoking: Strongly associated with RA and can make the disease worse.
- Environmental Factors: Factors such as exposure to asbestos, silica, and even traumatic events may increase your risk of RA.
- Obesity: Compared to those with a normal weight, individuals who are suffering from obesity are at increased risk for RA.
- History of Live Births: If you have never given birth, you are more likely to develop RA.
Interestingly, pregnancy can lead to remission (complete absence of symptoms) of RA and breastfeeding can decrease the risk of RA.
Signs and Symptoms
In most patients, the onset of RA is subtle. The hallmark of RA is the symmetrical involvement of multiple joints, especially the small joints of the hands and feet. Typically, the signs and symptoms of RA can wax and wane, as patients go through periods of flares (worsening symptoms) alternating with periods of remissions. Since RA is a systemic disease, it is common for patients to have manifestations of the disease beyond the joints, which are termed “extra-articular” manifestations.
Signs and symptoms of RA may include:
- Pain in more than one joint;
- Stiffness in more than one joint;
- Tenderness and swelling in more than one joint;
- The same symptoms on both sides of the body;
- Loss of joint function, and;
- Loss of range of motion.
Extra-articular manifestations of RA may include:
- Weight loss;
- Fever;
- Fatigue;
- Weakness;
- Rheumatoid nodules (occur in approximately 25 percent of RA patients), and;
- Depression.
Diagnosis
The diagnosis of RA is not straightforward. Therefore, your doctor will need to use a combination of clinical, laboratory, and imaging tests in order to diagnose the disease.
Process
First, your doctor will perform a physical examination looking for clinical clues of RA, such as joint swelling, warmth, redness, and/or tenderness. They will also check for deformities or functional limitations, reflexes, muscle strength, and rheumatoid nodules. The presence of at least one joint with definite swelling that cannot be explained by another disease (e.g., infection, gout, lupus, psoriatic arthritis, or osteoarthritis) heightens the suspicion for RA.
Your doctor may ask you questions like:
- What are your symptoms?
- When did your symptoms start?
- What makes your symptoms better or worse?
- What joints are painful and what activities cause pain?
- How often do you have symptoms?
- Are there other symptoms besides joint, muscle, or bone pain that seem to be related?
- Do you have a family history of joint pain?
After the establishment of heightened suspicion for RA, your doctor will most likely refer you to a rheumatologist, a specialist that treats arthritis and related diseases.
Tests
Laboratory tests are another integral part of the diagnosis of RA and may include the following:
- Rheumatoid factor (RF): An antibody that is present in 60 to 80 percent of those diagnosed with RA; not everyone who tests positive for this antibody has RA, as it may present in other autoimmune disorders, connective tissue diseases, and infections.
- Anti-cyclic citrullinated peptide (anti-CCP) antibody: This antibody is present in 50 to 75 percent of individuals with RA and can be relied upon if initial testing for RF is negative.
- Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP): Markers of inflammation; used to assess response to treatment and follow disease activity (i.e., flares vs. remissions).
- Complete blood count (CBC): Used to reveal anemia (low levels of red blood cells), which is common in many individuals with RA.
Imaging studies are also crucial to the diagnosis of RA. X-rays are the first choice for imaging in RA since they reveal bony erosions and cartilage loss that are typical for the disease. Also, doctors use x-rays to track the progression of the disease. Although costly, Magnetic resonance imaging (MRI) can provide an earlier diagnosis of RA when compared to x-rays and may also be used to track its progression. Ultrasound of joints is gaining increased acceptance in diagnosing and tracking progression/severity of RA, but its use is not the standard of care yet.
In Summation
In summary, the recommended criteria for the diagnosis of RA are as follows:
- Swelling in at least one joint that cannot be explained by another cause;
- A positive result from at least one blood test for RA, and;
- The presence of symptoms for at least six weeks.
Stages
Doctors agree that there are four stages of RA, which are primarily based upon the x-ray appearance of joints. Progression through these stages can take many years.
The stages of RA are:
- Stage 1: Early RA; there is no joint damage visible on x-ray, although the joints may be swollen, stiff, and painful.
- Stage 2: Moderate RA; the loss of cartilage as a result of ongoing inflammation is visible on x-ray; joint mobility may be limited.
- Stage 3: Severe RA; joint deformities are not only visible on x-ray but also visible with the naked eye.
- Stage 4: End-stage RA; extensive bone thinning and possible fusion of bone can be seen on x-ray; there is no longer inflammation; the joint becomes permanently non-functional.
Furthermore, rheumatologists can also consider the functional status of RA patients as follows:
- Class I: Complete ability to perform all the usual activities of daily living (ADLs).
- Class II: Ability to carry out self-care and work-related activities but limited in activities outside of these areas, such as participation in sports or household chores.
- Class III: Ability to perform self-care but limited in work-related and other activities.
- Class IV: Limited in all activities, including self-care, work, and other activities.
Complications
Because it is an inflammatory autoimmune disease, RA can cause complications in an array of body systems, including the heart, lungs, blood, and eyes.
Heart
Individuals with RA have twice the risk of developing cardiovascular disease, including heart attack, stroke, and hardening of the arteries (atherosclerosis), as compared to the general population. In fact, more than half of early deaths among those with RA are due to cardiovascular disease.
The risk of congestive heart failure is also increased along with other heart problems such as pericarditis (inflammation of the membrane that surrounds your heart) and myocarditis (inflammation of the heart muscle).
If you have RA, you can decrease your risk of cardiovascular disease by quitting smoking, eating a healthy diet, controlling cholesterol levels, and exercising regularly.
Lungs
Long-standing inflammation from RA can lead to serious lung complications.
Chronic lung diseases develop in 10 to 20 percent of individuals with RA. As a result, those with RA are at increased risk for pleurisy (inflammation of the tissue surrounding the lungs) and pulmonary fibrosis (scarring of lung tissue), as well as chronic obstructive pulmonary disease (COPD) and high blood pressure in the lungs (pulmonary hypertension).
Some drugs used to treat RA (i.e., methotrexate) may also increase your risk of lung complications.
Symptoms of lung complications related to RA may include shortness of breath, coughing up blood, chest pain, chronic cough, and fever.
Blood
Complications of RA may arise in the blood.
Anemia is a common complication of RA. It can lead to symptoms such as fatigue, rapid heartbeat, shortness of breath, and dizziness. Less commonly, RA may lead to thrombocytosis (elevated levels of platelets), which can lead to complications such as heart attack, stroke, or blood clots.
Eyes
Eye complications can also be a part of the damage done by RA.
Those with RA are at increased risk for eye problems, such as dry eye syndrome and inflammation of the cornea (the clear dome-shaped surface of the eye that helps your eye focus light) and sclera (the whites of the eyes), which has the potential to lead to permanent blindness.
Symptoms of eye complications related to RA may include eye pain, blurred vision, dry eyes, red eyes, and loss of vision.
A diagnosis of RA also increases your risk of infections (e.g., pneumonia), osteoporosis (thinning and weakening of bone that increases your risk of fractures), lymphoma (doubles the risk) and carpal tunnel syndrome.
Treatments
There is no cure for RA. Therefore, the optimal treatment of RA requires an approach that incorporates medications, alternative or home therapies, occupational or physical therapy, diet, regular exercise, and even surgery in obstinate cases.
The main treatment goals of RA are to control inflammation, relieve pain, and reduce the disability associated with the disease. Earlier diagnosis of RA allows for early, aggressive treatment, which improves outcomes.
Combinations of medications are often used to control the disease. Medication classes commonly used to treat RA include disease-modifying antirheumatic drugs (DMARDs), nonsteroidal anti-inflammatory drugs (NSAIDs), and steroids.
DMARDs
DMARDs are first-line medications for the treatment of RA. They work by blocking your body’s immune response. As a result, these agents can slow or prevent RA progression and, thus, joint destruction and future loss of function.
If DMARDs are prescribed, they are typically taken for life. Your doctor may try several before finding the most suitable one for you.
Doctors typically classify DMARDs as nonbiologic or biologic.
Examples of the more commonly used nonbiologic DMARDs include the following:
- Leflunomide (Arava);
- Methotrexate (Rheumatrex, Trexall);
- Sulfasalazine (Azulfidine);
- Minocycline (Dynacin, Minocin), and;
- Hydroxychloroquine (Plaquenil).
Methotrexate is the most commonly prescribed nonbiologic DMARD for RA. If you take hydroxychloroquine, an eye doctor (ophthalmologist) should monitor you, as it can cause vision changes. Also, you should avoid sulfasalazine if you have a sulfa allergy.
Biologic DMARDs target the response to inflammation rather than blocking your body’s entire immune system response. They may be prescribed for those who don’t respond to treatment with more traditional nonbiologic DMARDs or can be added to a nonbiologic DMARD for dual therapy. Patients taking biologic agents should be tested for hepatitis B, hepatitis C, and tuberculosis prior to initiation.
Examples of the more commonly used biologic DMARDs include the following:
- Etanercept (Enbrel);
- Adalimumab (Humira);
- Rituximab (Rituxan);
- Abatacept (Orencia), and;
- Tofacitinib (Xeljanz).
NSAIDs
NSAIDs can reduce swelling and pain but have no effect on joint destruction. As a result, they should not be used alone for the treatment of RA.
Some commonly used NSAIDs for the treatment of RA include the following:
- Ibuprofen (Motrin, Advil);
- Naproxen (Naprosyn, Aleve);
- Etodolac (Lodine);
- Celecoxib (Celebrex), and;
- Diclofenac (Voltaren).
The most common side effects of NSAIDs include upset stomach, abdominal pain, ulcers, and gastrointestinal bleeding. As a result, additional medications (e.g., sucralfate [Carafate], esomeprazole [Nexium], and misoprostol [Cytotec]) are frequently recommended to protect the stomach from the side effects of NSAIDs.
Steroids
Steroids are potent inhibitors of inflammation.
Since DMARDs can take four to six weeks for full effect, doctors may prescribe steroids as a bridge until DMARDs become effective. They can be administered orally or by injection (sometimes directly into an inflamed joint). Examples of some commonly used steroids include prednisone, methylprednisolone, and prednisolone.
Potential side effects of long-term steroid use include high blood pressure, osteoporosis, and diabetes.
Therapy
A physical therapy program — ideally designed by a certified physical therapist — can equip you with a personalized exercise plan that has the potential to significantly decrease RA symptoms.
An occupational therapist can help you learn innovative and effective ways to manage daily tasks with RA, thus minimizing stress on painful joints. For example, a person with painful or deformed fingers might benefit significantly from the use of a specially designed tool for gripping and grabbing objects.
Just ask your primary care provider or rheumatologist for a referral to one or both of these professionals before embarking on a regular exercise regimen and/or if you are having trouble managing everyday tasks.
Surgery
If your RA symptoms persist despite medications and physical/occupational therapy, your doctor may recommend surgery to repair damaged joints, correct skeletal deformities, and/or reduce pain.
The following are examples of surgeries/procedures that may be recommended:
- Total joint replacement: Also called arthroplasty; the most commonly replaced joints are the hip and knee.
- Tendon repair
- Synovectomy: removal of the inflamed membrane lining a joint; the knee is a common spot for this procedure.
- Joint fusion: Also called arthrodesis; typically used to realign or stabilize a joint, ultimately decreasing pain.
When to See a Doctor
Most individuals with RA are under the care of a rheumatologist. Certain signs and symptoms of RA may necessitate a visit to the emergency room (ER), while you can address others with an office visit to your rheumatologist.
Symptoms such as fever, severe chills, or unexplained pain or swelling in one or more joints necessitate immediate medical evaluation. Other signs and symptoms or scenarios that may necessitate an office visit to your rheumatologist are:
- Pain that does not improve;
- Pain, swelling, and/or tenderness in a new area;
- Possible side effects or reactions to RA medications, and;
- Prior to the commencement of new treatment approaches (e.g., exercise or complementary therapies).
Living with Rheumatoid Arthritis
If you are living with RA, experts recommend certain lifestyle adjustments that can have a significant impact on the course and progression of the disease.
Exercise
Exercise is one of the most important things you can do for your RA and overall health.
Unfortunately, studies estimate that greater than 80 percent of RA patients get no exercise. This is probably largely responsible for the fact that most RA patients experience accelerated loss of muscle mass.
Low-impact exercise — such as walking, yoga, tai chi, Pilates, and gardening — can help to increase your strength, flexibility, and mobility.
Diet
Diet is another key factor in the self-treatment of RA. Since inflammation is a key component of RA, most dietary measures target this phenomenon.
Increasing your intake of whole grains (e.g., wheat, corn, brown rice, oats, barley, millet, and sorghum) can help stave off the inflammation of RA.
Beans (also known as legumes) come packed with fiber, which lowers inflammation and other vitamins and minerals that can provide a boost to your immune system. Black, red, white, and pinto beans are examples of RA-friendly legumes.
Fish (e.g., salmon, trout, sardines, and anchovies) are rich in inflammation fighting omega-3 fatty acids. Eating baked fish at least two times per week can help ease aching RA joints.
Olive oil, a staple in the Mediterranean diet, is the only oil pressed from a fruit and is an RA-friendly oil. Yes, olives come from an olive tree, which technically makes them a fruit. Vibrantly colored fruits and vegetables contain the antioxidants anthocyanins and vitamin C, which are not only potent fighters of inflammation but also can provide an immune boost.
Foods to Avoid
There are also foods that should be avoided, as these are not RA-friendly. These include:
- Red meat: Excess amounts of red meat can increase levels of inflammation due to their high content of saturated fats and omega-6 fatty acids.
- Sugar: Potent inducers of inflammation; don’t forget about the “hidden sugars” in highly refined carbohydrates, such as white bread, pasta, and white rice.
- Gluten: Found in wheat, rye, and barley; may cause an allergic and inflammatory reaction in individuals with autoimmune disorders such as RA.
- Excessive alcohol: Not only does it increase inflammation, but also does not interact well with medications used to treat your RA.
Outlook
There is no cure for RA, but with early, aggressive treatment, the outlook for those diagnosed with RA can be very good. The course of the disease varies from person to person and symptoms can range from mild to severe with periods of increased symptoms and periods that are relatively symptom-free.
In addition, RA is a “progressive” disease. This means the longer you have the disease, the harder it becomes to control the disease. As a result, the outlook for RA is compromised most when its diagnosis and treatment are delayed, as almost 40 percent of patients with this disease become disabled after 10 years.
Other factors to consider, in addition to early treatment, are recognition of signs and symptoms, drug treatment regimen, alternative or home therapies, occupational and/or physical therapy, diet, regular exercise, and even surgery after progression of RA, leading to irreversible joint damage. All things considered, if you optimize each one of these themes, the life expectancy of those with RA will definitely increase.