Written by :
HOD & Senior Consultant Rheumatologist,
Dr. BL Kapur Hospital, New Delhi
What is rheumatoid arthritis?
Rheumatoid arthritis (RA) is a form of chronic inflammatory arthritis that causes persistent pain, swelling, stiffness and also loss of function in your joints. It can affect any joint but is common in the wrist and fingers, however involvement of joints of spinal column except uppermost cervical joint is rare. More women than men get rheumatoid arthritis. It often starts between ages 25 and 55 years.
Rheumatoid arthritis is different from osteoarthritis (OA), the common arthritis that often comes with older age. RA is a inflammatory condition by but OA is degenerative condition, most often occurring due to excessive wear and tear. RA can affect body parts besides joints, such as your eyes, mouth, heart, nerves and lungs.
What is the cause?
The cause of RA is unknown. It is considered an autoimmune disease. The body's immune system normally fights off foreign substances, like viruses, bacterias. But in an autoimmune disease, the immune system confuses healthy tissue for foreign substances and starts forming protein particles to attack the body itself. RA can occur at any age. Women are affected more often than men.
RA usually affects joints on both sides of the body equally. Wrists, fingers, knees, feet, and ankles are the most commonly affected. The course and the severity of the illness can vary considerably. Infection, genes, and hormones may trigger the onset of the disease.
What are the symptoms?
The disease usually begins gradually with:
- Loss of appetite
- Morning stiffness (lasting more than 1 hour)
- Widespread muscle aches
Eventually, joint pain and swelling appears. When the joints are not in use for a while, especially in the morning after overnight sleep, they can become warm, more tender and stiff. When the lining of the joints called synovium becomes inflamed, it gives off more fluid and the joint becomes swollen. Joint pain is often felt on both sides of the body, and may affect the fingers, wrists, elbows, shoulders, hips, knees, ankles, toes, and neck.
Additional symptoms include:
- Anaemia due to failure of the bone marrow to produce enough new red blood cells, it occurs due to persistent chronic inflammation.
- Eye burning, itching due to lesser secretion of tears and then called dry eyes. Due to similar reason mouth also become dry. In that case this is called Sjogren’s syndrome, and it is secondary to RA.
- Hand and feet deformities
- Limited range of motion
- Low-grade fever may be there due to inflammation.
- Lung nodules and inflammation of lining of the lung (pleurisy)
- Nodules under the skin (usually a sign of more severe disease), called Rheumatoid nodules
- Numbness or tingling due to the involvement of nerves
- Paleness due to less haemoglobin
- Skin redness or ulcers due to inflammation of vessels carrying the blood (It will require urgent care by Rheumatologist.
- Swollen parotid glands, this is also feature of Sjogren’s syndrome
As per latest research, Joint destruction starts after initial 12 weeks of persistent inflammation of the joints.
How is it diagnosed?
RA is diagnosed primarily on the basis of clinical features with which a patient presents to doctor, which includes history, physical examination of joints and other parts of the body. Then help of some specific blood tests like AntiCCP antibody and Rheumatoid factor are taken to finally diagnose RA. Other tests that are done include the test to differentiate the inflammatory nature of the RA from the various arthritides of noninflammatory nature and also for the purpose of monitoring to see whether any drug prescribed to control the inflammation is not having any toxic effect on the body. These are:
- Complete blood count
- C-reactive protein
- Joint ultrasound or MRI
- Joint x-rays
- Synovial fluid analysis
Here it is emphasised that because disease will require lifelong treatment and monitoring, a correct diagnosis is of para amount importance. It will be in public interest that diagnosis of RA is to be finally done by a Rheumatologist who is a specifically trained joint physician to diagnose and treat more than 100 types of arthritides.
What is the treatment?
RA usually requires lifelong treatment, including medications, physical therapy, exercise, education, and possibly surgery. The goal of treatment in rheumatoid arthritis is to reduce joint inflammation and pain, maximize joint function, and prevent joint destruction and deformity. Early medical intervention has been shown to be important in improving outcomes. Aggressive management can improve function, stop damage to joints as monitored on X-rays, and prevent work disability. Optimal treatment for the disease involves a combination of medications including Disease modifying anti rheumatic drugs and biologicals, rest, joint-strengthening exercises, joint protection, and patient (and family) education. Treatment is customized according to many factors such as disease activity, types of joints involved, general health, age, and patient occupation. Treatment is most successful when there is close cooperation between the doctor, patient, and family members.
Disease modifying anti-rheumatic drugs (DMARDs): These drugs are the current standard of care for RA, in addition to rest, strengthening exercises, and anti-inflammatory drugs. Methotrexate is the most commonly used DMARD for rheumatoid arthritis. They work best for RA. These medicines don't just relieve pain, they slow or stop damage in your joints. DMARDs come in two groups. Some are pills. The others are given by shot or IV. Both suppress the immune system. That means they slow down the body's attack on itself.
Anti-inflammatory medications: These include aspirin and non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen. Although NSAIDs work well, long-term use can cause stomach problems, such as ulcers and bleeding, and possible heart problems. NSAID packaging now carries a warning label to alert users of an increased risk for cardiovascular events (such as heart attack or stroke) and gastrointestinal bleeding.
Corticosteroids: These medications work well to reduce joint swelling and inflammation. Because of potential long-term side effects, however, corticosteroids should be given only for a short time and in low doses whenever possible.
Occasionally, surgery is needed to correct severely affected joints and to relieve pains. Surgeries can relieve joint pain, correct deformities, and modestly improve joint function. The most successful surgeries are those performed on the knees and hips. Surgical treatment called synovectomy, which is the removal of the joint lining (synovium) is sometimes done when synovial swelling causing the joint swelling and pain can not be reduced by medical means. However, in such cases radio-synovectomy is performed with good outcomes. When joints are damaged so much that causing severe pain and walking and performing the routine work is not possible is total joint replacement with a joint prosthesis is the answer. Surgical part of management is done by orthopaedic surgeons who are masters in surgery.
Range-of-motion exercises and individualised exercise programmes prescribed by a physical therapist can delay the loss of joint function. Joint protection techniques, heat and cold treatments, and splints or orthotic devices to support and align joints may be very helpful.
Occupational therapists can construct splints for the hand and wrist, and teach how to best protect and use joints when they are affected by arthritis. They also show people how to better cope with day-to-day tasks at work and at home, despite limitations caused by RA.
What are the complications?
Rheumatoid arthritis is not solely a disease of joint destruction. It can involve almost all organs. A life-threatening joint complication can occur when the cervical spine (neck bones) becomes unstable as a result of RA called Atlanto-occipital dislocation. Rheumatoid vasculitis (inflammation of the blood vessels) is a serious, potentially life-threatening complication of RA. It can lead to skin ulcerations and infections, bleeding stomach ulcers, and nerve problems that cause pain, numbness, or tingling. Vasculitis may also affect the brain, nerves, and heart, which can cause stroke, heart attack, or heart failure.
RA may cause the the outer lining of the heart to swell (pericarditis) and cause heart complications. Inflammation of the heart muscle, called myocarditis, can also develop. Both of these conditions can lead to congestive heart failure. The treatments for RA can also cause serious side effects, hence proper periodic monitoring is done by doctor trained in this field called Rheumatologist.
How can it be prevented?
Rheumatoid arthritis has no known prevention. However, it is often possible to prevent further damage of the joints with proper early treatment. Stop smoking. Research shows that the risk of developing RA is nearly double for current smokers compared with non-smokers. Smoking also causes the treatment to have lesser effect. Overweight individuals must normalize their weight to have all round benefits. Recent life styles perpetuates causes and perpetuates the vitamin D deficiency which has been suggested to be a regulator of immune cell functioning. Hence it is advised to have good sun exposure of about 1-2 hours for at least 4 times in a week; otherwise Vitamin D supplements have been seen to reduce the severity of joint symptoms. Finally reporting within 12 weeks for early diagnosis and management by Rheumatologist has been associated with best disease outcomes.