Rheumatoid Arthritis

What is Rheumatoid Arthritis?

Tens of millions of Americans experience the nagging pains and physical limitations of the more than 100 forms of arthritis. Rheumatoid arthritis is among the most debilitating of them all, causing joints to ache and throb and eventually become deformed. Sometimes these symptoms make even the simplest activities such as opening a jar or taking a walk difficult to manage.

Unlike osteoarthritis, which results from wear and tear on your joints, rheumatoid arthritis is an inflammatory condition. The exact cause is unknown, but it’s believed to be the body’s immune system attacking the synovium the tissue that lines your joints.

Rheumatoid arthritis affects about 2.1 million Americans. It’s two to three times more common in women than in men and generally strikes between the ages of 20 and 50. But rheumatoid arthritis can also affect young children and adults older than age 50.

There’s no cure for rheumatoid arthritis. But with proper treatment, a strategy for joint protection and changes in lifestyle, you can live a long, productive life with this condition.

Signs and symptoms of Rheumatoid Arthritis

The signs and symptoms of rheumatoid arthritis may come and go over time. They include:

• Pain and swelling in your joints, especially in the smaller joints of your hands and feet
• Generalized aching or stiffness of the joints and muscles, especially after sleep or after periods of rest
• Loss of motion of the affected joints
• Loss of strength in muscles attached to the affected joints
• Fatigue, which can be severe during a flare-up
• Low-grade fever
• Deformity of your joints over time
• General sense of not feeling well (malaise)

Rheumatoid arthritis usually causes problems in several joints at the same time. Early in rheumatoid arthritis, joints in your wrists, hands, feet and knees are the ones most often affected. As the disease progresses, your shoulders, elbows, hips, jaw and neck can become involved. It generally affects both sides of your body at the same time. The knuckles of both hands might be one example.

Small lumps, called rheumatoid nodules, may form under your skin at pressure points, and can occur at your elbows, hands, feet and Achilles tendons. Rheumatoid nodules may also occur elsewhere, including the back of your scalp, over your knee or even in your lungs. These nodules can range in size from as small as a pea to as large as a walnut. Usually these lumps aren’t painful.

In contrast to osteoarthritis, which affects only your bones and joints, rheumatoid arthritis can cause inflammation of tear glands, salivary glands, the linings of your heart and lungs, your lungs themselves and, in rare cases, your blood vessels.

Although rheumatoid arthritis is often a chronic disease, it tends to vary in severity and may even come and go. Periods of increased disease activity  called flare-ups or flares alternate with periods of relative remission, during which the swelling, pain, difficulty sleeping and weakness fade or disappear.

Swelling or deformity may limit the flexibility of your joints. But even if you have a severe form of rheumatoid arthritis, you’ll probably retain flexibility in many joints.

How is Rheumatoid Arthritis diagnosed?

If you have signs and symptoms of rheumatoid arthritis, your doctor will likely conduct a physical examination and order laboratory tests to determine if you have this form of arthritis. These tests may include:

• Blood tests. A blood test that measures your erythrocyte sedimentation rate (ESR, or sed rate) can indicate the presence of an inflammatory process in your body. People with rheumatoid arthritis tend to have elevated ESRs. The ESRs in those with osteoarthritis tend to be normal.Another blood test looks for an antibody called rheumatoid factor. Four out of five people with rheumatoid arthritis eventually have this abnormal antibody, although it may be absent early on in the disease. It’s also possible to have the rheumatoid factor in your blood and not have rheumatoid arthritis.
• Imaging. Doctors may take X-rays of your joints to differentiate between osteoarthritis and rheumatoid arthritis. A sequence of X-rays obtained over time can show the progression of arthritis.

How is Rheumatoid Arthritis treated?

Treatments for arthritis have improved in recent years. Most treatments involve medications. But in some cases, surgical procedures may be necessary.

Medications for Rheumatoid Arthritis

Medications for rheumatoid arthritis can relieve its symptoms and slow or halt its progression. They include:

• Nonsteroidal anti-inflammatory drugs (NSAIDs). This group of medications, which includes aspirin, helps relieve both pain and inflammation if you take the drugs regularly. NSAIDs that are available over-the-counter include aspirin, ibuprofen (Advil, Motrin, others) and naproxen sodium (Aleve). These are available at higher dosages, and other NSAIDs are available by prescription  such as ketoprofen (Oruvail), naproxen (Anaprox, Naprosyn), tolmetin (Tolectin), diclofenac (Arthrotec, Voltaren), nabumetone (Relafen) and indomethacin (Indocin). Taking NSAIDs can lead to side effects such as indigestion and stomach bleeding. Other potential side effects may include damage to the liver and kidneys, ringing in your ears (tinnitus), fluid retention and high blood pressure.
• COX-2 inhibitors. This class of NSAIDs may be less damaging to your stomach. Like other NSAIDs, COX-2 inhibitors celecoxib (Celebrex) and valdecoxib (Bextra) suppress an enzyme called cyclooxygenase (COX) that’s active in joint inflammation. Other types of NSAIDs work against two versions of the COX enzyme that are present in your body: COX-1 and COX-2. However, there’s evidence that by suppressing COX-1, NSAIDs may cause stomach and other problems because COX-1 is the enzyme that protects your stomach lining. Unlike other NSAIDs, COX-2 inhibitors suppress only COX-2, the enzyme involved in inflammation. Side effects may include fluid retention and causing or exacerbating high blood pressure. Some reports indicate that COX-2 inhibitors may be associated with an increased risk of heart attack. One called Viox has been removed from the market. Talk to your physician about recent findings in this debate.
• Corticosteroids. These medications, such as prednisone (Deltasone) and methylprednisolone (Medrol), reduce inflammation and pain, and slow joint damage. In the short term, corticosteroids can make you feel dramatically better. But when used for many months or years, they may become less effective and cause serious side effects. Side effects may include easy bruising, thinning of bones, cataracts, weight gain, a round face and diabetes. Doctors often prescribe a corticosteroid to relieve acute symptoms, with the goal of gradually tapering off the medication.
• Disease-modifying anti-rheumatic drugs (DMARDs). Physicians prescribe DMARDs to limit the amount of joint damage that occurs in rheumatoid arthritis. Taking these drugs at early stages in the development of rheumatoid arthritis is especially important in the effort to slow the disease and save the joints and other tissues from permanent damage. Because many of these drugs act slowly it may take weeks to months before you notice any benefit  DMARDs typically are used with an NSAID or a corticosteroid. While the NSAID or corticosteroid handles your immediate symptoms and limits inflammation, the DMARD goes to work on the disease itself. Some commonly used DMARDs include hydroxychloroquine (Plaquenil), the gold compound auranofin (Ridaura), sulfasalazine (Azulfidine) and minocycline (Dynacin, Minocin). Other forms of DMARDs include immunosuppressants and tumor necrosis factor (TNF) blockers.
• Immunosuppressants. These medications act to tame your immune system, which is out of control in rheumatoid arthritis. In addition, some of these drugs attack and eliminate cells that are associated with the disease. Some of the commonly used immunosuppressants include methotrexate (Rheumatrex), leflunomide (Arava), azathioprine (Imuran), cyclosporine (Neoral, Sandimmune) and cyclophosphamide (Cytoxan). These medications can have potentially serious side effects such as increased susceptibility to infection.
• TNF blockers. These are a class of DMARDs known as biologic response modifiers. TNF is a cytokine, or cell protein, that acts as an inflammatory agent in rheumatoid arthritis. TNF blockers, or anti-TNF medications, target or block this cytokine and can help reduce pain, morning stiffness and tender or swollen joints usually within one or two weeks after treatment begins. There is evidence that TNF blockers may halt progression of disease. These medications often are taken with the immunosuppressant methotrexate. TNF blockers approved for treatment of rheumatoid arthritis are etanercept (Enbrel), infliximab (Remicade) and adalimumab (Humira). If you have an active infection, don’t take these medications.
• Interleukin-1 receptor antagonist (IL-1Ra). IL-1Ra is another type of biologic response modifier and is a recombinant form of the naturally occurring interleukin-1 receptor antagonist (IL-1Ra). Interleukin-1 (IL-1) is a cell protein that promotes inflammation and occurs in excess amounts in people who have rheumatoid arthritis or other types of inflammatory arthritis. If IL-1 is prevented from binding to its receptor, the inflammatory response decreases. The first IL-1Ra that has been approved by the Food and Drug Administration for use in people with moderate to severe rheumatoid arthritis who haven’t responded adequately to conventional DMARD therapy is anakinra (Kineret). It may be used alone or in combination with methotrexate. Anakinra is given as a daily self-administered injection under the skin. Some potential side effects include injection site reactions, decreased white blood cell counts, headache and an increase in upper respiratory infections. There may be a slightly higher rate of respiratory infections in people who have asthma or chronic obstructive pulmonary disease. If you have an active infection, don’t use anakinra.
• Antidepressant drugs. Some people with arthritis also experience symptoms of depression. The most common antidepressants used for arthritis pain and nonrestorative sleep are amitriptyline (Elavil), nortriptyline (Aventyl, Pamelor) and trazodone (Desyrel).

Surgical or other procedures for Rheumatoid Arthritis

Although a combination of medication and self-care is the first course of action for rheumatoid arthritis, other methods are available for severe cases:

• Prosorba column. This blood-filtering technique removes certain antibodies that contribute to pain and inflammation in your joints and muscles and is usually performed once a week for 12 weeks as an outpatient procedure. Some of the side effects include fatigue and a brief increase in joint pain and swelling for the first few days after the treatment. The Prosorba column treatment isn’t recommended if you’re taking angiotensin-converting enzyme (ACE) inhibitors or if you have heart problems, high blood pressure or blood-clotting problems.
• Joint replacement surgery. For many people with rheumatoid arthritis, medicines and therapies can’t prevent joint destruction. When joints are severely damaged, joint replacement surgery can often help restore joint function, reduce pain or correct a deformity. You may need to have an entire joint replaced with a metal or plastic prosthesis. Surgery may also involve tightening tendons that are too loose, loosening tendons that are too tight, fusing bones to reduce pain or removing part of a diseased bone to improve mobility. Your doctor may also remove the inflamed joint lining (synovectomy).

Self care for Rheumatoid Arthritis

Treating rheumatoid arthritis typically involves using a combination of medical treatments and self-care strategies. The following self-care procedures are important elements for managing the disease:

• Exercise regularly. Different types of exercise achieve different goals. Check with your doctor or physical therapist first and then begin a regular exercise program for your specific needs. If you can walk, walking is a good starter exercise. If you can’t walk, try a stationary bicycle with little or no resistance or do hand or arm exercises. A chair exercise program may be helpful. Aquatic exercise is another option, and many health clubs with pools offer such classes.It’s good to move each joint in its full range of motion every day. As you move, maintain a slow, steady rhythm. Don’t jerk or bounce. Also, remember to breathe. Holding your breath can temporarily deprive your muscles of oxygen and tire them. It’s also important to maintain good posture while you exercise. Avoid exercising tender, injured or severely inflamed joints. If you feel new joint pain, stop. New pain that lasts more than two hours after you exercise probably means you’ve overdone it. If pain persists for more than a few days, call your doctor.
• Control your weight. Excess weight puts added stress on joints in your back, hips, knees and feet the places where arthritis pain is commonly felt. Excess weight can also make joint surgery more difficult and risky.
• Eat a healthy diet. A healthy diet emphasizing fruit, vegetables and whole grains can help you control your weight and maintain your overall health, allowing you to deal better with your arthritis. However, there’s no special diet that can be used to treat arthritis. It hasn’t been proved that eating any particular food will make your joint pain or inflammation better or worse.
• Apply heat. Heat will help ease your pain, relax tense, painful muscles and increase the regional flow of blood. One of the easiest and most effective ways to apply heat is to take a hot shower or bath for 15 minutes. Other options include using a hot pack, an electric heat pad set on its lowest setting or a radiant heat lamp with a 250-watt reflector heat bulb to warm specific muscles and joints. If your skin has poor sensation or if you have poor circulation, don’t use heat treatment.
• Apply cold for occasional flare-ups. Cold may dull the sensation of pain. Cold also has a numbing effect and decreases muscle spasms. Don’t use cold treatments if you have poor circulation or numbness. Techniques may include using cold packs, soaking the affected joints in cold water and ice massage.
• Practice relaxation techniques. Hypnosis, guided imagery, deep breathing and muscle relaxation can all be used to control pain.
• Take your medications as recommended. By taking medications regularly instead of waiting for pain to build, you will lessen the overall intensity of your discomfort.

Alternative medicine for Rheumatoid Arthritis

Many complementary medicine approaches haven’t been studied extensively by researchers using scientific methods. As a result it’s difficult for the scientific community to evaluate the effectiveness and safety of these alternative approaches. And with much of today’s research funding coming from the pharmaceutical industry, some low-tech, nontraditional approaches to managing diseases such as arthritis may not get as much attention from the research community as they deserve. For these reasons, many Western physicians just don’t know enough about these methods to endorse them. Nonetheless, a growing body of evidence indicates that complementary medicine practices could have a role in treating and managing some diseases.

Common forms of complementary and alternative medicine for treatment of arthritis include:

• Acupuncture
• Copper jewelry
• Nutritional supplements, including glucosamine and chondroitin sulfate
• Homeopathy
• Magnets

Be careful when considering alternative therapies. Many are expensive and some may be harmful. Before taking any complementary medications or dietary supplements, talk with your doctor to learn about potential dangers, particularly if you’re taking other medications.