Rheumatoid Arthritis
What is Rheumatoid Arthritis?
The term “Rheumatoid Arthritis” (RA) is based on the Greek term which translates as “joint inflammation that resembles rheumatic fever”. It involves inflammation of the joints as well as tissues around the joints such as tendons, ligaments and muscles. RA is a progressive illness that has the potential to cause joint destruction, disability and loss of mobility.
It is a chronic disease – recurring and long-lasting;
It is a systemic disorder – affecting multiple organs in the body;
It is an autoimmune disorder – that occurs when the body tissues are mistakenly attacked by their own immune system.
Symptoms of Rheumatoid Arthritis
The major symptoms of Rheumatoid Arthritis are:
01) Inflammation (soft, doughy swelling) of the joints
02) Inflammation of cartilage, tendons and ligaments
03) Deformity of joints (especially of fingers e.g. swan neck deformity and “Z-thumb”)
04) Lesions in the subcutaneous tissue under the skin of affected area
05) Fibrosis of lungs
06) Pleuritis – diffuse inflammation of the pleura (lung lining)
07) Pericarditis – inflammation of the pericardium (tissue surrounding the heart)
08) Episcleritis – inflammation of the sclera of the eye
09) Keratitis – dryness of the cornea
10) Felty’s syndrome – inflamed spleen
11) Renal amyloidosis – inflammation of kidney
12) Vasculitis – blood vessel inflammation
13) Anemia – abnormality of the blood cells
14) Peripheral neuropathy – compression of spine due to erosion of ligaments
15) Fatigue
16) Lack of appetite
17) Low grade fever
18) Muscle and joints aches and stiffness
19) Red, tender, painful joints
20) Sjogren’s syndrome (dryness of mouth and eyes)
21) Chest pain while breathing deeply or while coughing
22) Swollen and painful lymph nodes or even lymphoma (cancer)
23) Osteoporosis.
This disease is chronic and progressive, but there are two stages in the severity of symptoms: active stage – when the body tissues are inflamed; and remission – when the tissue inflammation subsides for a while. The switch from active stage to remission is spontaneous and can last for months or even years. But the symptoms recur and cause a relapse. This is called a “flare”.
Diagnosis of Rheumatoid Arthritis
Physical examination: These would involve checks for changes in the appearance inflammed joints and surrounding connective tissue to check severity; of skin and nails (to rule out psoriatic arthritis); and to check for asymmetrical inflammation (to rule out reactive arthritis); etc.
X-rays: These would show signs of bone erosions and bone resorption (abnormal regeneration).
Blood tests: Abnormal blood antibodies can be found in patients with RA. Blood tests are carried out to specifically check for the rheumatoid factor (RF), an antibody. The test would also show other causes of arthritis like lupus erythematosus, erythrocyte sedimentation rate (ESR), C-reactive protein, full blood count, renal function, liver enzymes, antinuclear antibody (ANA), ferritin levels, etc. But this test may even produce negative results during the development of the disease in the first year of symptoms.
A blood test called Sedimentation Rate (sed rate) is carried out to see how fast red blood cells fall to the bottom of the test tube. The sed rate is faster during disease flares and slower during remissions. This gauges the rate of fluctuation in flares-remissions as also the progress of the disease.
Arthrocentesis: In this procedure, a sterile needle and syringe are used to drain joint fluids for laboratory testing. This helps to eliminate possible causes of RA like infection and gout. Also, medications like cortisone can be administered to relieve swelling and pain, so this method has proved to be very effective.
Ultrasonography and Magnetic Resonance Imaging: Ultrasound and MRI are more sensitive methods of imaging the joints and have shown signs of RA earlier in the development of the disease than X-rays have revealed. They have proved that bone/joint damage occurs much earlier and in more sufferers than was previously thought.
The American College of Rheumatology, in 1987, has defined the following criteria for the classification for the diagnosis of rheumatoid arthritis, if any of these symptoms last for more than 6 weeks:
a) Symmetric arthritis and soft-tissue swelling
b) Morning stiffness
c) Subcutaneous nodules
d) Rheumatoid factor of 95th percentile (blood test)
e) Radiological changes showing erosion of joints
Causes of Rheumatoid Arthritis
Heredity: As there seems no specific cause for the occurrence of Rheumatoid Arthritis, the genetic framework seems to play a major role according to research studies. For some reason the patient’s immune system is geared up to promote inflammation in the joints and occasionally other tissues of the body. Clinical trials have proved that any imbalances in the major histocompatibility complex (MHC) or in human leukocyte antigen (HLA-DR4) can be a cause for RA.
Smoking: Habits can be factors causing Rheumatoid Arthritis. Recently, scientific findings have proved that use of tobacco based products increases the risk of Rheumatoid Arthritis.
Types of Rheumatoid Arthritis
As RA is a systemic disease, it affects a number of organs in the body besides bones. It can only be categorized into “mild” like in the first year of the disease: where the symptoms are just developing, are localized, not yet disabling; and “chronic”: where the symptoms have been persistent for a number of years; have spread to other parts of the body; and caused disability and lack of mobility.
Treatment of Rheumatoid Arthritis
As bone erosion is irreversible, prevention of erosion and relief from pain is the main aim of treatment. The rheumatologist also has to aim at reducing joint inflammation, maximizing joint function and mobility and prevent joint destruction and deformity. Aggressive and optimal treatment for the disease involves a combination of therapy: rest, joint-strengthening exercises, joint protection and patient education. Treatment is customized to individual patient’s disease activity, types of joints involved, general health, age and patient’s occupation. In all cases, a combination of physical/occupational therapy and pharmacotherapy are used.
Physical therapy: Physical therapy and occupational therapy is an essential part of the treatment. This treatment includes exercises under medical supervision which are aimed at maintaining and improving joint/muscle functionality and mobility.
Medications: Analgesics like aspirin for pain; non steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen; and oral/injectible steroids like corticosteroid are used to suppress the symptoms as first-line medication. Disease-modifying anti-rheumatic drugs (DMARDs) like methotrexate (MTX), parenteral gold salts and azathioprine and cytotoxic drugs like cyclophosphamide are the second-line medication required to prevent long-term damage.
Note: Gene profiling, also known as gene array analysis, is considered a helpful method of defining which people will respond to which medications.
Caution: NSAIDs can sometimes cause side effects like stomach upset, ulcers, abdominal pain and even bleeding of the gastrointestinal tract; hence must be administered under strict medical supervision. MTX has the potential to suppress bone marrow or cause hepatitis.
Biologics: Biological agents, produced through genetic engineering like moniclonal antibodies against B cells; tumor necrosis factor alpha blockers (TNFα); T cell costimulation blockers; adalimumab; rituximab; etc are also used in the treatment of RA.
Surgery: In the case of joint deformity, surgery becomes very essential to bring back the functionality of the affected joint(s).
Prosorba column therapy: This involves pumping blood drawn from a vein near the affected part into a machine. This machine separates the liquid part of the blood (the plasma) from the blood cells and acts on harmful antibodies called Protein A. The Prosorba column is used to cure severe rheumatoid arthritis in adult patients who are physiologically intolerant to DMARDs. This method is not commonly used.
Other traditional therapies: Other therapies include rest, ice-compression and elevation of joints, acupuncture, apple diet, nutmeg, moderate exercises, wearing copper bracelets, honey, vitamins, magnetotherapy, podiatry (foot and ankle therapies), physiotherapy (massages), joint injections, etc.
Living with Rheumatoid Arthritis
Living with RA is a major difficulty as it hampers daily life; treatment is expensive; and causes other health disorders. Some of the problems are:
Other diseases: RA patients are more prone to other disorders like atherosclerosis, myocardial infarction (heart attack), stroke, pericarditis, endocarditis, left ventricular failure, valvulitis and fibrosis.
Disability: The joint pain, inflammation and in some cases deformity, can cause disability and lack of mobility.
Reduces life span: RA has a life-shortening effect. It can reduce a person’s life by 5 to 10 years, as per research studies conducted by UK’s National Rheumatoid Arthritis Society.
Prevention of Rheumatoid Arthritis
The onset of Rheumatoid Arthritis (RA) cannot be truly prevented, although certain measures can be undertaken to reduce the severity of the disease and to prevent further degeneration of the joints.
1) Mild exercise to maintain functionality and mobility of joints
2) Dietary supplements of calcium and vitamin D
3) Intake of food rich in calcium, vitamin D and iron
4) Cessation of alcohol
5) Cessation of tobacco products
In the United States alone, Rheumatoid Arthritis is a common disease, affecting approximately 1.3 million people. The disease is three times more common in women than in men. The reason for this is unknown but it is conjectured that menopause and hormonal changes could be a factor. Also, multiple members of the same family are affected, implying a genetic basis for the disorder.
