Rheumatoid arthritis

Alternative Names

RA; Arthritis - rheumatoid

Definition

Rheumatoid arthritis (RA) is a long-term disease that leads to inflammation of the joints and surrounding tissues. It can also affect other organs.

Causes

The cause of RA is unknown. It is an autoimmune disease, which means the body's immune system mistakenly attacks healthy tissue.

RA can occur at any age, but is more common in middle age. Women get RA more often than men.

Infection, genes, and hormone changes may be linked to the disease.

Symptoms

Most of the time, RA usually affects joints on both sides of the body equally. Wrists, fingers, knees, feet, and ankles are the most commonly affected.

The disease often begins slowly. Early symptoms may include minor joint pain, stiffness, and fatigue.

Joint symptoms may include:

Morning stiffness, which lasts more than 1 hour, is common. Joints may feel warm, tender, and stiff when not used for an hour.
Joint pain is often felt on the same joint on both sides of the body.
Over time, joints may lose their range of motion and may become deformed.

Other symptoms include:

Chest pain when taking a breath (pleurisy)
Dry eyes and mouth (Sjogren syndrome)
Eye burning, itching, and discharge
Nodules under the skin (usually a sign of more severe disease)
Numbness, tingling, or burning in the hands and feet
Sleep difficulties

Exams and Tests

There is no test that can determine for sure whether you have RA. Most people with RA will have some abnormal test results. However, some people will have normal results for all tests.

Two lab tests that often help in the diagnosis are:

Rheumatoid factor
Anti-CCP antibody

Other tests that may be done include:

Treatment

RA usually requires lifelong treatment, including medications, physical therapy, exercise, education, and possibly surgery. Early, aggressive treatment for RA can delay joint destruction.

MEDICINES

Disease modifying antirheumatic drugs (DMARDs): These are often the drugs that are tried first in people with RA. They are prescribed along with rest, strengthening exercise, and anti-inflammatory drugs.

Methotrexate (Rheumatrex) is the most commonly used DMARD for rheumatoid arthritis. Leflunomide (Arava) and hydroxychloroquine may also be used.
Sulfasalazine is an anti-inflammatory drug that is often combined with methotrexate and hydroxychloroquine (triple therapy).
These drugs may have serious side effects, so you will need frequent blood tests when taking them.

Anti-inflammatory medications: These include aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen.

Although NSAIDs work well, long-term use can cause stomach problems, including ulcers and bleeding, and possible heart problems.
Celecoxib (Celebrex) is another anti-inflammatory drug. Drugs in this class (COX-2 inhibitors) may increase heart attack and stroke risk for some people. Talk to your doctor about whether these medicines are right for you.

Antimalarial medications: This group of medicines includes hydroxychloroquine (Plaquenil). They are most often used along with methotrexate. It may be weeks or months before you see any benefit from these drugs.

Corticosteroids: These medicines work very well to reduce joint swelling and inflammation, but they can have long-term side effects. Therefore should be taken only for a short time and in low doses when possible.

Biologic agents: These drugs are designed to affect parts of the immune system that play a role in the disease process of rheumatoid arthritis.

They may be given when other medicines for rheumatoid arthritis have not worked. At times, your doctor will start biologic drugs sooner, along with other rheumatoid arthritis drugs.

Most of them are given either under the skin (subcutaneously) or into a vein (intravenously). There are different types of biologic agents:

White blood cell modulators include: abatacept (Orencia) and rituximab (Rituxan)
Tumor necrosis factor (TNF) inhibitors include: adalimumab (Humira), etanercept (Enbrel), infliximab (Remicade), golimumab (Simponi), and certolizumab (Cimzia)
Interleukin-6 (IL-6) inhibitors: tocilizumab (Actemra)

Biologic agents can be very helpful in treating rheumatoid arthritis. However, people taking these drugs must be watched very closely because of serious risk factors:

Infections from bacteria, viruses, and fungi
Leukemia or lymphoma
Psoriasis
Allergic reactions

Other drugs:

Janus kinase inhibitor: Tofacitinib (Xeljanz). This is a medication taken by mouth that is now approved for treating RA.

SURGERY

Surgery may be needed to correct severely damaged joints. Surgery may include:

Removal of the joint lining (synovectomy)
Total joint replacement in extreme cases; may include total knee, hip replacement, ankle replacement, shoulder replacement, and others

PHYSICAL THERAPY

Range-of-motion exercises and exercise programs prescribed by a physical therapist can delay the loss of joint function and help keep muscles strong.

Sometimes, therapists will use special machines to apply deep heat or electrical stimulation to reduce pain and improve joint movement.

Other therapies that may help ease joint pain include:

Joint protection techniques
Heat and cold treatments
Splints or orthotic devices to support and align joints
Frequent rest periods between activities, as well as 8 to 10 hours of sleep per night

NUTRITION

Some people with RA may have intolerance or allergies to certain foods. A balanced nutritious diet is recommended. It may be helpful to eat foods rich in fish oils (omega-3 fatty acids).

Support Groups

Some people may benefit from taking part in an arthritis support group.

Outlook (Prognosis)

How well a person does depends on the severity of symptoms.

People with rheumatoid factor, the anti-CCP antibody, or subcutaneous nodules seem to have a more severe form of the disease. People who develop RA at a younger age also seem to get worse more quickly.

Permanent joint damage may occur without proper treatment. Early treatment with a three-drug combination known as "triple therapy" can decrease joint pain and damage. Many of the newer drugs have also shown positive results.

Possible Complications

Rheumatoid arthritis can affect nearly every part of the body. Complications may include:

Damage to the lung tissue (rheumatoid lung)
Increased risk of hardening of the arteries
Spinal injury when the neck bones become damaged
Inflammation of the blood vessels (rheumatoid vasculitis), which can lead to skin, nerve, heart, and brain problems
Swelling and inflammation of the outer lining of the heart (pericarditis) and of the heart muscle (myocarditis), which can lead to congestive heart failure

The treatments for RA can also cause serious side effects. Talk to your doctor about the possible side effects of treatment and what to do if they occur.

When to Contact a Medical Professional

Call your health care provider if you think you have symptoms of rheumatoid arthritis.

Prevention

There is no known prevention. Smoking cigarettes appears to worsen RA, so it is important to avoid tobacco. Proper early treatment can help prevent further joint damage.

References

Huizinga TW, Pincus T. In the clinic. Rheumatoid arthritis. Ann Intern Med. 2010 Jul 6;153(1).

Scott DL, Wolfe F, Huizinga TW. Rheumatoid arthritis. Lancet. 2010 Sep 25;376(9746):1094-108.

Firestein GS. Etiology and pathogenesis of rheumatoid arthritis. In: Firestein GS, Budd RC, Gabriel SE, et al, eds. Kelley's Textbook of Rheumatology. 9th ed. Philadelphia, Pa: Saunders Elsevier; 2012:chap 69.

O'Dell JR, Mikuls TR, Taylor TH, et al. Therapies for active rheumatoid arthritis after methotrexate failure. N Engl J Med. 2013; 369:307.