- Rheumatoid arthritis is characterised by symmetrical inflammation of the peripheral joints.
- It is a chronic condition.
- The cause is not known, but there is a strong genetic predisposition.
- It is more prevalent amongst women.
- The main symptoms are early morning stiffness, pain, swelling and tenderness in inflamed joints.
- Although there is no cure for rheumatoid arthritis, new therapies offer real hope for complete control of the condition, if not cure.
Rheumatoid arthritis is a chronic condition characterised by inflammation of the peripheral joints of the hands, wrists, elbows, shoulders, hips, knees and feet, usually on both sides of the body, potentially resulting in damage. Damage is caused by persistent inflammation of the synovium, the membrane lining the joint, with subsequent damage of the cartilage, bone erosion and joint deformities. Although normally confined to the joints, in rare cases it may affect other systems such as the lungs, heart and nervous system.
The cause is not known, but there may be a strong genetic predisposition. It is now understood that there is an immune reaction against the body's own synovial tissue, called an autoimmune reaction.
Who gets it and who is at risk?
About one per cent of the population is affected, although we have no accurate prevalence figures for South Africa. Women are affected about two to three times more often than men. The incidence increases with age and the sex difference diminishes in older people. Rheumatoid arthritis is seen around the world and all races are affected.
It can start at any age and often affects young people. The peak onset is in the 4th and 5th decade, with 80 per cent of people developing the disease between the ages of 35 and 50.
There is a strong genetic predisposition: severe rheumatoid arthritis is found at four times the expected rate in first-degree relatives of people with the disease.
Symptoms and signs
Rheumatoid arthritis is characterised by chronic polyarthritis – meaning that it affects many joints. In about two thirds of patients it begins insidiously with fatigue, and vague muscle and joint symptoms until the appearance of the synovial inflammation is apparent. This may persist for weeks or months.
Specific symptoms usually appear gradually as several joints, particularly those of the hands, wrists, knees and feet become affected on both sides of the body.
About 10 per cent of people have a more atypical presentation with sudden onset of polyarthritis, sometimes together with fever and a systemic illness, or with a single joint such as a knee involved.
The main symptoms are stiffness, pain and tenderness in all inflamed joints. Generalised stiffness is common and usually worse after inactivity. There is usually morning stiffness lasting more than one hour. The duration of morning stiffness can be used as a crude measure of the degree of inflammation, as it improves with treatment.
Inflammation of the synovium causes swelling, tenderness and limitation of motion. The joint may be warm to the touch, particularly the large joints.
Joint swelling results from accumulation of fluid within the synovial space, thickening of the synovium and thickening of the joint capsule. The inflamed joint maybe held in a partly flexed position since this minimises pain. Later, fixed deformities of the joints arise as a result of joint damage.
There are also many non-joint manifestations of rheumatoid arthritis.
A firm diagnosis of rheumatoid arthritis can be made when the patient fulfils four out of seven specified American College of Rheumatology (ACR) criteria. However, the diagnosis may be tentatively made on the basis of clinical suspicion, even if these criteria are not present. The diagnosis does not require use of blood tests or X-rays. It is a mistake to discount the diagnosis on the basis of normal investigations. The clinical examination is the most important aspect of assessment of the problem.
There are no specific tests for rheumatoid arthritis. A positive Rheumatoid Factor is found in less than 85% of patients with the disease. These patients are termed seropositive. The test is negative in many patients, where it is termed seronegative. Although its presence does not establish the diagnosis, high levels of Rheumatoid Factor may predict a more severe and progressive disease, often with non-joint manifestations. In addition, the test may be positive in other conditions and in the elderly. Once shown to be present, there is no value in testing repeatedly. A new antibody test, anti-CCP antibodies, has been shown to be more specific and useful in the diagnosis of early rheumatoid arthritis.
Those with active rheumatoid arthritis often have anaemia. The erythrocyte sedimentation rate (ESR) is increased in many patients with active disease, as is the C-reactive protein, (CRP). These markers of inflammation are useful when raised as they can be used to monitor progress.
X-rays are not always useful early in the disease, revealing mainly swelling of the soft tissues around the joint and fluid in the joint space. However, the early appearance of erosion of bone around the joint margin indicates a more aggressive disease process and should prompt more aggressive treatment. As the disease progresses, the abnormalities become more obvious, with narrowing of joint space and damage to joint margins. X-rays are useful in monitoring progress as they provide independent information as to the patient's response to particular therapy.
There is no known prevention. Routine blood testing of family members is not advised. Smoking has been shown to be a risk factor for the development of RA, and persistent smoking in patients suffering from RA may predict a poorer outcome.
It is important to realise that rheumatoid arthritis is a treatable condition, requiring urgent intervention at the earliest possible moment. It is a medical problem and the specialist of choice is a rheumatologist.
Although homeopathic remedies such as Omega 3 and 6 may help alleviate pain and inflammation, there is no scientific evidence to prove that they in any way modify the outcome of the disease. Disease-modifying Antirheumatic Drugs (DMARDs) are the cornerstone of all therapy for RA and should be introduced as soon as possible in order to achieve remission. Remission is defined as the absence of any tender or swollen joints, or laboratory indicators of inflammation in patients on treatment.
The goals of rheumatoid arthritis therapy are:
• Pain relief
• Reduction of inflammation
• Control of the disease with early induction of remission
• Preservation of function
Exercise and physiotherapy can help. Exercises are aimed at maintaining muscle strength and joint mobility without exacerbating the joint inflammation. Early on this includes immobilising inflamed joints with splints but allowing passive stretch to maintain range of movement. As the swelling is controlled, activity and exercise are encouraged. The message is – ‘If it’s swollen – rest it. If it isn’t swollen – move it’.
(a) Relief of symptoms and reduction of inflammation
Simple painkillers, analgesics, and anti-inflammatories, NSAIDs, are used to decrease pain and stiffness. Cox 2 selective anti-inflammatories (COXIBs) are available with less gastro-intestinal side-effects. These include Celebrex and Prexige. The safety profile of the COXIBs are superior to the older NSAIDs.
However, they should be used with caution in patients with cardiovascular disease.
(b) Disease-modifying Antirheumatic Drugs (DMARDS)
Early aggressive treatment with DMARDS is essential. These drugs reduce the amount of joint destruction and X-ray damage. Methotrexate is the most commonly used DMARD. Although developed as chemotherapy, it is extremely effective in RA and remains the backbone of most treatment programmes. Chloroquine (Nivaquin), an anti-malarial drug, and Sulphasalazine (Salazopyrine) are older drugs which are commonly used alone or in combination with Methotrexate. Leflunomide (Arava) is a more expensive but powerful DMARD which is often used when Methotrexate fails to produce remission.
Cortisone is very useful in low dose for treatment of the symptoms of disease whilst waiting for the disease-modifying drugs to work. It works rapidly to counter all aspects of the disease. However, side effects are dose-dependent and preclude long-term use thereof. Persistent need for oral cortisone indicates incomplete contol of the underlying disease and the need for more aggressive DMARD therapy.
Judicious injection of cortisone either intramuscularly or directly into joints is helpful in controlling flare-ups of the disease. Large doses are restricted for the potential life-threatening situation where there is systemic disease and organ involvement. In these cases the drug may be life-saving.
Surgery can be helpful relatively early in the disease if there is persistent inflammation of a single large joint such as the knee or wrist. This is called a synovectomy and can produce prolonged relief of symptoms. Replacement surgery is reserved for patients with severely damaged joints. The most successful procedures are carried out on hips and knees. Goals of surgery are to relieve pain, correct deformity and provide functional improvement. Rheumatoid arthritis is primarily a medical problem and surgery should be for patients who are under the care of an experienced rheumatologist or physician.
The course of rheumatoid arthritis is variable and difficult to predict. If treated appropriately within the first three to six months of the disease, the outlook is generally very good. A delay in initiating treatment has a major effect on the eventual prognosis. Most people experience persistent but fluctuating disease activity, along with variable degrees of joint deformity.
Early treatment with disease-modifying drugs has improved the outcome of the disease over the last ten years. A small number of patients with rheumatoid arthritis will have a short-lived inflammatory process that leaves no major deformity. Remission of disease activity can occur in the first year, but usually requires medication to achieve. The greatest progression of the disease takes place in the first two to six years and is slower after that.
Those who are likely to have severe disease are older people and those with evidence of more severe disease on X-ray, rheumatoid nodules or high levels of Rheumatoid Factor.
The average life expectancy of people with rheumatoid arthritis is slightly reduced. It has been shown that optimal medical therapy not only improves the quality of life of patients, but that it may restore the life expectancy to normal. The main causes of increased mortality are from infection, gastrointestinal bleeding, malignancy and cardiovascular disease.
The aim of the DMARDs is remission. It is important to realise that the drugs are long-term, as withdrawal will almost inevitably result in flare-up of the disease, usually within three weeks of stopping. Re-establishing disease control may thereafter be more difficult. Drug treatment requires proper monitoring, as the drugs may have potential side effects. DMARDs usually require regular blood testing.
When to see your doctor
Consult your doctor if:
- You are feeling tired, and have a poor appetite, generalised weakness and non-specific joint pains - particularly if you have a family history of rheumatoid arthritis.
- You already know you have rheumatoid arthritis and experience more pain, swelling and limitation of movement.
- You are on an old anti-inflammatory (NSAID) drug for rheumatoid arthritis and experience pain and discomfort in your stomach, black stools or are vomiting blood.
- You are on medication for rheumatoid arthritis but joint swelling, pain or stiffness persists.
Additional important points
- Don’t be scared to ask for a specialist opinion.
- Ask about DMARD drugs to treat the disease process itself.
- Remember the diagnosis is a clinical one, not a laboratory or radiology one.
- The specialist of choice is a rheumatologist, not a surgeon.
- Remission of disease is the goal of treatment - do not be satisfied with less.
Remember that with optimal treatment and good compliance the disease can be kept at bay. This requires early intervention, compliance with treatment and a positive mental attitude.
Reviewed by Dr Dr I C Louw, Rheumatologist/Physician and Dr A Halland, Rheumatologist/Physician, March 2007
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