Rheumatoid Arthritis
Introduction:
Rheumatoid arthritis (RA) is a chronic, systemic inflammatory disorder that may affect many tissues and organs, but principally attacks synovial joints. The process produces an inflammatory response of the synovium (synovitis) secondary to hyperplasia of synovial cells, excess synovial fluid, and the development of pannus in the synovium. The pathology of the disease process often leads to the destruction of articular cartilage and ankylosis of the joints. Rheumatoid arthritis can also produce diffuse inflammation in the lungs, pericardium, pleura, and sclera, and also nodular lesions, most common in subcutaneous tissue. Although the cause of rheumatoid arthritis is unknown, autoimmunity plays a pivotal role in both its chronicity and progression, and RA is considered a systemic autoimmune disease.
About 1% of the world’s population is afflicted by rheumatoid arthritis, women three times more often than men. Onset is most frequent between the ages of 40 and 50, but people of any age can be affected.
The cause of RA is unknown. It is considered an autoimmune disease. The body’s immune system normally fights off foreign substances, like viruses. But in an autoimmune disease, the immune system confuses healthy tissue for foreign substances. As a result, the body attacks 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 disease often begins slowly, with symptoms that are seen in many other illnesses:
A specific blood test is available for diagnosing RA and distinguishing it from other types of arthritis. It is called the anti-CCP antibody test. Other tests that may be done include:
RA usually requires lifelong treatment, including medications, physical therapy, exercise, education, and possibly surgery. Early, aggressive treatment for RA can delay joint destruction.
MEDICATIONS
Disease modifying antirheumatic drugs (DMARDs): These drugs are the current standard of care for RA, in addition to rest, strengthening exercises, and anti-inflammatory drugs.
Corticosteroids: These medications work very well to reduce joint swelling and inflammation. Because of long-term side effects, corticosteroids should be taken only for a short time and in low doses when possible.
BIOLOGIC AGENTS:
Biologic 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:
Occasionally, surgery is needed to correct severely affected joints. Surgeries can relieve joint pain and deformities.
The first surgical treatment may be a synovectomy, which is the removal of the joint lining (synovium).
At some point, total joint replacement is needed. In extreme cases, total knee, hip replacement, ankle replacement, shoulder replacement, and others may be done. These surgeries can mean the difference between being totally dependent on others and having an independent life at home.
PHYSICAL THERAPY
Range-of-motion exercises and exercise programs 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.
Sometimes therapists will use special machines to apply deep heat or electrical stimulation to reduce pain and improve joint mobility.
Occupational therapists can create 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.
Rheumatoid arthritis is not only a disease of joint destruction. It can involve almost all organs.
Problems that may occur include:
Rheumatoid arthritis (RA) is a chronic, systemic inflammatory disorder that may affect many tissues and organs, but principally attacks synovial joints. The process produces an inflammatory response of the synovium (synovitis) secondary to hyperplasia of synovial cells, excess synovial fluid, and the development of pannus in the synovium. The pathology of the disease process often leads to the destruction of articular cartilage and ankylosis of the joints. Rheumatoid arthritis can also produce diffuse inflammation in the lungs, pericardium, pleura, and sclera, and also nodular lesions, most common in subcutaneous tissue. Although the cause of rheumatoid arthritis is unknown, autoimmunity plays a pivotal role in both its chronicity and progression, and RA is considered a systemic autoimmune disease.
About 1% of the world’s population is afflicted by rheumatoid arthritis, women three times more often than men. Onset is most frequent between the ages of 40 and 50, but people of any age can be affected.
Causes, incidence, and risk factors
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.
Symptoms
- Fatigue
- Loss of appetite
- Low fever
- Swollen glands
- Weakness
- Morning stiffness, which lasts more than 1 hour, is common. Joints can even become warm, tender, and stiff when not used for as little as an hour.
- Joint pain is often felt on both sides of the body.
- The fingers (but not the fingertips), wrists, elbows, shoulders, hips, knees, ankles, toes, jaw, and neck may be affected.
- The joints are often swollen and feel warm and boggy (or spongy) to the touch.
- Over time, joints lose their range of motion and may become deformed.
- Usually there is deviation of hands towards ULNA(Ulnar Deviation of hand)
- Chest pain when taking a breath (pleurisy)
- 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
Signs and tests
- Complete blood count(Leucocytosis)
- C-reactive protein
- Erythrocyte sedimentation rate Raised
- Joint ultrasound or MRI
- Joint x-rays
- Rheumatoid factor test (positive in about 75% of people with symptoms)
- Synovial fluid analysis
- Spindle shape fingers
- Clubbing of nails
- Subcutaneous nodules
- Muscle Wasting and Contracture
- Anemia
Treatment
MEDICATIONS
Disease modifying antirheumatic drugs (DMARDs): These drugs are the current standard of care for RA, in addition to rest, strengthening exercises, and anti-inflammatory drugs.
- Methotrexate (Rheumatrex) is the most commonly used DMARD for rheumatoid arthritis. Leflunomide (Arava) may be substituted for methotrexate.
- These drugs may have serious side effects, so you will need frequent blood tests when taking them.
- Although NSAIDs work well, long-term use can cause stomach problems, such as ulcers and bleeding, and possible heart problems.
- Celecoxib (Celebrex) is another anti-inflammatory drug, but it is labeled with strong warnings about heart disease and stroke. Talk to your doctor about whether COX-2 inhibitors are right for you.
- Aspirin 4-6 gram/day is enough.
- Naproxen Sodium 500mg twice daily is best drug to reduce inflamation and pain
- Indomethacin 1 cap tid.
Corticosteroids: These medications work very well to reduce joint swelling and inflammation. Because of long-term side effects, corticosteroids should be taken only for a short time and in low doses when possible.
BIOLOGIC AGENTS:
Biologic 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)
- Infections from bacteria, viruses, and fungi
- Leukemia
- Possibly psoriasis
Occasionally, surgery is needed to correct severely affected joints. Surgeries can relieve joint pain and deformities.
The first surgical treatment may be a synovectomy, which is the removal of the joint lining (synovium).
At some point, total joint replacement is needed. In extreme cases, total knee, hip replacement, ankle replacement, shoulder replacement, and others may be done. These surgeries can mean the difference between being totally dependent on others and having an independent life at home.
PHYSICAL THERAPY
Range-of-motion exercises and exercise programs 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.
Sometimes therapists will use special machines to apply deep heat or electrical stimulation to reduce pain and improve joint mobility.
Occupational therapists can create 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.
Complications
Problems that may occur include:
- Anemia due to failure of the bone marrow to produce enough new red blood cells
- Damage to the lung tissue (rheumatoid lung)
- Injury to the spinal cord when the cervical spine (neck bones) becomes unstable as a result of RA
- Rheumatoid vasculitis (inflammation of the blood vessels), which can lead to skin ulcers 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.
- Swelling and inflammation of the outer lining of the heart (pericarditis) and of the heart muscle (myocarditis). Both of these conditions can lead to congestive heart failure.
