by Nathan Wei, MD, FACP, FACR
Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.
Click here: Second Opinion Arthritis Treatment Kit
The most common inflammatory form of arthritis is rheumatoid arthritis.
Rheumatoid arthritis is a chronic, systemic, inflammatory disease that primarily affects the joints and surrounding tissues, but can also affect other organ systems.
The cause of rheumatoid arthritis (RA) is unknown. However, infectious, genetic, and hormonal factors may play a role.
The disease can occur at any age, but it begins most often between the ages of 25 and 55. The disease appears to have a bimodal distribution, affecting younger women more than men and older people in a more gender equal distribution. Approximately 1-2% of the total population is affected. The course and the severity of the illness can vary.
The onset of the disease can be either explosive or gradual, with fatigue, morning stiffness (lasting more than one hour), generalized muscle aches, loss of appetite, and weakness. Eventually, joint pain appears, with warmth, swelling, tenderness, and stiffness of the joint after inactivity.
RA is usually symmetric, affecting joints on both sides of the body equally -- wrists, fingers, knees, feet, and ankles are the most commonly affected.
The immune dysfunction preferentially attacks the synovium (the lining of the joint) and causes it to become inflamed. This leads to joint swelling. Later, the cartilage becomes rough and pitted as a result of destructive changes that spread from the synovium. The inflamed synovium acts much like a slow-growing tumor. The underlying bone is also eventually affected. Joint destruction may begin, often within six months to one year after the appearance of the disease.
Deformities result from cartilage destruction, bone erosions, and tendon inflammation and rupture. A life-threatening joint complication can occur when the cervical spine (neck) becomes unstable as a result of RA.
Other features of the disease that do not involve the joints may occur. Rheumatoid nodules are painless, hard, round or oval masses that appear under the skin, usually on pressure points, such as the elbow, back of the scalp, or Achilles tendon. These are present in about 20% of cases and tend to reflect more severe disease.
On occasion, nodules appear in the eye where they sometimes cause inflammation. If they occur in the lungs, inflammation of the lining of the lung (pleurisy) may occur, causing shortness of breath and fluid accumulation in the lung.
Anemia may occur due to failure of the bone marrow to produce enough new red cells to make up for the lost ones. Iron supplements will not usually help this condition because iron use in the body becomes impaired. Other blood abnormalities can also be found, for example, platelet counts that are either too high or too low.
Rheumatoid vasculitis (inflammation of the blood vessels) is a serious complication of RA and can be life-threatening. It can lead to skin ulcerations (and subsequent infections), bleeding stomach ulcers (which can lead to massive hemorrhage), and neuropathies (nerve problems causing pain, numbness or tingling).
Vasculitis may also affect the brain, nerves, and heart causing strokes, sensory neuropathies (numbness and tingling), heart attacks, or heart failure.
Heart complications of RA commonly affect the outer lining of the heart. When inflamed, the condition is referred to as pericarditis. Inflammation of heart muscle, called myocarditis, can also develop. Both of these conditions can lead to congestive heart failure characterized by shortness of breath and fluid accumulation in the lung.
Also, there is strong evidence that RA increases the risk of cardiovascular complications including stroke and heart attack.
Eye complications include inflammation of various parts of the eye. These must be screened for in RA patients.
A rundown of the common symptoms...
• Loss of appetite
• Low-grade fever
• Joint pain, joint stiffness, and joint swelling -- most often symmtric
• Joint pain may include wrist pain, knee pain, elbow pain, finger pain, toe pain, ankle pain, or neck pain
• Limited range of motion
• Morning stiffness lasting more than one hour
• Deformities of hands and feet
• Round, painless nodules under the skin
• Skin redness or inflammation
• Swollen glands
• Eye burning, itching, and discharge
• Numbness or tingling in the hands or feet
SIGNS AND TESTS
• Joint x-rays are usually not helpful. MRI or diagnostic ultrasound is the preferred method for imaging.
• Rheumatoid factor test is positive in about 75% of people with symptoms. Anti-CCP antibodies are more specific for the disease.
• Erythrocyte sedimentation rate is elevated
• CBC may show low hematocrit (anemia) or abnormal platelet counts
• C-reactive protein may be elevated in patients... even those who are negative for rheumatoid factor
• Synovial fluid analysis
RA usually requires longterm treatment, including various medications, physical therapy, education, and possibly surgery to relieve the symptoms of the disease.
Early, aggressive treatment for RA can delay joint destruction. In addition to rest, strengthening exercises, and anti-inflammatory drugs, the current standard of care is to begin aggressive therapy with disease-modifying anti-rheumatic drugs (DMARDs).
Methotrexate is the most commonly used DMARD for rheumatoid arthritis with proven effectiveness.
While non-steroidal-anti-inflammatory drugs are widely used, the side effects associated with frequent use of many of these medications include gastrointestinal bleeding and kidney damage.
Hydroxychloroquine (Plaquenil) and Sulfasalazine (Azulfidine) are also sometimes used as disease-modifying drugs (DMARD).They can be combined with methotrexate. Another DMARD is leflunomide (Arava).
The benefits from these medications may take weeks or months to be apparent. Because they are associated with toxic side effects, frequent monitoring of blood tests while on these medications is imperative.
More recently, though, the trend is to introduce biologic drugs into the mix as soon as possible. These are drugs that target specific disturbances in the immune system. The drugs that are most often used first and are added to methotrexate are inhibitors of an inflammatory protein called tumor necrosis factor (TNF). These medications include etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira), certolizumab (Cimzia), and golimumab (Simponi).
Second generation biologics such as Actemra, Rituxan and Orencia are effective for many patients who don't respond to TNF-inhibitors. Finally third and fourth generation biologic medicines also show great promise.
The use of tissue biomarkers to predict response to medication may allow us to "customize" therapies in the future.
Corticosteroids have been used to reduce inflammation in RA for more than 40 years. However, because of potential long-term side effects, corticosteroid use is usually limited to short courses and low doses where possible. Side effects may include bruising, psychosis, thinning of the bones (osteoporosis), cataracts, weight gain, susceptibility to infections, diabetes, and high blood pressure. A number of medications can be administered with steroids to minimize osteoporosis.
Occasionally, surgery is performed for severely affected joints. The most successful surgeries are those on the knees and hips. Usually, the first surgical treatment is removal of the synovium (synovectomy). Withe use of the newer medicines described above, this type of surgery is required much less often.
A later alternative is total joint replacement with a joint prosthesis. Surgeries can relieve joint pain, correct deformities, and modestly improve joint function. In extreme cases, total knee or hip replacement can mean the difference between being totally dependent on others and having an independent life at home.Even joint replacement surgery is required less often for rheumatoid patients than it once was.
Depending on the medications being taken, regular blood or urine tests should be done to monitor both progress in regards to treatment as well as to discover and attend to negative side effects.
The approach to treating RA that is most in vogue now is the "treat to target" method. This requires a rapid diagnosis and then aggressive treatment with the patient being followed closely to either eliminate disease entirely (remission) or at the very least, to obtain "low disease activity.
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Click here Second Opinion Arthritis Treatment Kit
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