Rheumatoid Arthritis

Rheumatoid arthritis is the most common type of chronic arthritis caused by the immune system – affecting 1.3 million Americans. Symptoms and their degree of impact can vary greatly, and the earlier the disease is diagnosed and treatment begins the better. Fortunately, there have been exciting advancements in the treatment of the disease and slowing down the progression of joint damage.

What are the symptoms of rheumatoid arthritis?

Common signs of rheumatoid arthritis include:

• pain, stiffness, swelling, and decreased range of motion and function in the joints
• more often, smaller joints of the feet and hands are affected
• pain and stiffness that can last throughout the day but is worse in the morning, lasting one to two hours (this, in particular, establishes an important pattern for rheumatologists as this is uncommon in other arthritic diseases)
• decreased energy
• slight fever
• appetite loss
• development of hard bumps, called rheumatoid nodules, that grow beneath the skin near the joints

What are the risk factors for rheumatoid arthritis?

Rheumatoid arthritis is a very common form of arthritis, most often affecting:

• adults over age 40, although the disease can develop at any age
• women; roughly 75 percent of rheumatoid arthritis patients are female
• genetics (family history)
• smoking    

How is rheumatoid arthritis diagnosed?

Rheumatoid arthritis is an autoimmune disease that develops when certain cells of the immune system are not working properly and begin to attack healthy joints. The disease is difficult to diagnose as it can begin with easy-to-miss symptoms – such as subtle aching and stiffness in the morning. Further complicating the diagnosis, many other diseases – particularly in the beginning – can have the same symptoms.

Because diagnosis of rheumatoid arthritis can be difficult, it is important to have a complete evaluation by a rheumatologist who has the special expertise in complex bone and joint disorders.  Along with warmth, swelling, and pain in the joints, certain blood tests can help in establishing the diagnosis.

Signs of rheumatoid arthritis include:

• anemia (low blood count)
• detection of rheumatoid factor which is an antibody found in 80 percent of patients with the disease
• antibodies to cyclic citrullinated peptides
• inflammation in the joints caused by an elevated sedimentation rate in the blood

Also, x-rays can be used to help diagnose rheumatoid arthritis, but abnormalities might not show up in the first three to six months of the disease. In these early stages of rheumatoid arthritis, there is not one test that can confirm a diagnosis. Generally, the diagnosis comes after evaluating the symptoms from a physical exam, lab tests, and x-ray.

In early disease and in cases which there may be a question of diagnosis, magnetic resonance imaging (MRI) and ultrasound may be helpful in demonstrating inflammation and damage in the joints.

The cause of the disease is not known. However, we do know that a key site of inflammation in rheumatoid arthritis is the lining layer of the joints, a tissue known as synovium. In RA, the synovium stops nourishing and protecting the joint, and instead starts to produce harmful chemicals that injure the bone and cartilage, as well as invading directly into these vital structures. This process appears to be driven by the immune system. Researchers at BWH and elsewhere are helping to understand the role of genes, environmental triggers such as cigarette smoke, and the functions of the different synovial cells in the development of this destructive disease.

How is rheumatoid arthritis treated?

While there is no cure for the disease, newer therapies have been developed for rheumatoid arthritis that block the body’s signals to attack its own immune system – a causing symptoms and joint damage. An important goal of the treatment therapy is to help slow down or stop damage to the joints, and this is why early intervention and aggressive treatment are necessary.

The most common therapies are disease-modifying anti-rheumatic (DMARD) medications including methotrexate or the anti-malarial drug hydroxychloroquine, often prescribed in conjunction with nonsteroidal drugs like advil – or occasionally with low-dose corticosteroids, such as prednisone. Much improved over the past 25 years, these treatments provide most patients with dramatic symptom relief, enabling them to function near normal or normally.

Biologic response modifiers, also called biologic agents, are used in patients in whom drugs like methotrexate are not totally effective. These therapies target specific parts of the immune system that lead to inflammation and joint damage.

One therapy does not work for all rheumatoid arthritis patients and, over the course of their lifetime, therapies often need to be adjusted. In addition, coordinated care between all of the patient’s physicians along with physical therapy and occupational therapy are important components of proper rheumatoid arthritis care.