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Rheumatoid Arthritis

(RA; Arthritis, Rheumatoid)

Definition

Rheumatoid arthritis (RA) is an autoimmune disease. It causes pain, swelling, stiffness, and loss of function in the joints. RA usually affects the same joint on both sides of the body. It occurs mostly in the:
  • Fingers
  • Wrists
  • Elbows
  • Shoulders
  • Jaw
  • Hips
  • Knees
  • Toes
Rheumatoid Arthritis
rheumatoid arthritis
© 2011 Nucleus Medical Media, Inc.

Causes

RA is caused by a combination of genetic and environmental factors that trigger an abnormal immune response. Possible causes:
  • Genetic factors—Certain genes that play a role in the immune system are associated with RA development.
  • Defects in the immune system can cause ongoing inflammation.
  • Environmental factors—Certain infectious agents, such as some viruses or bacteria, may increase susceptibility to RA.
  • Other factors—Some evidence suggests that hormonal factors may promote RA development in combination with genetic factors and environmental exposure.

Risk Factors

These factors increase your chance of developing RA. Tell your doctor if you have any of these risk factors:
  • Family members with RA
  • Sex: female
  • Ethnic background: Pima Indians
  • Heavy or long-term smoking

Symptoms

When RA begins, symptoms may include:
  • Joint pain and stiffness that is:
    • Symmetrical
    • Most prominent in the morning
    • Lasts for at least half an hour
  • Red, warm, or swollen joints
  • Joint deformity
  • Mild fever, tiredness
  • Loss of appetite
  • Small lumps or nodules under the skin
As RA progresses, it may cause complications with the:
  • Heart
  • Lungs
  • Eyes
  • Skin
  • Liver
  • Kidneys
  • Blood
  • Nervous system
  • Blood vessels
It is also linked to early cardiovascular disease and death.

Diagnosis

The doctor will ask about your symptoms and medical history. You will also be examined. To be diagnosed with RA, you must have at least one swollen or tender joint or a history of a swollen joint. How many joints, and which joints are involved, will help aid your doctor in the diagnosis. The doctor will also rule out other conditions that may have similar symptoms, like lupus or gout.
To aid in the diagnosis, your doctor will order tests, such as:
  • Blood tests to determine if you have an autoimmune disease:
    • Rheumatoid factor (RF)
    • Anti-citrullinated protein antibody
    • Erythrocyte sedimentation rate (ESR)
    • C-reactive protein (CRP)
  • Imaging tests, such as x-rays

Treatment

There is no cure for RA. The goals of treatment are to:
  • Relieve pain
  • Reduce inflammation
  • Slow down joint damage
  • Improve functional ability

Medications

There are a variety of medicines to treat the pain and inflammation of RA. In some cases, medicines may be used in combination.
  • Disease-modifying anti-rheumatic drugs (DMARDS)—to slow the course of the disease; used early in the course of the disease to prevent long-term damage:
    • Methotrexate (such as, Rheumatrex)
    • Hydroxychloroquine (such as, Plaquenil)
    • Sulfasalazine (such as, Azulfidine)
    • Leflunomide (such as, Arava)
    • Cyclosporine (such as, Neoral)
    • Penicillamine (such as, Cuprimine)
    • Gold (such as, Ridaura)
    • Minocycline (such as, Minocin)
  • Immunosuppressive drugs (only used when other DMARDS are ineffective):
    • Azathioprine (such as, Imuran)
    • Cyclophosphamide (such as, Cytoxan)—rarely used
    • Chlorambucil (such as, Leukeran)—rarely used
  • Over-the-counter medicines:
    • Acetaminophen (such as, Tylenol)
    • Nonsteroidal anti-inflammatory drugs (NSAIDs) including ibuprofen and naproxen
  • Biologic response modifiers—drugs that interfere with the autoimmune response; includes tumor necrosis factor (TNF)-inhibitors, such as:
    • Etanercept (such as, Enbrel)
    • Infliximab (such as, Remicade)
    • Adalimumab (such as, Humira)
    • Golimumab (such as, Simponi)
    • Certolizumab (such as, Cimzia)

Steroids

Low-dose corticosteroids (such as, prednisone) are often used first. They may be tapered when other drugs start working. Avoid long-term steroid use. Corticosteroid injections to inflamed joints may also be used.

Rest and Exercise

Rest reduces active joint inflammation and pain and fights fatigue. Exercise is important for maintaining muscle strength and flexibility. It also preserves joint mobility.

Joint Care

Splints applied to painful joints may reduce pain and swelling. Devices that help with daily activities can also reduce stress on joints. Devices include:
  • Zipper extenders
  • Long-handled shoehorns
  • Specially designed kitchen tools

Stress Reduction

Stress reduction can ease the difficulties of living with a chronic, painful disease. Participating in an exercise program or joining a support group are two strategies you can use to reduce stress. Cognitive behavioral therapy, a form of talk therapy, and meditation may also offer benefits in reducing your pain and improving your ability to cope with RA.

Surgery

Joint replacement and tendon reconstruction help relieve severe joint damage.

Lifestyle Measures

These may relieve stiffness and weakness and reduce inflammation:
  • Maintain a balance between rest and exercise.
  • Attempt mild strength training.
  • Participate in aerobic exercise (such as, walking, swimming, dancing).
  • Avoid heavy-impact exercise.
  • If you smoke, quit.
  • Control weight.
  • Participate in a physical therapy program.

Prevention

There are no guidelines for preventing RA.

RESOURCES

American College of Rheumatology http://www.rheumatology.org

Arthritis Foundation http://www.arthritis.org

CANADIAN RESOURCES

Canadian Orthopaedic Association http://www.coa-aco.org

Canadian Rheumatology Association http://rheum.ca

References

Rheumatoid arthritis (RA). EBSCO DynaMed website. Available at: https://dynamed.ebscohost.com/about/about-us. Updated September 3, 2010. Accessed September 10, 2010.

Rheumatoid arthritis. National Institute of Arthritis and Musculoskeletal and Skin Disorders website. Available at: http://www.niams.nih.gov/Health%5FInfo/Rheumatic%5FDisease/default.asp. Published January 1998. Updated May 2004. Accessed June 18, 2008.

Tanaka E, Saito A, et al. Impact of shoulder, elbow, and knee joint involvement on assessment of rheumatoid arthritis using the American College of Rheumatology Core Data Set. Arthritis Rheum. 2005;53:864-871.

Verstappen SM, Bijlsma JW, et al. Overview of work disability in rheumatoid arthritis patients as observed in cross-sectional and longitudinal surveys. Arthritis Rheum. 2004;51:488-497.

4/16/2009 DynaMed's Systematic Literature Surveillance http://www.ebscohost.com/dynamed/what.php : Zautra AJ, Davis MC, Reich JW, et al. Comparison of cognitive behavioral and mindfulness meditation interventions on adaptation to rheumatoid arthritis for patients with and without history of recurrent depression. J Consult Clin Psychol. 2008;76:408-421.

1/4/2011 DynaMed Systematic Literature Surveillance https://dynamed.ebscohost.com/about/about-us: Tumor necrosis factor (TNF) blockers (marketed as Remicade, Enbrel, Humira, Cimzia, and Simponi). US Food and Drug Administration website. Available at: http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm175843.htm. Updated August 31, 2009. Accessed November 4, 2009.

1/4/2011 DynaMed's Systematic Literature Surveillance https://dynamed.ebscohost.com/about/about-us: Anis A, Zhang W, Emery P, et al. The effect of etanercept on work productivity in patients with early active rheumatoid arthritis: results from the COMET study. Rheumatology (Oxford). 2009;48:1283-1289.

1/4/2011 DynaMed's Systematic Literature Surveillance https://dynamed.ebscohost.com/about/about-us: Aletaha D, Neogi T, Silman AJ, Funovits J, et al. 2010 rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Ann Rheum Dis. 2010;69(9):1580-1588.

Revision Information

This content is reviewed regularly and is updated when new and relevant evidence is made available. This information is neither intended nor implied to be a substitute for professional medical advice. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with questions regarding a medical condition.

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