Rheumatoid Arthritis

About 2.1 million Americans have rheumatoid arthritis. Rheumatoid arthritis is one of more than 100 forms of arthritis. It is a chronic (ongoing) condition in which the synovium (the tissue that lines and lubricates the joints) becomes inflamed. Large and small joints, as well as both sides of the body, are usually affected. Over time, the joints become deformed and knotted-looking if the disease is not treated properly. However, modern treatment and early recognition of the disease has led to fewer deformities and a much better outlook.

Symptoms and Signs

The symptoms of rheumatoid arthritis tend to come and go. Periods of severe symptoms (flare-ups) will be followed by periods when the symptoms of rheumatoid arthritis are nearly gone. While rheumatoid arthritis can begin suddenly, it usually appears gradually and affects the smaller joints of the body, such as the fingers and toes. The main symptom is pain, and the major sign of the disease is tenderness in nearly all inflamed joints. Eventually, the synovial lining inside the joint becomes thicker.

If a joint on one side of the body is affected, usually the same joint on the other side of the body will also be affected. For example, if the left wrist is inflamed, the right one usually is, too. It usually affects the hands, feet, wrists, elbows and ankles, but it can occur in any joint, even the neck.

Other symptoms or signs include:

  • A low-grade fever
  • Changes in appearance of the joints
  • Difficulty sleeping because of the pain
  • Feeling tired, fatigued or unwell in the early afternoon
  • Inflammation of the tear glands, salivary glands, linings of the heart and lung, lungs and (in rare cases) the blood vessels. These are more rare today with modern treatment and early recognition of the disease.
  • Small lumps (rheumatoid nodules) that form under the skin at pressure points, such as the elbows, hands, feet and Achilles tendons. They may also occur in other places, such as the back of the scalp or in the lungs. These nodules can range from being as small as a pea to as large as a walnut. They usually do not hurt.
  • Stiffness that lasts 45 minutes or more when getting up in the morning or after a period of not moving
Causes and Risk Factors

Unlike osteoarthritis, which results from wear and tear on the joints, rheumatoid arthritis is an inflammatory condition. The cause of rheumatoid arthritis is not known. Some researchers suspect that rheumatoid arthritis is triggered by an infection in people who have inherited the tendency to develop rheumatoid arthritis. Other environmental factors are currently being examined as triggers, such as prior exposure to immunizations, medications, etc. Other researchers believe that hormones may play a role in the development or severity of rheumatoid arthritis. We already know that smoking is a risk factor for rheumatoid arthritis susceptibility as well as severity. Women are two to three times more likely than men to develop rheumatoid arthritis. It can develop at any age, but it most often occurs in people between the ages of 25 and 50.

The inflammation and damage to the joints may be a result of the body's immune attacking the joints as if they were foreign bodies. White blood cells, which normally attack bacteria or viruses, move from the bloodstream into the synovium, making it swell and become tender. This inflammation causes proteins to be released that over months and years make the synovium grow thicker. These proteins also damage cartilage, bone, tendons and ligaments. In time, if treatment is not instituted promptly, the joint loses its shape and the bones no longer line up correctly.

Diagnosis

To diagnose rheumatoid arthritis, a doctor will perform a physical examination and discuss the symptoms. If arthritis of any kind is suspected, the patient is referred to a rheumatologist, a specialist who is trained to recognize and treat rheumatoid arthritis, as well as other kinds of arthritis. There are a number of forms of arthritis, and each must be considered and ruled out before a diagnosis can be made. Additionally, conditions like lupus, sarcoidosis, amyloidosis, ankylosing spondylitis and Whipple's disease can mimic rheumatoid arthritis. The doctor may order the following tests:

  • Blood tests. These may show a higher than normal level of antibodies called rheumatoid factors. (Higher levels of these factors are also found in a number of other chronic conditions, and a positive test does not necessarily mean rheumatoid arthritis.)
  • Samples of synovial fluid.
  • X-rays. During the first months of the disease, only the swelling of the soft tissues around the joint can be seen. As the disease condition progresses, there may be a narrowing of the space in which the joints move and damage to the ends of the bones.
  • Magnetic resonance imaging (MRI). This test may be used early in the course of the disease to help make a diagnosis and separate the condition (rheumatoid arthritis) from other possible problems that affect the bones and joints.
Treatment

During the first year after a diagnosis, three out of four people with rheumatoid arthritis will require a more aggressive approach with drugs that can effectively eliminate pain, reduce functional disability and prevent damage to the joints. Rheumatologists typically use combinations of drugs, even including new agents that have been developed through research into the molecular mechanisms that cause joint inflammation.

Some patients (a minority) will be managed effectively with anti-inflammatory drugs only or local injections of cortisone into the joints. A determination of the risk for disease progression is important for your rheumatologist to make because this assessment will guide therapeutic decisions. In addition to management of the disease with medications, a number of important maneuvers and adjunctive approaches can be employed, including:

If medical approaches do not control the symptoms, surgery may be needed. Available surgical procedures include:
  • Arthroscopic synovectomy
  • Arthroplasty, in which parts of the joint are replaced with artificial parts. This may be done if there is joint damage that limits the movement of the joint
  • Total joint replacement. This is typically done with the hip and knee
  • Fusion of joints, so that the damaged parts are not moving against each other
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