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Rheumatoid Arthritis

Alternative names: Inflammatory Joint Disease, Arthritis

What is rheumatoid arthritis?

Rheumatoid arthritis affects between 0.5 and 1 percent of the U.S. adult population (about 2.1 million people). The condition can develop at any age, but mostly it occurs in people over 40. It is an inflammatory disease that causes pain, swelling, stiffness, and loss of function in the joints. This usually happens on both sides of the body symmetrically – both hands or both knees – and it often feels worse in the mornings. Rheumatoid arthritis is also not limited to joints and can affect other organs.

What are the signs of rheumatoid arthritis?

  • Hot, red, tender joints
  • Stiffness in a joint even when it is not being used
  • Swelling in the joints
  • Deformities in the joints
  • Nodules around the elbows in particular
  • Bunions, foot pain, and hammer toes (in later stages)
  • Fever, anemia (low red blood cell count) and lack of appetite and energy

What causes rheumatoid arthritis?

Rheumatoid arthritis is an autoimmune disease (the body attacking itself). So far, scientists still do not know exactly what causes the immune system to react this way with this particular condition, but recent research points to the following causes:

  • Genetic or inherited factors
  • Environmental factors, such as a virus or bacterial infection (but not one you can catch from someone else)
  • Other factors such as the effect of hormones – women are more likely to develop rheumatoid arthritis than men. Pregnancy may improve the disease, and the disease may flare up after a pregnancy. Breastfeeding may make it worse. Contraceptive use may even alter a person's likelihood of developing rheumatoid arthritis.

How does my doctor tell if I have rheumatoid arthritis?

There is no single test that a doctor can perform to diagnose rheumatoid arthritis. Is it especially difficult to identify in its early stages because symptoms differ so much from person to person. The signs can also appear to be like other types of arthritis. Your providers may take some of the following steps to see if you have the condition:

  • Take a medical history, asking in details about when and how the symptoms began, along with a description of the kinds of sensations the patient feels
  • Do a physical examination of the joints, skin, reflexes, and muscle strength.
  • Arrange for laboratory tests for rheumatoid factor, an antibody that is present eventually in the blood of most (but not all) people with rheumatoid arthritis
  • Test for anemia and other possible indicators
  • Order X-rays to determine the degree of joint destruction, as indicated, often later in the condition's progress

How is rheumatoid arthritis treated?

Most effective treatment programs involve a combination of things tailored to the patient's needs, lifestyle, and health.

Rheumatoid arthritis treatment has four general goals:

  • Relieve pain
  • Reduce inflammation
  • Slow down or stop joint damage
  • Improve the patient's sense of well-being and ability to function

Non-surgical treatments

Exercise: Research shows that exercise is one of the best treatments for rheumatoid arthritis. Exercise can improve mood and outlook, decrease pain, increase flexibility, improve the heart and blood flow, maintain weight, and promote general physical fitness. Exercise is also inexpensive and, if done correctly, has few negative side effects. The amount and form of exercise will depend on which joints are involved, how stable the joints are, and whether a joint replacement has already been done.

Rest and joint care: Treatment plans include regularly scheduled rest. Patients must learn to recognize the body's signals, and know when to stop or slow down, which prevents pain caused by overexertion. Some patients find that relaxation techniques, stress reduction, and biofeedback help. Some use canes, trekking poles, or splints to protect joints and take pressure off them. Splints or braces provide extra support for weakened joints. They also keep the joint in proper position during sleep or activity. Splints should be used only for limited periods because joints and muscles need to be exercised to prevent stiffness and weakness. An occupational therapist or a doctor can help the patient get a properly fitting splint.

Non-drug pain relief: People with rheumatoid arthritis may find ways to relieve pain without drugs or medicines. Warm towels, hot packs, or a warm bath or shower to apply moist heat to the joint can relieve pain and stiffness. In some cases, cold packs (a bag of ice or frozen vegetables wrapped in a towel) can relieve pain or numb the sore area. (Check with a doctor or physical therapist to find out if heat or cold is the best treatment.) Water therapy in a heated pool or whirlpool also may relieve pain and stiffness. For rheumatoid arthritis in the knee, patients may wear insoles or cushioned shoes to redistribute weight and reduce joint stress.

Weight control: Rheumatoid arthritis patients who are overweight or obese need to lose weight. Weight loss can reduce stress on weight-bearing joints and limit further injury. A dietitian can help patients develop healthy eating habits. A healthy diet and regular exercise help reduce weight.

Climate and stress reduction: Some patients notice that their arthritis gets worse when there is a sudden change in the weather; however, moving to a place with a more even climate does not usually make a long-term difference in a person's rheumatoid arthritis. In addition, work and family stresses can put extra strain on the emotional well-being of patients dealing with the pain and fear that can accompany this condition. Lifestyle changes should be discussed with your doctor.

Medicines: Doctors usually prescribe medicines to eliminate or reduce inflammation and/or pain, and to improve functioning. A number of factors are considered when choosing medicines for their patients with rheumatoid arthritis. Two important factors are how bad the pain is and the possible side effects of the medicine. Patients should always consult with their doctor about choice of medication. Medicines must be used carefully and patients should tell their doctors about any changes that occur.

The following types of medicines are commonly used in treating rheumatiod arthritis, but a complete list of medications should be obtained from your provider. Many medications have known side effects, which should be discussed when the prescription is issued:

  • Disease-modifying antirheumatic drugs (DMARDs) relieve painful, swollen joints and slow joint damage. They take a few weeks or months to have an effect, and may produce significant improvements for many patients. Exactly how they work is still unknown.
  • Aspirin, used to reduce pain, swelling, and inflammation, allows patients to move more easily and carry out normal activities. It is generally part of early and ongoing therapy.
  • Acetaminophen, a pain reliever such as Tylenol*, which does not reduce inflammation does not irritate the stomach and is less likely than nonsteroidal anti-inflammatory drugs (NSAIDs) to cause long-term side effects.
  • NSAIDs (nonsteroidal anti-inflammatory drugs), some over-the-counter medications such as aspirin, Advil*, Motrin IB*, Aleve*, ketoprofen, and other prescription medicines
  • COX-2 inhibitors, new NSAIDs such as celecoxi and Celebrex* reduce inflammation
  • Other medications: topical pain-relieving creams, rubs, and sprays; mild narcotic painkillers (may be addictive and are not commonly used); corticosteroids (short-term use), powerful anti-inflammatory hormones made naturally in the body or manmade may be injected into the affected joints to temporarily relieve pain – oral corticosteroids should not be used to treat rheumatoid arthritis; hyaluronic acid, a medicine for joint injection and a normal component of the knee.
  • Biologic response modifiers selectively block parts of the immune system called cytokines. Cytokines play a role in inflammation. Long-term efficacy and safety are uncertain.

* Brand names included here are provided as examples only. Their inclusion does not mean they are endorsed by Dartmouth-Hitchcock. Also, if a certain brand name is not mentioned, this does not mean or imply that the product is unsatisfactory

Most medicines used to treat rheumatoid arthritis have side effects, so it is important for people to learn about the medicines they take. Even nonprescription drugs should be checked. Several groups of patients are at high risk for side effects from NSAIDs, such as people with a history of peptic ulcers or digestive tract bleeding, people taking oral corticosteroids or anticoagulants (blood thinners), smokers, and people who consume alcohol. Some patients may be able to help reduce side effects by taking some medicines with food. Others should avoid stomach irritants such as alcohol, tobacco, and caffeine. Some patients try to protect their stomachs by taking other medicines that coat the stomach or block stomach acids. These measures help, but they are not always completely effective.

Surgical treatments

Several kinds of surgery are available to patients with severe joint damage; however, the decision to use surgery depends on several things, including the risks, the current state of the joint, the cost of the procedure. Types of surgery include:

Joint replacement: This is the most frequently performed surgery for rheumatoid arthritis, and it is done primarily to relieve pain and improve or preserve joint function. Artificial joints are not always permanent and may eventually have to be replaced. This may be an important consideration for young people. Examples include Hip Replacements and Shoulder Joint Replacements.

Tendon reconstruction: Rheumatoid arthritis can damage and even rupture tendons, the tissues that attach muscle to bone. This surgery, which is used most frequently on the hands, reconstructs the damaged tendon by attaching an intact tendon to it. This procedure can help to restore hand function, especially if the tendon is completely ruptured.

Synovectomy: In this surgery, the doctor actually removes the inflamed synovial tissue, which cushions the bone within the joint. Synovectomy by itself is seldom performed now because not all of the tissue can be removed, and it eventually grows back. Synovectomy is done as part of reconstructive surgery, especially tendon reconstruction.

Nontraditional approaches

As with any therapy, patients should discuss the benefits and drawbacks with their doctors before beginning an alternative or new type of therapy. Patients with rheumatoid arthritis have been known to try:

  • Acupuncture
  • Herbal treatments
  • Special diets and/or vitamin supplements
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