Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic inflammatory disorder that typically affects the small joints in your hands, feet, wrists, elbows, knees, and ankles. It usually affects joints on both sides of the body. RA is an autoimmune disorder; it occurs when your immune system mistakenly attacks your body's own tissues.

RA affects the lining of your joints, causing a painful swelling that can eventually result in bone erosion and joint deformity. RA can sometimes affect other organs of the body such as the skin, eyes, lungs, and blood vessels.

Approximately 1.5 million people in the United States have RA. Nearly three times as many women have the disease as men. Although RA can occur at any age, it usually begins after age 40.

There is no cure for RA, and treatment focuses on controlling symptoms and preventing joint damage. This can be accomplished with lifestyle changes and medicines.

Signs and symptoms of RA include:

• tender, warm, swollen joints
• morning stiffness that may last for hours
• firm bumps of tissue under the skin on your arms (rheumatoid nodules)
• fatigue, fever and weight loss

Along with pain, many people experience fatigue, loss of appetite and a low-grade fever.

Early RA tends to affect your smaller joints first, particularly the joints that attach your fingers to your hands and your toes to your feet. As the disease progresses, symptoms often spread to the wrists, knees, ankles, elbows, hips and shoulders. In most cases, symptoms occur in the same joints on both sides of your body.

RA signs and symptoms may vary in severity and may even come and go. Periods of increased disease activity, called flares, alternate with periods of relative remission — when the swelling and pain fade or disappear. Over time, RA can cause joints to deform and shift out of place.

The cause of RA is not yet fully understood, although doctors do know that an abnormal response of the immune system plays a leading role in the inflammation and joint damage that occurs. No one knows for sure why the immune system begins attacking its own body, but there is scientific evidence that genes, hormones, and environmental factors are involved. Genes likely do not actually cause RA, but they can make you more susceptible to environmental factors — such as infection with certain viruses and bacteria — that may trigger the disease. If you have a family member with RA, you may have an increased chance of developing the disease.

RA can be difficult to diagnose in its early stages because the early signs and symptoms mimic those of many other diseases, including other types of arthritis. There is no single blood test or physical finding to confirm the diagnosis.

A doctor will conduct a physical examination and obtain a personal and family medical history. During the physical exam, your doctor will check your joints for swelling, redness, and warmth. He or she will also check your reflexes and muscle strength.

Blood tests can measure inflammation levels and look for biomarkers such as antibodies (blood proteins) linked with RA. People with RA also tend to have an elevated erythrocyte sedimentation rate (ESR, or sed rate) and/or a high C-reactive protein (CRP) level. Both of these markers indicate the presence of an inflammatory process in the body.

An X-ray, ultrasound, or magnetic resonance imaging scan may be done to look for joint damage, such as erosions, which is a loss of bone within the joint and narrowing of joint space. Your doctor may also recommend imaging tests to help track the progression of RA in your joints over time.

Self-care measures may help improve the symptoms of RA.

Exercise regularly. Gentle exercise can help strengthen the muscles around your joints, and it can help fight fatigue you might feel. Avoid exercising tender, injured, or severely inflamed joints.

Apply heat or cold. Heat can help ease your pain and relax tense, painful muscles. Cold may dull the sensation of pain. Cold also has a numbing effect and decreases muscle spasms.

Relax. Find ways to cope with pain by reducing stress in your life. Techniques such as guided imagery, distraction, and muscle relaxation can all be used to control pain.

Eat a healthy diet. While there is no specific “diet” for RA, researchers have identified certain foods that are rich in antioxidants and can help control and reduce inflammation, such as fish, vegetables, fruits, and olive oil, among other healthy foods. Eliminate or significantly reduce processed and fast foods that fuel inflammation.

Rest when you need to. Rest is important when RA is active and joints feel painful, swollen, or stiff. Rest helps reduce inflammation and fatigue that can come with a flare. Taking breaks throughout the day conserves energy and protects joints.

Have a positive attitude and accept help from a support system. Many studies have demonstrated that resilience, an ability to “bounce back,“ encourages a positive outlook. Having a network of friends, family members and co-workers can help provide emotional support. It can help a patient with RA cope with life changes and pain.

There is no cure for RA. The goals of RA treatment are to:

• stop inflammation (put disease in remission)
• relieve symptoms
• prevent joint and organ damage
• improve physical function and overall well-being
• reduce long-term complications

Medications can reduce inflammation in your joints in order to relieve pain and prevent or slow joint damage, and occupational and physical therapy can teach you how to protect your joints. If your joints are severely damaged by rheumatoid arthritis, surgery may be necessary.

Several medicines are used in the treatment of RA.

• NSAIDs. Nonsteroidal anti-inflammatory drugs (NSAIDs) can relieve pain and reduce inflammation. Over-the-counter NSAIDs include ibuprofen (Advil, Motrin IB) and naproxen sodium (Aleve). Stronger NSAIDs are available by prescription.
• Steroids. Corticosteroid medications, such as prednisone, reduce inflammation and pain and slow joint damage. Steroids are usually used for only a short time.
• Disease-modifying antirheumatic drugs (DMARDs). These drugs can slow the progression of RA and save the joints and other tissues from permanent damage. Common DMARDs include methotrexate (Trexall), leflunomide (Arava), hydroxychloroquine (Plaquenil), and sulfasalazine (Azulfidine).
• Biologic agents. Also known as biologic response modifiers, this newer class of DMARDs includes abatacept (Orencia), adalimumab (Humira), anakinra (Kineret), certolizumab (Cimzia), etanercept (Enbrel), golimumab (Simponi), infliximab (Remicade), rituximab (Rituxan) and tocilizumab (Actemra). Tofacitinib (Xeljanz), a new, synthetic DMARD, is also available in the U.S. These drugs can target parts of the immune system that trigger inflammation that causes joint and tissue damage.

Therapy may teach you ways to protect your joints and improve your symptoms. A physical or occupational therapist can teach you exercises to help keep your joints flexible and suggest new ways to do daily tasks, which will be easier on your joints. Assistive devices can make it easier to avoid stressing your painful joints.

If medications fail to prevent or slow joint damage, you and your doctor may consider surgery to repair damaged joints. Surgery may help restore your ability to use your joint. It can also reduce pain and correct deformities. RA surgery could involve total joint replacement, tendon repair, or joint fusion.