Rheumatoid Arthritis

What is rheumatoid arthritis?

Rheumatoid arthritis is a chronic inflammatory condition. It affects about one in every 100 individuals. The condition can affect many different tissues throughout the body, but usually the joints are most severely affected. The specific causes of rheumatoid arthritis are unknown.

The symptoms of rheumatoid arthritis develop gradually and it is not always possible to know when it first developed. The onset, severity, course and specific symptoms of this condition can vary greatly from person to person. Some patients may have symptoms from time to time, while others have it continuously.

Symptoms of rheumatoid arthritis

The main symptoms of rheumatoid arthritis are joint stiffness, which typically presents as morning stiffness for about 45 minutes after you get out of bed, pain, swelling and tenderness in inflamed joints. When the lining of the joint becomes inflamed, it gives off more fluid and the joint will also become swollen.

Other symptoms include:

• hand and feet deformities;
• fatigue;
• loss of appetite;
• limited range of motion;
• low-grade fever;
• numbness or tingling;
• round, painless nodules under skin (usually a sign of more severe disease);
• skin redness or inflammation; and
• swollen glands.

Treatment options available

Treatment plays a key role in controlling inflammation and minimising the joint damage of rheumatoid arthritis. Treatment usually includes a combination of drug and non-drug therapies.

The treatment of rheumatoid arthritis must be tailored to the particular case and is determined by the severity of the condition, the effectiveness of specific therapies and the occurrence of any side effects. Treatment choices may vary for persons with rheumatoid arthritis who have other conditions, especially those of the liver or kidneys. It is important to work with a healthcare provider to create an effective and acceptable plan for treating rheumatoid arthritis.

The aim of treatment is to control a patient's signs and symptoms, and to maintain his/her physical function and quality of life.

Joint damage caused by rheumatoid arthritis generally occurs within the first two years of diagnosis, and it is difficult to predict which individuals will develop long-term complications. Therefore, the initial treatment of rheumatoid arthritis aims to eliminate or minimise inflammation. However, the risk of side effects from treatment must be weighed up against the benefits.

Treatments that can potentially stop joint damage are generally recommended for all patients with rheumatoid arthritis, with the exception of those in whom the condition is very mild. Long-term medical care with regularly scheduled visits is essential for the successful treatment of rheumatoid arthritis.

Alternate treatments

Non-pharmacologic therapies

This includes treatments other than medication and are the foundation of treatment for all people with rheumatoid arthritis. There is a wide variety of non-pharmacologic therapies available.

Education and counselling

This may help the patient better understand the nature of rheumatoid arthritis and cope with the challenges of this condition. People with rheumatoid arthritis and their healthcare providers can work together to formulate a long-term treatment plan, define reasonable expectations, and evaluate both standard and alternative treatment options.

Rest

Fatigue is a common symptom of rheumatoid arthritis. Resting inflamed joints by taking naps often helps restore energy. Rest should be alternated with exercise.

Exercise

Pain and stiffness often prompt people with rheumatoid arthritis to become inactive. Unfortunately, inactivity can lead to a loss of joint motion, contractions and a loss of muscle strength. Weakness, in turn, decreases joint stability and further increases fatigue. Regular exercise can help prevent and reverse these effects. Several different kinds of exercise can be beneficial, including a range of motion exercises to preserve and restore joint motion, exercises to increase strength, and exercises to increase endurance (walking, swimming, and cycling). One study suggests that, in the short term, regular aerobic exercise improves muscle function, joint stability, aerobic capacity, physical function and pain control without worsening arthritis. Additional studies are needed to determine if the benefits persist in the long term. Another study suggests that aerobic weight-bearing exercise helps prevent the bone loss associated with steroid treatment and does not worsen rheumatoid arthritis.

Exercise programmes for people with rheumatoid arthritis should be designed by a physiotherapist and tailored to the severity of the condition, a person's body build and their former activity level.

Physiotherapy

This can relieve pain, reduce inflammation, and help preserve joint structure and function for patients with rheumatoid arthritis. Specific types of physiotherapy are used to address specific effects of rheumatoid arthritis:

• The application of heat or cold can relieve pain or stiffness.
• Ultrasound treatment may reduce inflammation of the sheaths surrounding tendons (tenosynovitis).
• Passive and active exercises can improve and maintain range of motion of the joints.
• Rest and rest splinting can reduce joint pain and improve joint function.
• Finger splinting can prevent deformities and improve hand function.
• Relaxation techniques can relieve secondary muscle spasm.
• Physiotherapy may also include a consultation with a podiatrist who can make foot orthoses (devices that ensure correct positioning of the foot) and supportive footwear.

Nutrition and dietary therapy

People with active rheumatoid arthritis may experience a loss of appetite and consequently have a poor dietary intake. Dietary therapy ensures that you eat adequate amounts of calories and nutrients. However, weight loss may be recommended for obese patients to reduce the stress on inflamed joints. High blood cholesterol in patients with rheumatoid arthritis is one risk factor for coronary disease that can respond to changes in diet. A dietician or your doctor can recommend specific foods to eat or avoid trying to achieve a desirable cholesterol level. There is no proven diet that can cure rheumatoid arthritis. Claims that food supplements can cure rheumatoid arthritis are unsubstantiated.

Measures to reduce bone loss

Bone loss in rheumatoid arthritis is likely with an increasing level of disability and a decreasing level of weight-bearing activity. The use of prednisone or other corticosteroid (steroid) drugs further accelerates bone loss, especially in postmenopausal women.

Several measures can minimise the bone loss associated with steroid therapy: Use of the lowest possible effective doses of steroids and limiting steroid therapy to less than six months, whenever possible, can minimise bone loss.

Bone loss can be countered by taking adequate amounts of calcium (1 000 to 1 500mg per day) and vitamin D in the diet or by taking supplements. Medications called biphosphonates can reduce bone loss.

Drug therapy

Drug therapy is the cornerstone of treatment for active rheumatoid arthritis. Drug therapy is appropriate for all patients, with the exception of some patients whose condition is inactive. The goals of drug therapy are for the condition to become inactive and to prevent further damage of the joints and loss of function, without causing permanent or unacceptable side effects. The type and intensity of drug therapy depends upon the severity of rheumatoid arthritis, presence of factors associated with a better or worse prognosis, effectiveness of previous treatments and side effects. In most cases, the level of drug therapy is increased until inflammation is suppressed or drug side effects become unacceptable.

All patients with rheumatoid arthritis who use medication need regular medical care and laboratory tests to check for the presence of side effects. The type of medication used determines the frequency and type of testing. If side effects occur, they can often be minimised or eliminated by reducing the dose or switching to a different drug.

The main classes of drugs used to treat rheumatoid arthritis are:

• Simple analgesics: These relieve pain, but they have no effect on inflammation. Patients with a badly damaged joint, who cannot undergo joint replacement surgery, may benefit from long-term stronger analgesics under the strict supervision of a doctor.

• Non-steroidal anti-inflammatory drugs (NSAIDs): NSAIDs relieve pain and reduce minor inflammation, but they are not strong enough to alter the long-term damaging effects of rheumatoid arthritis on the joints. Furthermore, NSAIDs must be taken continuously and at a specific dose to have an anti-inflammatory effect and to provide pain relief. Normally, even at anti-inflammatory doses, NSAIDs must usually be taken for two to four weeks before their true effectiveness is known.

• Non-selective NSAIDs: Non-selective NSAIDs include over-the-counter medication such as aspirin, ibuprofen, naproxen and prescription-strength NSAIDs.

• Selective NSAIDs: Selective NSAIDs (also called COX-2 inhibitors) are as effective as non-selective NSAIDs and are less likely to cause gastrointestinal injury and side effects. Many of these have, however, been retracted from the market due to unforeseen side effects. Please discuss this with your doctor. Selective NSAIDs are not recommended for people with kidney disease, congestive heart failure, cirrhosis, who take diuretics, or are sensitive to aspirin.

• Disease-modifying drugs: These are increasingly used as first-line drugs, and include drugs such as methotrexate, salazopyrin and chloroquine.

• Biologicals: These drugs are reserved for cases where the above have not been successful and must preferably be prescribed by a rheumatologist. A strict pre-authorisation process is usually followed, due to the high costs and certain side effects of these drugs.

Some of these medication may have an adverse effect on your unborn child during pregnancy. Please contact your doctor if you have rheumatoid arthritis and plan to get pregnant.

Surgery

Surgery is used in patients with severely damaged joints. The most successful procedures are carried out on hips and knees. Realistic goals of such surgery are to relieve pain, correct deformity and provide significant functional improvement. Indications for joint replacement include mechanical problems and loss of function or uncontrolled disease despite proper medical therapy. The condition is a medical problem and surgery should be for patients who are also being treated medically for their condition.

Curability of the condition

Rheumatoid arthritis sufferers must understand that it is a lifelong condition. Sometimes it can remit (become inactive) for a while with treatment. If this happens, it is important that you see your doctor if the symptoms re-appear.

Consult your doctor if:

• you are feeling tired, have a poor appetite, generalised weakness and non-specific joint pains - particularly if you have a family history of rheumatoid arthritis;
• you already know you have rheumatoid arthritis and experience more pain, swelling and limitation of movement or if you are on medication for rheumatoid arthritis but severe joint swelling, pain or stiffness persists;
• you are on any anti-inflammatory (NSAID) drugs for rheumatoid arthritis and experience pain and discomfort in your stomach, black stools or are vomiting blood;
• other signs of problems with drugs are fever and infection; and
• you have rheumatoid arthritis and are planning a pregnancy.

References

1. American Family Physician. 72 (6). 15 September 2005.

2. Miani, RN. UpToDate.