Understanding Rheumatoid Arthritis symptoms, diagnosis and treatment.
What is Rheumatoid Arthritis? Rheumatoid Arthritis (commonly called RA) is a disease causing inflammation of the joints. The lining membrane of the joints, called synovium, becomes inflamed. This causes joint swelling, warmth, pain and decreased movement of the affected joints. It can also affect non-joint areas such as lungs, blood vessels, eyes, bone marrow etc.
Why should I take medications for Rheumatoid Arthritis? Unfortunately, Rheumatoid Arthritis is an aggressive inflammatory arthritis that can cause persistent inflammation of the joints. This can cause progressive and permanent damage to bone and joints. The joint inflammation causes bone erosions and deformities. See this picture. If the damage continues, you may notice inability to use the joint. For example if your hands are involved, you may not be able to make a fist, open door knobs, hold a cup of coffee etc. Thus medications are essential to prevent joint damage.
What are the medications for treatment of Rheumatoid arthritis? Generally there are 2 categories of medications: 1) Symptomatic medications… NSAIDS like aleve, naproxen, nabumetone, celebrex etc and pain medications like Tylenol, Vicodin etc. Steroids like prednisone help to control the symptoms of the disease quickly. Prednisone is not a pain medication. It is an effective medication against inflammation. By reducing inflammation, it indirectly reduces pain.
2) Disease modifying medications: Traditional DMARDs like methotrextae, Leflunomide, Sulfasalazine, Plaquenil, Imuran etc and newer biologicals like Enbrel, Humira, Remicade, Rituxan, Orencia etc.
I do not want to take DMARDs or Biologicals. I just want to try supplements, herbal medications and vitamins. Will this help? Herbal medications and supplements are best avoided in RA. As mentioned above, RA is an aggressive and damaging disease that can cause deformities and disability. Herbal medications and supplements may help RA, but the degree of helpfulness compared to the mainstream medications is negligible (and that is the reason they are not mainstream. Think about it. If they are as effective as the manufacturer (not regulated by FDA) claims, why are they not the mainstream treatment for RA.?
I do not like medications and do not want to take any medications. What will the disease do to me? As noted above, without the use of powerful RA medications (DMARDs and/or Biologicals), there will be progressive joint damage, leading to deformities and disability (inability to work). While your physician may respect your decision, it is in your best interest that you understand that the deformities are preventable and by not taking the medications, you are causing harm to your body. In most instances, the risks associated with the medications (side effects) are very less, compared to the risk of not taking the medications. The benefits of taking the medication outweigh the risks.
I was diagnosed with RA last month. When should I start treatment? Right away. It is extremely important that treatment for RA be started right away after the diagnosis is made and confirmed by a rheumatologist.
I already have deformities. Will the medications reverse the deformities? The goal of using DMARDs and Biological medications is to limit or stop the progression of the joint damage and deformities. If you already have joint damage (erosions or deformities), the medications do not reverse the damage. However, they will help in preventing further progression.
Is Rheumatoid Arthritis Curable? Rheumatoid Arthritis is not curable. However with continuous use of powerful medicines (DMARDs and Biologicals), the disease can be well controlled, thus minimizing the symptoms and preventing joint damage. Some patients can go into a state called remission (disease has been controlled so well by medications that there is no current disease activity). Generally if you have been in a state of RA remission for more than 2 years, your physician may try to wean (reduce) your medications slowly over several months.
Is this a common disease? It is fairly common. In the United States, one percent of the population (2.1 million people) has RA. Women are three times more likely to get RA than men. In women, RA usually begins in the 30 to 60 age group. In men it usually occurs later in life. However, anyone can get RA at anytime in life, including children.
What causes RA? The exact reason is unknown. There have been several theories including prior exposure to infection, certain foods, chemicals etc. The immune system of the body is supposed to protect us from viruses, bacteria and foreign substances. In rheumatoid arthritis (as also in some other immune diseases like Lupus), the immune system for some reason, gets confused and mistakenly attacks your normal cells, joints and organs, thus causing the joint inflammation and damage. In the simplest sense it can be thought of as“immune system hyperactivity”. Instead of attacking the enemy (bacteria, viruses etc), the immune system attacks your own body. Because there is immune system hyperactivity, the medications (DMARDS, Biologicals) are used to suppress the immune system and calm it. This calms the disease. However the side effect of this suppression of the immune system is that the body’s ability to fight infections is also suppressed. So you can catch an infection more easily than someone who is not on these medications. More about this later…
Why am I not on the same medications as my neighbor, who also has RA? There is no “one size fits all” treatment for RA. Your rheumatologist will customize your treatment program. So, you may not be on the same medications as your neighbor with RA.
Why do I need to do a blood test every 8 weeks? Because of the powerful and potentially dangerous sideeffects of the above medications, you will be carefully monitored with close followup visits once every few months and by blood tests once every 8 weeks. The blood tests monitor your Liver, Kidneys and bone marrow.
Why did my Rheumatologist tell me to stop smoking? Recent research has found that smoking increases your risk of developing rheumatoid arthritis.
What are the symptoms of rheumatoid arthritis? RA causes joint swelling, warmth, pain and decreased movement of the affected joints. You may notice stiffness in the joints, especially in the mornings. RA is generally a symmetrical disease, so if your left wrist is affected, your right wrist is also affected. RA can also cause systemic symptoms like loss of appetite, feeling sick, low grade fever, anemia, and loss of energy. It can also affect non-joint areas such as lungs, blood vessels, eyes, bone marrow etc.
How severe is RA? Rheumatoid Arthritis can be mild, moderate or severe. Mild rheumatoid arthritis usually presents with mild symptoms. People affected will be able to carry on most day to day activities. They may get periods of flares lasting a few weeks. Flares are increased periods of disease activity (increased joint inflammation, leading to worsening symptoms). In moderate and severe rheumatoid arthritis, the disease activity level is high leading to continuous joint swelling, pain and inability to function well.
What are the bumpy nodules that I have on my elbows and forearms? Rheumatoid nodules are lumps of tissue found usually on elbows, forearms, fingers, feet and other parts of the body including the lungs.
Does RA only affect the joints? No. rheumatoid arthritis can cause inflammation of the lining of the heart (called pericarditis) and inflammation of the lining of the lungs (called pleuritis). It can also cause inflammation inside the lung tissue. It can cause inflammation of the tear and saliva producing glands, thus causing dryness of eyes and mouth (Sjogrens syndrome). Rarely RA may affect the blood vessels (vasculitis), and other organs.
How is the diagnosis of rheumatoid arthritis made? Generally the diagnosis of rheumatoid arthritis is a complex process involving physical examination of the joints by a rheumatologist (or other physician), blood tests and X-rays.
What are the blood tests for Rheumatoid Arthritis? Rheumatoid Factor (RF) is usually positive in people with Rheumatoid arthritis. However, this test is also positive in people who do not have rheumatoid arthritis. So, the test must not be used in isolation to diagnose rheumatoid arthritis, but rather in conjunction with the rheumatologist’s clinical examination of your joints and x ray findings. Anti-Cyclic Citrullinated peptide (CCP) is an antibody that is also found in RA. In general, CCP is more reliable for diagnosis of RA and its presence may indicate that the course of your RA can be aggressive (moderate or severe RA; rather than mild RA). Inflammation markers in the blood called Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are usually elevated in RA.
What are the X-rays for? X-rays commonly ordered in RA are that of hands, wrists and feet. They are usually normal in early RA, but may show joint erosions (bone bites) if you have had symptoms for a few years. Initial X-rays serve as baseline films to compare with future X-Rays over the years, for evaluation of joint damage. Generally X-rays of the joints are ordered once every 2 years to assess for progression of joint damage. MRI is generally not necessary to diagnose RA, except in unusual presentations of the disease or to guide specific treatment decisions.
My primary physician diagnosed me with RA. Do I still need to see a Rheumatologist? There are more than 50 forms of arthritis, and it is crucial to accurately diagnose your specific type of arthritis. All patients with RA should be diagnosed and followed continuously by a rheumatologist. There is no single blood test that can be used to make a diagnosis of RA. A rheumatologist must physically examine your joints to make a reliable diagnosis of rheumatoid arthritis.
Link to ACR criteria.
Should I exercise? Yes. Exercises (in conjunction with medications) help to keep the joints flexible, and prevent damage. Exercise should be avoided in the early stages (untreated inflammation) and during flares (periods of increased disease activity). At other times, exercising helps keep your joints and body fit. Caution: if exercising hurts your joints, you should slow or stop exercising and talk to your rheumatologist.
Can I control my RA with diet changes? The short answer is No. Although people perceive that certain foods can aggravate their RA, there is no definite scientific evidence of this. Changes in diet do not control RA disease activity. However, Omega 3 fatty acids have been shown to help reduce RA inflammation mildly.
Is joint replacement surgery the right choice for me? In general the indications for joint surgery are persisting severe pain and deformities causing severe loss of joint function. If your Rheumatologist or primary physician determines that you may benefit from joint replacement, he will refer you to an Orthopedic Surgeon who does the actual surgery.