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Rheumatoid Arthritis

Definition
Rheumatoid arthritis is an inflammatory form of arthritis that causes joint pain and
damage. Rheumatoid arthritis attacks the lining of your joints (synovium) causing
swelling that can result in aching and throbbing and eventually deformity. Sometimes
rheumatoid arthritis symptoms make even the simplest activities — such as opening a
jar or taking a walk — difficult to manage.

Rheumatoid arthritis is two to three times more common in women than in men and
generally occurs between the ages of 40 and 60. But rheumatoid arthritis can also
affect young children and older adults.

There's no cure for rheumatoid arthritis. With proper treatment, a strategy for joint
protection and changes in lifestyle, you can live a long, productive life with
rheumatoid arthritis.

Symptoms
Signs and symptoms of rheumatoid arthritis may include:

 Joint pain
 Joint swelling
 Joints that are tender to the touch
 Red and puffy hands
 Firm bumps of tissue under the skin on your arms (rheumatoid nodules)
 Fatigue
 Morning stiffness that lasts at least 30 minutes
 Fever
 Weight loss

Signs and symptoms appear in smaller joints first


Rheumatoid arthritis usually causes problems in several joints at the same time. Early
rheumatoid arthritis tends to affect your smaller joints first — the joints in your
wrists, hands, ankles and feet. As the disease progresses, your shoulders, elbows,
knees, hips, jaw and neck can also become involved.

Signs and symptoms of a rheumatoid arthritis flare


Rheumatoid arthritis signs and symptoms may vary in severity and may even come
and go. Periods of increased disease activity — called flare-ups or flares — alternate
with periods of relative remission, during which the swelling, pain, difficulty
sleeping, and weakness fade or disappear.
Causes
Rheumatoid arthritis occurs when white blood cells — whose usual job is to attack
unwanted invaders, such as bacteria and viruses — move from your bloodstream into
the membranes that surround your joints (synovium). The blood cells appear to play a
role in causing the synovium to become inflamed. The inflammation causes the
release of proteins that, over months or years, cause the synovium to thicken. The
proteins can also damage the cartilage, bone, tendons and ligaments near your joint.
Gradually, the joint loses its shape and alignment. Eventually, it may be destroyed.

Doctors don't know what causes this process that leads to rheumatoid arthritis. It's
likely that rheumatoid arthritis occurs as a result of a complex combination of factors,
including your genes, your lifestyle choices, such as smoking, and things in your
environment, such as viruses.
Risk factors
Factors that may increase your risk of rheumatoid arthritis include:

 Sex. Women are more likely to develop rheumatoid arthritis than men are.
 Age. Rheumatoid arthritis occurs most commonly between the ages of 40 and
60. However, it can also occur in older adults and in children (juvenile
rheumatoid arthritis).
 Family history. If a member of your family has rheumatoid arthritis, you may
have an increased risk of the disease. Doctors don't believe you can directly
inherit rheumatoid arthritis. Instead, it's believed that you can inherit a
predisposition to rheumatoid arthritis.
 Smoking. Smoking cigarettes increases your risk of rheumatoid arthritis.
Quitting can reduce your risk.

When to seek medical advice


Make an appointment with your doctor if you have persistent discomfort and swelling
in multiple joints on both sides of your body.

If you've already been diagnosed with rheumatoid arthritis, contact your doctor if you
experience side effects from your rheumatoid arthritis medications. Side effects may
include nausea, abdominal discomfort, black or tarry stools, changes in bowel habits,
constipation, and drowsiness.

Tests and diagnosis


Diagnosing rheumatoid arthritis usually begins with a physical exam. Your doctor
will ask you about your signs and symptoms and examine your affected joints.

In addition, your doctor may recommend:

 Blood tests. People with rheumatoid arthritis tend to have an elevated


erythrocyte sedimentation rate (ESR, or sed rate), which indicates the presence
of an inflammatory process in the body. Other common blood tests look for
antibodies called rheumatoid factor and anti-cyclic citrullinated peptide (anti-
CCP) antibodies in the blood. While commonly found in the blood of people
with rheumatoid arthritis, rheumatoid factor and anti-CCP antibodies aren't
present in all cases.

In early rheumatoid arthritis, the presence of rheumatoid factor and anti-CCP


antibodies in the blood may be associated with an increased risk of joint
damage. Rheumatoid factor and anti-CCP antibodies can be present in people
who have chronic infections, such as active tuberculosis, and other
autoimmune rheumatic diseases, such as lupus and Sjogren's syndrome.

 Joint fluid analysis. Your doctor may draw fluid from your joint using a
needle. The fluid can be tested to help rule out other diseases and conditions.
 X-rays. Your doctor may recommend X-rays to help track the progression of
rheumatoid arthritis in your joint over time.

Complications
Rheumatoid arthritis causes joint damage that can be both debilitating and disfiguring.
Damage to your joints may make it difficult or impossible to go about your daily
activities. You may find at first that tasks take more energy to accomplish. With time
you may find you are no longer able to do them at all. Newer treatments may stop
joint damage or prevent it so you can continue the activities you enjoy.

Treatments and drugs


There is no cure for rheumatoid arthritis. Treatment for rheumatoid arthritis aims to
reduce inflammation in your joints in order to relieve pain and prevent or slow joint
damage. Early and aggressive rheumatoid arthritis treatments may slow joint damage
and help reduce the risk of disability. Treatment typically involves medications,
though surgery may be necessary in cases of severe joint damage.

Medications
Rheumatoid arthritis medications can relieve pain and slow or halt the progression of
joint damage. Medications used to treat rheumatoid arthritis include:

 NSAIDs. Nonsteroidal anti-inflammatory drugs (NSAIDs) can relieve pain and reduce
inflammation. Over-the-counter NSAIDs include ibuprofen (Advil, Motrin, others) and
naproxen sodium (Aleve). Stronger versions of these NSAIDs and others are available by
prescription. NSAIDs have risks of side effects that increase when used at high dosages for
long-term treatment. Side effects may include ringing in your ears, gastric ulcers, heart
problems, stomach bleeding, and liver and kidney damage. Consuming alcohol or taking
corticosteroids while using NSAIDs also increases your risk of gastrointestinal bleeding.
 Steroids. Corticosteroid medications, such as prednisone and methylprednisolone (Medrol),
reduce inflammation and pain, and slow joint damage. In the short term, corticosteroids
can make you feel dramatically better. But when used for many months or years, they may
become less effective and cause serious side effects. Side effects may include easy bruising,
thinning of bones, cataracts, weight gain, a round face and diabetes. Doctors often
prescribe a corticosteroid to relieve acute symptoms, with the goal of gradually tapering off
the medication.
 Disease-modifying antirheumatic drugs (DMARDs). Doctors prescribe DMARDs to limit the
amount of joint damage that occurs in rheumatoid arthritis. These drugs are typically used
in the early stages of rheumatoid arthritis in an effort to slow the disease and save the joints
and other tissues from permanent damage. You may need to take DMARDs for weeks or
months before you notice any benefit. For that reason, they may be combined with other
medications that give you more immediate relief from signs and symptoms, such as NSAIDs
or corticosteroids. Common DMARDs include hydroxychloroquine (Plaquenil), the gold
compound auranofin (Ridaura), sulfasalazine (Azulfidine), minocycline (Dynacin,
Minocin) and methotrexate (Rheumatrex).
 Immunosuppressants. These medications act to tame your immune system, which is out of
control in rheumatoid arthritis. In addition, some of these drugs attack and eliminate cells
that are associated with the disease. Some of the commonly used immunosuppressants
include leflunomide (Arava), azathioprine (Imuran), cyclosporine (Neoral, Sandimmune)
and cyclophosphamide (Cytoxan). These medications can have potentially serious side
effects such as increased susceptibility to infection.
 TNF-alpha inhibitors. TNF-alpha is a cytokine, or cell protein, that acts as an inflammatory
agent in rheumatoid arthritis. TNF inhibitors target or block this cytokine and can help
reduce pain, morning stiffness, and tender or swollen joints — usually within one or two
weeks after treatment begins. There is evidence that TNF inhibitors may stop progression of
disease. These medications often are taken with methotrexate. TNF inhibitors approved for
treatment of rheumatoid arthritis are etanercept (Enbrel), infliximab (Remicade) and
adalimumab (Humira). Potential side effects include injection site irritation (adalimumab
and etanercept), worsening congestive heart failure (infliximab), blood disorders,
lymphoma, demyelinating diseases, and increased risk of infection, including serious
infection leading to death if treatment is delayed. Infections due to tuberculosis and certain
types of invasive fungi, such as histoplasmosis, coccidioidomycosis and blastomycosis, have
been associated with the use of TNF-alpha inhibitors. If you have an active infection, don't
take these medications.
 Anakinra (Kineret). Anakinra is similar to a naturally occurring chemical in your body —
interleukin-1 receptor antagonist (IL-1Ra) — that stops a certain chemical signal from
causing inflammation. You might consider anakinra if you have moderate to severe
rheumatoid arthritis and haven't been helped by conventional DMARD therapy. Anakinra
is given as a daily self-administered injection under the skin, and is sometimes combined
with methotrexate. Potential side effects include injection site reactions, decreased white
blood cell counts, headache and an increase in upper respiratory infections. There may be a
slightly higher rate of respiratory infections in people who have asthma or chronic
obstructive pulmonary disease. If you have an active infection, don't use anakinra.
 Abatacept (Orencia). Abatacept reduces the inflammation and joint damage caused by
rheumatoid arthritis by inactivating T cells — a type of white blood cell. People who haven't
been helped by TNF-alpha inhibitors might consider abatacept, which is administered
monthly through a vein in your arm (intravenously). Side effects may include headache,
nausea and mild infections, such as upper respiratory tract infections. Serious infections,
such as pneumonia, can occur.
 Rituximab (Rituxan). Rituximab reduces the number of B cells in your body. B cells are
involved in inflammation. People who haven't found relief using TNF inhibitors might
consider using rituximab, which is usually given along with methotrexate. Rituximab is
administered as an infusion into a vein in your arm. Side effects include flu-like signs and
symptoms, such as fever, chills and nausea. Some people experience extreme reactions to
the infusion, such as difficulty breathing and heart problems. Ritixumab has been linked to
a fatal brain infection in one person with rheumatoid arthritis.

What medications you can consider will depend on the severity of your rheumatoid
arthritis, the length of time that you've been experiencing signs and symptoms, results
from blood tests and X-rays, your overall physical function, and other medical
problems you have. Doctors use these factors to determine the duration of your
disease, its severity and your prognosis, which help to develop a treatment plan.

In 2008, the American College of Rheumatology (ACR) updated its recommendations


for selecting certain rheumatoid arthritis medications. The ACR recommends
hydroxychloroquine or minocycline for people with mild rheumatoid arthritis that has
been present for less than two years, sulfasalazine for all levels of disease severity in
people without a poor prognosis, and methotrexate or leflunomide for all levels of
disease severity with or without a poor prognosis. For people with more severe
rheumatoid arthritis, the ACR recommends combinations of DMARDs or a TNF-
alpha inhibitor.

Surgery
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. Rheumatoid arthritis surgery
may involve one or more of the following procedures:
 Total joint replacement (arthroplasty). During joint replacement surgery, your surgeon
removes the damaged parts of your joint and inserts a metal and plastic prosthesis.
 Tendon repair. Inflammation and joint damage may cause tendons around your joint to
loosen or tighten. Your surgeon may be able to repair the tendons around your joint.
 Removal of the joint lining (synovectomy). If the lining around your joint (synovium) is
inflamed and causing pain, your surgeon may recommend removing the lining of the joint.

Surgery carries a risk of bleeding, infection and pain. Discuss the benefits and risks
with your doctor.

Lifestyle and home remedies


You can take steps to care for your body if you have rheumatoid arthritis. These self-
care measures, when used along with your rheumatoid arthritis medications, can help
you cope with your signs and symptoms. Consider trying to:

 Exercise regularly. Gentle exercise can help strengthen the muscles around your joints, and
it can help fight fatigue you might feel. Check with your doctor before you start exercising.
If you're just getting started, begin by taking a walk. Try swimming or gentle water
aerobics. Public pools and health clubs in your area may offer classes. Avoid exercising
tender, injured or severely inflamed joints. If you feel new joint pain, stop. New pain that
lasts more than two hours after you exercise probably means you've overdone it. If pain
persists for more than a few days, call your doctor.
 Eat a healthy diet. A healthy diet emphasizing fruit, vegetables and whole grains can help
you control your weight and maintain your overall health. However, there's no special diet
that can be used to treat rheumatoid arthritis. It hasn't been proved that eating any
particular food will make your joint pain or inflammation better or worse.
 Protect your joints. Find different ways to approach everyday tasks in order to take stress off
your painful joints. For instance, if your fingers are sore, pick up an object using your
forearms. Lean into a glass door to force it open, rather than pushing on the door with sore
arms.
 Use assistive devices. Assistive devices can make it easier to go about your day without
stressing your painful joints. For instance, using specially designed gripping and grabbing
tools may make it easier to work in the kitchen if you have pain in your fingers. Try a cane
to help you get around. Your doctor or occupational therapist may have ideas about what
sorts of assistive devices may be helpful to you. Catalogs and medical supply stores may also
be places to look for ideas.
 Apply heat. Heat can help ease your pain and relax tense, painful muscles. One of the
easiest and most effective ways to apply heat is to take a hot shower or bath for 15 minutes.
Other options include using a hot pack or an electric heat pad set on its lowest setting. If
your skin has poor sensation or if you have poor circulation, don't use heat treatments.
 Apply cold. Cold may dull the sensation of pain. Cold also has a numbing effect and
decreases muscle spasms. Don't use cold treatments if you have poor circulation or
numbness. Techniques may include using cold packs, soaking the affected joints in cold
water and ice massage.
 Relax. Find ways to cope with pain by reducing stress in your life. Techniques such as
hypnosis, guided imagery, deep breathing and muscle relaxation can all be used to control
pain.
Coping and support
The degree to which rheumatoid arthritis affects your daily activities depends in part
on how well you cope with the disease. Talk to your doctor or nurse about strategies
for coping. With time you'll find what strategies work best for you. In the meantime,
try to:

 Keep a positive attitude. With your doctor, make a plan for managing your
arthritis. This will help you feel in charge of your disease. Studies show that
people who take control of their treatment and actively manage their arthritis
experience less pain and make fewer visits to the doctor.
 Know your limits. Rest when you're tired. Rheumatoid arthritis can make you
prone to fatigue and muscle weakness. A rest or short nap that doesn't interfere
with nighttime sleep may help.
 Connect with others. Keep your family aware of how you're feeling. They
may be worried about you but might not feel comfortable asking about your
pain. Find a family member or friend you can talk to when you're feeling
especially overwhelmed. Also connect with other people who have rheumatoid
arthritis — whether through a support group in your community or online.
Contact the Arthritis Foundation for more information. Sometimes you'll feel
like your friends and family can't understand what it's like to have rheumatoid
arthritis, and other people with the disease can offer unique support during
these times.
 Take time for yourself. It's easy to get busy and not take time for yourself.
Find time for what you like, whether it's time to write in a journal, go for a
walk or listen to music. Use this time to relieve stress and reflect on your
feelings.

Alternative medicine
People who are frustrated by conventional rheumatoid arthritis treatments sometimes
turn to complementary and alternative medicine practices for relief. Mainstream
doctors are becoming more open to discussing these options. But, since few of these
treatments have been extensively studied in clinical trials, it's difficult to assess
whether these treatments are helpful for rheumatoid arthritis pain. In some cases, the
risks of these treatments aren't known.

If you're interested in trying complementary and alternative medicine therapies for


your rheumatoid arthritis pain, discuss these treatments with your doctor first.
Together you can weigh the benefits and risks and decide whether the treatments will
interfere with your current rheumatoid arthritis medications.

Some common complementary and alternative treatments that have shown promise
for rheumatoid arthritis include:

 Plant oils that contain gamma-linolenic acid (GLA). GLA is a type of


omega-6 fatty acid that comes from plant oils, such as evening primrose,
borage and black currant. Some studies indicate GLA may help with
rheumatoid arthritis pain and morning stiffness, though more research is
needed. Side effects may include nausea, diarrhea and gas. Some plant oils can
cause liver damage or interfere with medications, so check with your doctor
first.
 Fish oil that contains eicosapentaenoic acid (EPA) or docosahexaenoic
acid (DHA). EPA and DHA are omegea-3 fatty acids commonly found in fish
oil. Some preliminary studies have found that fish oil may reduce rheumatoid
arthritis pain and stiffness, but more study is needed. Side effects can include
nausea, belching and a fishy taste in the mouth. More serious side effects can
include bleeding and mercury poisoning. Fish oil can interfere with
medications, so check with your doctor first.
 Tai chi. This movement therapy involves gentle exercises and stretches
combined with deep breathing. Many people use tai chi to relieve stress in
their lives. Small studies have found tai chi may reduce rheumatoid arthritis
pain, though more study is needed. Talk to your doctor if you'd like to give tai
chi a try. When led by a knowledgeable instructor, tai chi is safe. But don't do
any moves that cause pain.

Be careful when considering alternative therapies. Many are expensive and some may
be harmful. Before taking any complementary medications or dietary supplements,
talk with your doctor to learn about potential dangers, particularly if you're taking
other medications.