Rheumatoid arthritis (RA) facts

Rheumatoid arthritis is anautoimmune disease that can cause chronic

inflammation of the joints and other areas of the body.
Rheumatoid arthritis can affect people of all ages.
The cause of rheumatoid arthritis is not known.
Rheumatoid arthritis is a chronic disease, characterized by periods of disease
flares and remissions.
In rheumatoid arthritis, multiple joints are usually, but not always, affected in a
symmetrical pattern.
Chronic inflammation of rheumatoid arthritis can cause permanent joint
destruction and deformity.
Damage to joints can occur early and does not correlate with the seerity of
symptoms.
The !rheumatoid factor! is an antibody that can be found in the blood of "#$ of
people with rheumatoid arthritis.
There is no known cure for rheumatoid arthritis.
The treatment of rheumatoid arthritis optimally inoles a combination of patient
education, rest and e%ercise, joint protection, medications, and occasionally surgery.
&arly treatment of rheumatoid arthritis results in better outcomes.
What is rheumatoid arthritis (RA)?
Rheumatoid arthritis 'R() is an autoimmune disease that causes chronic inflammation of
the joints. Rheumatoid arthritis can also cause inflammation of the tissue around the
joints, as well as in other organs in the body. (utoimmune diseases are illnesses that
occur when the body*s tissues are mistakenly attacked by their own immune system.
The immune system contains a comple% organization of cells and antibodies designed
normally to !seek and destroy! inaders of the body, particularly infections. +atients with
autoimmune diseases hae antibodies in their blood that target their own body tissues,
where they can be associated with inflammation. ,ecause it can affect multiple other
organs of the body, rheumatoid arthritis is referred to as a systemic illness and is
sometimes called rheumatoid disease.
-hile rheumatoid arthritis is a chronic illness, meaning it can last for years, patients may
e%perience long periods without symptoms. .oweer, rheumatoid arthritis is typically a
progressie illness that has the potential to cause joint destruction and functional
disability.
Picture of a joint with rheumatoid arthritis
( joint is where two bones meet to allow moement of body parts. (rthritismeans joint
inflammation. The joint inflammation of rheumatoid arthritis causes
swelling, pain, stiffness, and redness in the joints. The inflammation of rheumatoid
disease can also occur in tissues around the joints, such as the tendons, ligaments, and
muscles.
In some people with rheumatoid arthritis, chronic inflammation leads to the destruction of
the cartilage, bone, and ligaments, causing deformity of the joints. Damage to the joints
can occur early in the disease and be progressie. /oreoer, studies hae shown that
the progressie damage to the joints does not necessarily correlate with the degree of
pain, stiffness, or swelling present in the joints.
Rheumatoid arthritis is a common rheumatic disease, affecting appro%imately 0.1 million
people in the 2nited 3tates, according to current census data. The disease is three
times more common in women as in men. It afflicts people of all races e4ually. The
disease can begin at any age and een affects children 'juenile rheumatoid arthritis),
but it most often starts after 5# years of age and before 6# years of age. In some
families, multiple members can be affected, suggesting a genetic basis for the disorder.
What causes rheumatoid arthritis?
The cause of rheumatoid arthritis is unknown. &en though infectious agents such as
iruses, bacteria, and fungi hae long been suspected, none has been proen as the
cause. The cause of rheumatoid arthritis is a ery actie area of worldwide research. It is
belieed that the tendency to deelop rheumatoid arthritis may be genetically inherited
'hereditary). It is also suspected that certain infections or factors in the enironment
might trigger the actiation of the immune system in susceptible indiiduals. This
misdirected immune system then attacks the body*s own tissues. This leads to
inflammation in the joints and sometimes in arious organs of the body, such as the
lungs or eyes.
It is not known what triggers the onset of rheumatoid arthritis. Regardless of the e%act
trigger, the result is an immune system that is geared up to promote inflammation in the
joints and occasionally other tissues of the body. Immune cells, called lymphocytes, are
actiated and chemical messengers 'cytokines, such as tumor necrosis factor7T89,
interleukin:07I;:0, and interleukin:67I;:6) are e%pressed in the inflamed areas.
&nironmental factors also seem to play some role in causing rheumatoid arthritis. 9or
e%ample, scientists hae reported thatsmoking tobacco increases the risk of deeloping
rheumatoid arthritis.
What are the symptoms and signs of rheumatoid arthritis?
The symptoms of rheumatoid arthritis come and go, depending on the degree of tissue
inflammation. -hen body tissues are inflamed, the disease is actie. -hen tissue
inflammation subsides, the disease is inactie 'in remission). Remissions can occur
spontaneously or with treatment and can last weeks, months, or years. During
remissions, symptoms of the disease disappear, and people generally feel well. -hen
the disease becomes actie again 'relapse), symptoms return. The return of disease
actiity and symptoms is called a flare. The course of rheumatoid arthritis aries among
affected indiiduals, and periods of flares and remissions are typical.
-hen the disease is actie, symptoms can include fatigue, loss of energy,lack of
appetite, low:grade feer, muscle and joint aches, and stiffness. /uscle and joint
stiffness are usually most notable in the morning and after periods of inactiity. (rthritis
is common during disease flares. (lso during flares, joints fre4uently become red,
swollen, painful, and tender. This occurs because the lining tissue of the joint 'synoium)
becomes inflamed, resulting in the production of e%cessie joint fluid 'synoial fluid). The
synoium also thickens with inflammation 'synoitis).
Rheumatoid arthritis usually inflames multiple joints in a symmetrical pattern 'both sides
of the body affected). &arly symptoms may be subtle. The small joints of both the hands
and wrists are often inoled. 3ymptoms in the hands with rheumatoid arthritis include
difficulty with simple tasks of daily liing, such as turning door knobs and opening jars.
The small joints of the feet are also commonly inoled, which can lead to
painful walking, especially in the morning after arising from bed. <ccasionally, only one
joint is inflamed. -hen only one joint is inoled, the arthritis can mimic the joint
inflammation caused by other forms of arthritis, such as gout or joint infection. Chronic
inflammation can cause damage to body tissues, including cartilage and bone. This
leads to a loss of cartilage and erosion andweakness of the bones as well as the
muscles, resulting in joint deformity, destruction, and loss of function. Rarely, rheumatoid
arthritis can een affect the joint that is responsible for the tightening of our ocal cords
to change the tone of our oice, the cricoarytenoid joint. -hen this joint is inflamed, it
can cause hoarseness of the oice. =oint symptoms in children with rheumatoid arthritis
include limping, irritability, crying, and poor appetite.
3ince rheumatoid arthritis is a systemic disease, its inflammation can affect organs and
areas of the body other than the joints. Inflammation of the glands of the eyes and mouth
can cause dryness of these areas and is referred to as 3jogren*s syndrome. Dryness of
the eyes can lead to corneal abrasion. Inflammation of the white parts of the eyes 'the
sclerae) is referred to as scleritis and can be ery dangerous to the eye. Rheumatoid
inflammation of the lung lining 'pleuritis) causes chest pain with deep
breathing, shortness of breath, or coughing. The lung tissue itself can also become
inflamed, scarred, and sometimes nodules of inflammation 'rheumatoid nodules)
deelop within the lungs. Inflammation of the tissue 'pericardium) surrounding the heart,
called pericarditis, can cause a chest pain that typically changes in intensity when lying
down or leaning forward. The rheumatoid disease can reduce the number of red blood
cells 'anemia) and white blood cells. Decreased white cells can be associated with
anenlarged spleen 'referred to as 9elty*s syndrome) and can increase the risk of
infections. 9irm lumps under the skin 'rheumatoid nodules) can occur around the elbows
and fingers where there is fre4uent pressure. &en though these nodules usually do not
cause symptoms, occasionally they can become infected. 8eres can become pinched
in the wrists to cause carpal tunnel syndrome. ( rare, serious complication, usually with
long:standing rheumatoid disease, is blood essel inflammation 'asculitis). >asculitis
can impair blood supply to tissues and lead to tissue death 'necrosis). This is most often
initially isible as tiny black areas around the nail beds or as leg ulcers.
How is rheumatoid arthritis diagnosed?
There is no singular test for diagnosing rheumatoid arthritis. Instead, rheumatoid arthritis
is diagnosed based on a combination of the presentation of the joints inoled,
characteristic joint stiffness in the morning, the presence of blood rheumatoid factor
andcitrulline antibody, as well as findings of rheumatoid nodules and radiographic
changes '?:ray testing).
The first step in the diagnosis of rheumatoid arthritis is a meeting between the doctor
and the patient. The doctor reiews the history of symptoms, e%amines the joints for
inflammation, tenderness, swelling, and deformity, the skin for rheumatoid nodules 'firm
bumps under the skin, most commonly oer the elbows or fingers), and other parts of the
body for inflammation. Certain blood and ?:ray tests are often obtained. The diagnosis
will be based on the pattern of symptoms, the distribution of the inflamed joints, and the
blood and ?:ray findings. 3eeral isits may be necessary before the doctor can be
certain of the diagnosis. ( doctor with special training in arthritis and related diseases is
called a rheumatologist.
The distribution of joint inflammation is important to the doctor in making a diagnosis. In
rheumatoid arthritis, the small joints of the hands, wrists, feet, and knees are typically
inflamed in a symmetrical distribution 'affecting both sides of the body). -hen only one
or two joints are inflamed, the diagnosis of rheumatoid arthritis becomes more difficult.
The doctor may then perform other tests to e%clude arthritis due to infection or gout. The
detection of rheumatoid nodules 'described aboe), most often around the elbows and
fingers, can suggest the diagnosis.
(bnormal antibodies can be found in the blood of people with rheumatoid arthritis. (n
antibody called !rheumatoid factor! can be found in "#$ of patients with rheumatoid
arthritis. +atients who are felt to hae rheumatoid arthritis and do not hae positie
rheumatoid factor testing are referred as haing !seronegatie rheumatoid arthritis.!
Citrulline antibody 'also referred to as anticitrulline antibody, anticyclic citrullinated
peptide antibody, and anti:CC+) is present in most people with rheumatoid arthritis. It is
useful in the diagnosis of rheumatoid arthritis when ealuating cases of une%plained joint
inflammation. ( test for citrulline antibodies is most helpful in looking for the cause of
preiously undiagnosed inflammatory arthritis when the traditional blood test for
rheumatoid arthritis, rheumatoid factor, is not present. Citrulline antibodies hae been
felt to represent the earlier stages of rheumatoid arthritis in this setting. (nother antibody
called the !antinuclear antibody! '(8() is also fre4uently found in people with
rheumatoid arthritis.
( blood test called the sedimentation rate 'sed rate) is a measure of how fast red blood
cells fall to the bottom of a test tube. The sed rate is used as a crude measure of the
inflammation of the joints. The sed rate is usually faster during disease flares and slower
during remissions. (nother blood test that is used to measure the degree of
inflammation present in the body is the C:reactie protein. ,lood testing may also reeal
anemia, since anemia is common in rheumatoid arthritis, particularly because of the
chronic inflammation.
The rheumatoid factor, (8(, sed rate, and C:reactie protein tests can also be abnormal
in other systemic autoimmune and inflammatory conditions. Therefore, abnormalities in
these blood tests alone are not sufficient for a firm diagnosis of rheumatoid arthritis.
=oint ?:rays may be normal or only show swelling of soft tissues early in the disease. (s
the disease progresses, ?:rays can show bony erosions typical of rheumatoid arthritis in
the joints. =oint ?:rays can also be helpful in monitoring the progression of disease and
joint damage oer time. ,one scanning, a procedure using a small amount of a
radioactie substance, can also be used to demonstrate the inflamed
joints. /RI scanning can also be used to demonstrate joint damage.
The (merican College of Rheumatology has deeloped a system for classifying
rheumatoid arthritis that is primarily based upon the ?:ray appearance of the joints. This
system helps medical professionals classify the seerity of your rheumatoid arthritis with
respect to cartilage, ligaments, and bone.
3tage I
no damage seen on ?:rays, although there may be signs of bone thinning
3tage II
on ?:ray, eidence of bone thinning around a joint with or without slight bone
damage
slight cartilage damage possible
joint mobility may be limited@ no joint deformities obsered
atrophy of adjacent muscle
abnormalities of soft tissue around joint possible
3tage III
on ?:ray, eidence of cartilage and bone damage and bone thinning around the
joint
joint deformity without permanent stiffening or fi%ation of the joint
e%tensie muscle atrophy
abnormalities of soft tissue around joint possible
3tage I>
on ?:ray, eidence of cartilage and bone damage and osteoporosis around joint
joint deformity with permanent fi%ation of the joint 'referred to as ankylosis)
e%tensie muscle atrophy
abnormalities of soft tissue around joint possible
Rheumatologists also classify the functional status of people with rheumatoid arthritis as
followsA
Class IA completely able to perform usual actiities of daily liing
Class IIA able to perform usual self:care and work actiities but limited in actiities
outside of work 'such as playing sports, household chores)
Class IIIA able to perform usual self:care actiities but limited in work and other
actiities
Class I>A limited in ability to perform usual self:care, work, and other actiities
The doctor may elect to perform an office procedure called arthrocentesis. In this
procedure, a sterile needle and syringe are used to drain joint fluid out of the joint for
study in the laboratory. (nalysis of the joint fluid in the laboratory can help to e%clude
other causes of arthritis, such as infection and gout. (rthrocentesis can also be helpful in
relieing joint swelling and pain. <ccasionally, cortisone medications are injected into the
joint during the arthrocentesis in order to rapidly reliee joint inflammation and further
reduce symptoms
How is rheumatoid arthritis treated?
There is no known cure for rheumatoid arthritis. To date, the goal of treatment in
rheumatoid arthritis is to reduce joint inflammation and pain, ma%imize joint function, and
preent joint destruction and deformity. &arly medical interention has been shown to be
important in improing outcomes. (ggressie management can improe function, stop
damage to joints as monitored on ?:rays, and preent work disability. <ptimal treatment
for the disease inoles a combination of medications, rest, joint:strengthening
e%ercises, joint protection, and patient 'and family) education. Treatment is customized
according to many factors such as disease actiity, types of joints inoled, general
health, age, and patient occupation. Treatment is most successful when there is close
cooperation between the doctor, patient, and family members.
Two classes of medications are used in treating rheumatoid arthritisA fast:acting !first:line
drugs! and slow:acting !second:line drugs! 'also referred to as disease:modifying
antirheumatic drugs or D/(RDs). The first:line drugs, such as aspirin and cortisone
'corticosteroids), are used to reduce pain and inflammation. The slow:acting second:line
drugs, such as gold, methotre%ate'Rheumatre%, Tre%all),
andhydro%ychloro4uine '+la4uenil), promote disease remission and preent progressie
joint destruction, but they are not anti:inflammatory agents.
The degree of destructieness of rheumatoid arthritis aries among affected indiiduals.
Those with uncommon, less destructie forms of the disease or disease that has 4uieted
after years of actiity '!burned out! rheumatoid arthritis) can be managed with rest plus
pain control and anti:inflammatory medications alone. In general, howeer, function is
improed and disability and joint destruction are minimized when the condition is treated
earlier with second:line drugs 'disease:modifying antirheumatic drugs), een within
months of the diagnosis. /ost people re4uire more aggressie second:line drugs, such
as methotre%ate, in addition to anti:inflammatory agents. 3ometimes these second:line
drugs are used in combination. In some cases with seere joint deformity, surgery may
be necessary.
"First-ine" rheumatoid arthritis medications
(cetylsalicylate 'aspirin), napro%en'8aprosyn), ibuprofen '(dil, /edipren, /otrin),
and etodolac ';odine) are e%amples of nonsteroidal anti:inflammatory drugs '83(IDs).
83(IDs are medications that can reduce tissue inflammation, pain, and swelling.
83(IDs are not cortisone. (spirin, in doses higher than those used in treating
headaches and feer, is an effectie anti:inflammatory medication for rheumatoid
arthritis. (spirin has been used for joint problems since the ancient &gyptian era. The
newer 83(IDs are just as effectie as aspirin in reducing inflammation and pain and
re4uire fewer dosages per day. +atients* responses to different 83(ID medications ary.
Therefore, it is not unusual for a doctor to try seeral 83(ID drugs in order to identify the
most effectie agent with the fewest side effects. The most common side effects of
aspirin and other 83(IDs include stomach upset, abdominal pain, ulcers, and een
gastrointestinal bleeding. In order to reduce gastrointestinal side effects, 83(IDs are
usually taken with food. (dditional medications are fre4uently recommended to protect
the stomach from the ulcer effects of 83(IDs. These medications include
antacids,sucralfate 'Carafate), proton:pump inhibitors'+reacid and others),
and misoprostol'Cytotec). 8ewer 83(IDs include selectieCo%:B inhibitors, such
as celeco%ib'Celebre%), which offer anti:inflammatory effects with less risk of stomach
irritation and bleeding risk.
Corticosteroid medications can be gien orally or injected directly into tissues and joints.
They are more potent than 83(IDs in reducing inflammation and in restoring joint
mobility and function. Corticosteroids are useful for short periods during seere flares of
disease actiity or when the disease is not responding to 83(IDs. .oweer,
corticosteroids can hae serious side effects, especially when gien in high doses for
long periods of time. These side effects include weight gain, facial puffiness, thinning of
the skin and bone, easy bruising, cataracts, risk of infection, muscle wasting, and
destruction of large joints, such as the hips. Corticosteroids also carry some increased
risk of contracting infections. These side effects can be partially aoided by gradually
tapering the doses of corticosteroids as the indiidual achiees improement in
symptoms. (bruptly discontinuing corticosteroids can lead to flares of the disease or
other symptoms of corticosteroid withdrawal and is discouraged. Thinning of the bones
due to osteoporosis may be preented by calcium and itamin D supplements.
"!econd-ine" or "sow-acting" rheumatoid arthritis drugs
("isease-modifying anti-rheumatic drugs or "#AR"s)
-hile !first:line! medications '83(IDs and corticosteroids) can reliee joint inflammation
and pain, they do not necessarily preent joint destruction or deformity. Rheumatoid
arthritis re4uires medications other than 83(IDs and corticosteroids to stop progressie
damage to cartilage, bone, and adjacent soft tissues. The medications needed for ideal
management of the disease are also referred to as disease:modifying antirheumatic
drugs or D/(RDs. They come in a ariety of forms and are listed below. These
!second:line! or !slow:acting! medicines may take weeks to months to become effectie.
They are used for long periods of time, een years, at arying doses. If ma%imally
effectie, D/(RDs can promote remission, thereby retarding the progression of joint
destruction and deformity. 3ometimes a number of D/(RD second:line medications are
used together as combination therapy. (s with the first:line medications, the doctor may
need to try different second:line medications before treatment is optimal.
Recent research suggests that patients who respond to a D/(RD with control of the
rheumatoid disease may actually decrease the known risk 'small but real)
of lymphoma 'cancer of lymph nodes) that e%ists from simply haing rheumatoid arthritis.
The arious aailable D/(RDs are reiewed ne%t.
.ydro%ychloro4uine '+la4uenil) is related to4uinine and is also used in the treatment
ofmalaria. It is used oer long periods for the treatment of rheumatoid arthritis. +ossible
side effects include upset stomach, skin rashes, muscle weakness, and ision changes.
&en though ision changes are rare, people taking +la4uenil should be monitored by an
eye doctor 'ophthalmologist).
3ulfasalazine '(zulfidine) is an oral medication traditionally used in the treatment of mild
to moderately seere inflammatory bowel diseases, such as ulceratie
colitis and Crohn*s colitis. (zulfidine is used to treat rheumatoid arthritis in combination
with anti:inflammatory medications. (zulfidine is generally well tolerated. Common side
effects include rash and upset stomach. ,ecause (zulfidine is made up of sulfa and
salicylate compounds, it should be aoided by people with known sulfa allergies.
/ethotre%ate has gained popularity among doctors as an initial second:line drug
because of both its effectieness and relatiely infre4uent side effects. It also has an
adantage in dose fle%ibility 'dosages can be adjusted according to needs).
/ethotre%ate is an immunosuppressie drug. It can affect the bone marrow and the lier,
een rarely causing cirrhosis. (ll people taking methotre%ate re4uire regular blood tests
to monitor blood counts and lier function.
Cold salts hae been used to treat rheumatoid arthritis throughout most of the past
century. Cold thioglucose '3olganal) and gold thiomalate '/yochrysine) are gien by
injection, initially on a weekly basis, for months to years. <ral gold, auranofin 'Ridaura),
was introduced in the 0D"#s. 3ide effects of gold 'oral and injectable) include skin rash,
mouth sores, kidney damage with leakage of protein in the urine, and bone marrow
damage withanemia and low white cell count. Those receiing gold treatment are
regularly monitored with blood and urine tests. <ral gold can causediarrhea. These gold
drugs hae lost faor because of the aailability of more effectie treatments.
D:penicillamine 'Depen, Cuprimine) can be helpful in selected cases of progressie
forms of rheumatoid arthritis. 3ide effects are similar to those of gold. They
include feer, chills, mouth sores, a metallic taste in the mouth, skin rash, kidney and
bone marrow damage, stomach upset, and easybruising. +eople taking this medication
re4uire routine blood and urine tests. D:penicillamine can rarely cause symptoms of
other autoimmune diseases and is no longer commonly used for the treatment of
rheumatoid arthritis.
Immunosuppressie medicines are powerful medications that suppress the body*s
immune system. ( number of immunosuppressie drugs are used to treat rheumatoid
arthritis. They include methotre%ate as described
aboe,azathioprine 'Imuran), cyclophosphamide 'Cyto%an), chlorambucil';eukeran),
and cyclosporine '3andimmune). ,ecause of potentially serious side effects,
immunosuppressie medicines 'other than methotre%ate) are generally resered for
those who hae ery aggressie disease or those with serious complications of
rheumatoid inflammation, such as blood essel inflammation 'asculitis). The e%ception
is methotre%ate, which is not fre4uently associated with serious side effects and can be
carefully monitored with blood testing. /ethotre%ate has become a preferred second:line
medication as a result.
Immunosuppressie medications can depress bone:marrow function and cause anemia,
a low white cell count, and low platelet counts. ( low white count can increase the risk of
infections, while a low platelet count can increase the risk of bleeding. /ethotre%ate
rarely can lead to lier cirrhosis, as described aboe, and allergic reactions in the lung.
Cyclosporine can cause kidney damage and high blood pressure. ,ecause of potentially
serious side effects, immunosuppressie medications are used in low doses, usually in
combination with anti:inflammatory agents.
What are newer treatments for rheumatoid arthritis?
8ewer !second:line! drugs for the treatment of rheumatoid arthritis
include leflunomide'(raa) and the !biologic!
medicationsetanercept '&nbrel), infli%imab 'Remicade),anakinra 'Eineret), adalimumab '
.umira),ritu%imab 'Ritu%an), abatacept '<rencia),golimumab '3imponi), certolizumab
pegol'Cimzia), and tocilizumab '(ctemra). &ach of these medications can increase the
risk for infections, and the deelopment of any infections should be reported to the
health:care professional when taking these newer second:line drugs.
;eflunomide '(raa) is aailable to reliee the symptoms and halt the progression of the
disease. It seems to work by blocking the action of an important enzyme that has a role
in immune actiation. (raa can cause lier disease, diarrhea, hair loss, and7or rash in
some people. It should not be taken just before or during pregnancy because of
possible birth defects and is generally aoided in women who might become pregnant.
8ewer medications that represent a noel approach to the treatment of rheumatoid
arthritis are products of modern biotechnology. These are referred to as the biologic
medications or biological response modifiers. In comparison with traditional D/(RDs,
the biologic medications hae a much more rapid onset of action and can hae powerful
effects on stopping progressie joint damage. In general, their methods of action are
also more directed, defined, and targeted.
&tanercept, infli%imab, adalimumab, golimumab, and certolizumab pegol are biologic
medications that intercept a messenger protein in the joints 'tumor necrosis factor or
T89) that promotes inflammation of the joints in rheumatoid arthritis. These T89:
blockers intercept T89 before it can act on its natural receptor to !switch on! the process
of inflammation. This effectiely blocks the T89 inflammation messenger from recruiting
the cells of inflammation. 3ymptoms can be significantly, and often rapidly, improed in
those using these drugs. &tanercept must be injected subcutaneously once or twice a
week. Infli%imab is gien by infusion directly into a ein 'intraenously). (dalimumab is
injected subcutaneously either eery other week or weekly. Colimumab is injected
subcutaneously on a monthly basis. Certolizumab pegol is injected subcutaneously
eery two to four weeks. &ach of these medications is being ealuated by doctors in
practice to determine what role they may hae in treating patients in arious stages of
rheumatoid arthritis. Research has shown that biological response modifiers also
preent the progressie joint destruction of rheumatoid arthritis. They are currently
recommended for use after other second:line medications hae not been effectie. The
biological response modifiers 'T89:inhibitors) are e%pensie treatments. They are also
fre4uently used in combination with methotre%ate and other D/(RDs. 9urthermore, it
should be noted that the T89:blocking biologics all are more effectie when combined
with methotre%ate. These medications should be aoided by people with
significant congestie heart failure or demyelinating diseases 'such as multiple sclerosis)
because they can worsen these conditions.
(nakinra is another biologic treatment that is used to treat moderate to seere
rheumatoid arthritis. (nakinra works by binding to a cell messenger protein 'I;:0, a
proinflammatory cytokine). (nakinra is injected under the skin daily. (nakinra can be
used alone or with other D/(RDs. The response rate of anakinra does not seem to be
as high as with other biologic medications.
Ritu%imab is an antibody that was first used to treat lymphoma, a cancer of the lymph
nodes. Ritu%an can be effectie in treating autoimmune diseases like rheumatoid arthritis
because it depletes ,:cells, which are important cells of inflammation and in the
production of abnormal antibodies that are common in these conditions. Ritu%an is now
aailable to treat moderate to seerely actie rheumatoid arthritis in patients who hae
failed treatment with the T89:blocking biologics. +reliminary studies hae shown that
Ritu%an was also found to be beneficial in treating seere rheumatoid arthritis
complicated by blood essel inflammation 'asculitis) and cryoglobulinemia. Ritu%imab is
an intraenous infusion gien in two doses, two weeks apart, appro%imately eery si%
months.
(batacept is a biologic medication that blocks T:cell actiation. <rencia is now aailable
to treat adult patients who hae failed treatment with a traditional D/(RD or T89:
blocking biologic medication. (batacept is an intraenous infusion gien monthly.
Tocilizumab has recently been approed for the treatment of adult patients with
moderately to seerely actie rheumatoid arthritis 'R() who hae had an inade4uate
response to one or more tumor necrosis factor 'T89) antagonist therapies. Tocilizumab
is the first approed biologic medication that blocks interleukin:6 'I;:6), which is a
chemical messenger of the inflammation of rheumatoid arthritis. Tocilizumab is an
intraenous infusion gien monthly.
-hile biologic medications are often combined with traditional D/(RDs in the treatment
of rheumatoid arthritis, they are generally not used with other biologic medications
because of the unacceptable risk for serious infections.
The +rosorba column therapy inoles pumping blood drawn from a ein in the arm into
an apheresis machine, or cell separator. This machine separates the li4uid part of the
blood 'the plasma) from the blood cells. The +rosorba column is a plastic cylinder about
the size of a coffee mug that contains a sand:like substance coated with a special
material called +rotein (. +rotein ( is uni4ue in that it binds unwanted antibodies from
the blood that promote the arthritis. The +rosorba column works to counter the effect of
these harmful antibodies. The +rosorba column is indicated to reduce the signs and
symptoms of moderate to seere rheumatoid arthritis in adult patients with long:standing
disease who hae failed or are intolerant to disease:modifying antirheumatic drugs
'D/(RDs). The e%act role of this treatment is being ealuated by doctors, and it is not
commonly used currently.
Rheumatoid arthritis diet and other treatments
There is no special diet or diet !cure! for rheumatoid arthritis. <ne hundred years ago, it
was touted that !night:shade! foods, such as tomatoes, would aggraate rheumatoid
arthritis. This is no longer accepted as true. 9ish oil may hae anti:inflammatory
beneficial effects, but so far this has only been shown in laboratory e%periments studying
inflammatory cells. ;ikewise, the benefits of cartilage preparations remain unproen.
3ymptomatic pain relief can often be achieed with oral acetaminophen 'Tylenol) or
oer:the:counter topical preparations, which are rubbed into the skin. (ntibiotics, in
particular the tetracycline drug minocycline'/inocin), hae been tried for rheumatoid
arthritis recently in clinical trials. &arly results hae demonstrated mild to moderate
improement in the symptoms of arthritis. /inocycline has been shown to impede
important mediator enzymes of tissue destruction, called metalloproteinases, in the
laboratory as well as in humans.
The areas of the body other than the joints that are affected by rheumatoid inflammation
are treated indiidually. 3jogren*s syndrome 'described aboe, see symptoms) can be
helped by artificial tears and humidifying rooms of the home or office. /edicated
eyedrops, cyclosporine ophthalmic drops'Restasis), are also aailable to help the dry
eyes in those affected. Regular eye checkups and early antibiotic treatment for infection
of the eyes are important. Inflammation of the tendons 'tendinitis), bursae 'bursitis), and
rheumatoid nodules can be injected with cortisone. Inflammation of the lining of the heart
and7or lungs may re4uire high doses of oral cortisone.
+roper, regular e%ercise is important in maintaining joint mobility and in strengthening
the muscles around the joints. 3wimming is particularly helpful because it allows
e%ercise with minimal stress on the joints. +hysical and occupational therapists are
trained to proide specific e%ercise instructions and can offer splinting supports. 9or
e%ample, wrist and finger splints can be helpful in reducing inflammation and maintaining
joint alignment. Deices such as canes, toilet seat raisers, and jar grippers can assist in
the actiities of daily liing. .eat and cold applications are modalities that can ease
symptoms before and after e%ercise.
3urgery may be recommended to restore joint mobility or repair damaged joints. Doctors
who specialize in joint surgery are orthopedic surgeons. The types of joint surgery range
from arthroscopy to partial and complete replacement of the joint. (rthroscopy is a
surgical techni4ue whereby a doctor inserts a tube:like instrument into the joint to see
and repair abnormal tissues.
Total joint replacement is a surgical procedure whereby a destroyed joint is replaced
with artificial materials. 9or e%ample, the small joints of the hand can be replaced with
plastic material. ;arge joints, such as the hips orknees, are replaced with metals.
9inally, minimizing emotional stress can help improe the oerall health in people with
rheumatoid arthritis. 3upport and e%tracurricular groups proide those with rheumatoid
arthritis time to discuss their problems with others and learn more about their illness.
What is the outoo$ (prognosis) for patients with rheumatoid
arthritis?
-ith early, aggressie treatment, the outlook for those affected by rheumatoid arthritis
can be ery good. The oerall attitude regarding ability to control the disease has
changed tremendously since the turn of the century. Doctors now strie to eradicate any
signs of actie disease while preenting flare:ups. The disease can be controlled and a
cooperatie effort by the doctor and patient can lead to optimal health.
+atients hae a less faorable outlook when they hae deformity, disability, ongoing
uncontrolled joint inflammation, and7or rheumatoid disease affecting other organs of the
body. <erall, rheumatoid arthritis tends to be potentially more damaging when
rheumatoid factor or citrulline antibody is demonstrated by blood testing.
Future treatments for rheumatoid arthritis
3cientists throughout the world are studying many promising areas of new treatment
approaches for rheumatoid arthritis. Indeed, treatment guidelines are eoling with the
aailability of newer treatments. These areas include treatments that block the action of
the special inflammation factors, such as tumor necrosis factor 'T89alpha), ,:cell and T:
cell function, as well as interleukin:0 'I;:0), as described aboe. /any other drugs are
being deeloped that act against certain critical white blood cells inoled in rheumatoid
inflammation. (lso, new 83(IDs with mechanisms of action that are different from
current drugs are on the horizon.
,etter methods of more accurately defining which patients are more likely to deelop
more aggressie disease are becoming aailable. Recent antibody research has found
that the presence of citrulline antibodies in the blood 'see aboe, in diagnosis) has been
associated with a greater tendency toward more destructie forms of rheumatoid
arthritis.
3tudies inoling arious types of the connectie tissue collagen are in progress and
show encouraging signs of reducing rheumatoid disease actiity. 9inally, genetic
research and engineering is likely to bring forth many new aenues for earlier diagnosis
and accurate treatment in the near future. Cene profiling, also known as gene array
analysis, is being identified as a helpful method of defining which people will respond to
which medications. 3tudies are under way that are using gene array analysis to
determine which patients will be at more risk for more aggressie disease. This is all
occurring because of improements in technology. -e are at the threshold of
tremendous improements in the way rheumatoid arthritis is managed.