Rheumatoid Arthritis Treatment

What is Rheumatoid Arthritis?

Rheumatoid arthritis is a very common type of inflammatory joint disease that results in pain and swelling in the joints, especially the hands and wrists. The disease is mostly seen in middle-aged women (peaks between 30 and 50 years). It can lead to significant joint destruction and immobility if treatment is not initiated early in patients with severe disease.

Since this is such a common condition and may affect quality of life, it is important to become educated about its causes, diagnosis, and treatment.  By the end of this article, you will be able to answer the following important questions:

What causes Rheumatoid Arthritis?

The origin of rheumatoid arthritis has not been fully elucidated, but experts believe the condition occurs in patients with a genetic predisposition and exposure to certain environmental factors.  Risk factors include family history, smoking history, female gender, and older age.

Rheumatoid arthritis is a form of autoimmune disease – these diseases are characterized by the inappropriate activation of the immune response against normal tissues in the body.  This leads to tissue and joint inflammation, especially in the hands and wrists.  Inflammation causes joint stiffness, immobility, and pain – long-term inflammation can lead to scarring and bone destruction.

How common is Rheumatoid Arthritis?

Rheumatoid arthritis is one of the most common inflammatory joint conditions and often requires referral to a rheumatologist (medical joint specialist).  It currently affects approximately 1.3 million Americans, which makes up about 1% of the United States population. The condition is most frequently seen in women aged 30-50.

What are the symptoms and signs of Rheumatoid Arthritis?

The most common symptoms of rheumatoid arthritis include:

  • Hand pain
  • Hand swelling and inflammation
  • Joint stiffness
  • Decreased joint mobility
  • Fatigue

Symptoms are usually worse in the first hour of the day and gradually improve with increased joint use – this is an important distinction between rheumatoid arthritis and osteoarthritis.  Osteoarthritis pain usually worsens throughout the day.

Interestingly, patients with rheumatoid arthritis who become pregnant usually have an improvement in their symptoms during pregnancy, but are at an increased risk for flare post-pregnancy.

Patients with long-term untreated disease can develop significant joint destruction and severely reduced mobility.  Rheumatoid arthritis commonly involves the hands and wrists – therefore, patients may lose the ability to use their hands for daily activities such as cooking, eating, bathing, and maintaining proper hygiene.  The condition can be severely debilitating and may significantly reduce quality of life.

Patients may occasionally develop other manifestation of the disease.  This can include the formation of rheumatoid nodules.  These nodules are full of calcium and can appear as hard, white or yellow, bumps that deposit on the surface of joints (e.g. elbows) and on the ears.

Patients may also develop organ inflammation and pericarditis (inflammation of the heart sac).  Some have intermittent eye inflammation – a condition called scleritis.  Others can develop peripheral nerve damage (neuropathy).

How is Rheumatoid Arthritis diagnosed?

Rheumatoid arthritis is diagnosed based on the patient’s symptoms, physical examination findings, and presence of certain blood test findings.

Your doctor will typically order a complete blood cell count, comprehensive metabolic pain, ESR (erythrocyte sedimentation rate), and CRP (C-reactive protein).  They will also likely obtain more specific tests such as RF (rheumatoid factor) and anti-CCP.  If your joint is significantly swollen, red, and warm, your doctor may perform a joint tap (arthrocentesis) to rule out an infection or other forms of inflammatory arthritis (eg. gout).

X-rays of the affected joints are also typically obtained in addition to the laboratory tests we have already covered.  X-rays may show evidence of erosions at the joint line – severe joint deformity can also be seen in severe cases.

How is Rheumatoid Arthritis treated?

The treatment of rheumatoid arthritis depends on disease severity.  Mild cases that occur infrequently may be treated with the intermittent use of non-steroidal anti-inflammatory drugs (NSAIDs).  Some of the most commonly prescribed NSAIDs include:

  • Advil (ibuprofen)
  • Naprosyn (naproxen)
  • Celebrex (celecoxib)
  • Mobic (meloxicam)

Moderate to severe cases of rheumatoid arthritis may necessitate the use of oral corticosteroids such as prednisone or Medrol (Solumedrol).  These medications work my reducing inflammation in the joints, thereby decreasing pain and tissue swelling.  Corticosteroids are generally not used long term due to their potential side effects (e.g. weight gain, diabetes, osteoporosis).  They should also be used cautiously in patients with a history of stomach ulcers and gastrointestinal bleeding.

Some patients will be initiated on a treatment called Trexall (methotrexate).  Your doctor may recommend checking regular complete cell counts while taking this medication.  They may also recommend a class of medications called biologics.  Some of the most common drugs within this class include:

  • Enbrel (etanercept)
  • Remicade (infliximab)
  • Humira (adalimumab)

Your doctor may test you for tuberculosis prior to starting any of these medications.

Patients with severe joint destruction and impaired mobility may require surgery.

Rheumatoid Arthritis Patient Summary:

  • Rheumatoid is a common inflammatory joint condition that typically involves the hands and affects women age 30-50.
  • Patients typically develop recurrent episodes of swelling, stiffness, and reduced mobility in the joints (especially hands) within the first hour of awakening – pain tends to improve throughout the day and with joint activity.
  • Other manifestations of the disease include the deposition of hard nodules (rheumatoid nodules) on joint surfaces such as the elbow. Patients can also develop pericarditis, eye inflammation (scleritis), and peripheral neuropathy
  • The diagnosis of rheumatoid arthritis depends on symptoms, physical examination findings, and laboratory tests such as RF and anti-CCP. Joint x-rays are also usually obtained.
  • Mild cases may be treated with NSAIDS (eg. Advil, Aleve, Naproxen, Celebrex).
  • Moderate to severe cases may require the short-term use of corticosteroids (eg. prednisone, Medrol – Solumedrol).
  • Some patients can benefit from treatment with Trexall (methotrexate).
  • Your rheumatologist may also recommend biologic medications such as Enbrel (etanercept), Remicade (infliximab), or Humira (adalimumab) – they usually test you for tuberculosis prior to starting treatment.
  • Patients with severe joint destruction that interrupts with daily activities may require surgery.

 

References:

  1. Wasserman AM1. Diagnosis and management of rheumatoid arthritis. Am Fam Physician. 2011 Dec 1;84(11):1245-52.
  2. Smolen JS, Aletaha D, McInnes IB. Rheumatoid arthritis. Lancet. 2016 Oct 22;388(10055):2023-2038.

Popular Rheumatoid Arthritis Medications

The above information is an educational aid only. It is not intended as medical advice for individual conditions or treatments. Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you.