Rheumatoid Arthritis – Diagnosis, Symptoms, and Treatment

What is Rheumatoid Arthritis?

Rheumatoid arthritis is an inflammatory joint disease. These types of diseases generally involve the immune system attacking the tissues of the joints for one reason or another, this makes them a form of autoimmune disease. 

Rheumatoid arthritis has a tendency to affect the joints of the hands and wrists and can cause significant disability and deformity of these joints if not treated. It is most common in women over the age of 60. 

Since rheumatoid arthritis is somewhat common and many of its more disabling effects can be prevented with treatment, early recognition of this condition is very important. 

What Causes Rheumatoid Arthritis?

The exact cause of rheumatoid arthritis is uncertain, experts believe that genetics, lifestyle, and the environment we live in all play a major role in who will eventually develop rheumatoid arthritis. Some of the factors that are known to significantly increase the risk of rheumatoid arthritis are:

• Family history of rheumatoid arthritis

• Specific genetic changes known as human leukocyte antigen class II genes.

• A personal history of smoking or exposure to secondhand smoke

• Female gender

• Obesity

• Age over 60

Rheumatoid arthritis is an autoimmune disease. These diseases result from the body inappropriately recognizing its own cells as foreign and attempting to destroy them. This attack by the immune system results in inflammation. Simply put, inflammation is a process that the body uses to attract more immune system cells to an area in an attempt to quickly kill whatever foreign material the body believes to be there. The chemicals released during inflammation result in swelling, pain, and redness.

Long-term inflammation leads to severe damage that the body cannot repair. This damage results in the formation of scar tissue and destruction of the bony tissue of the joints that causes deformation, stiffness, and immobility.

How common is Rheumatoid Arthritis?

Rheumatoid arthritis is relatively common, the United States Centers for Disease Control and Prevention states that 0.24 to 1% of the U.S. population is living with rheumatoid arthritis, which is nearly 1.2 million individuals. 

Women are twice as likely to suffer from rheumatoid arthritis and are more likely to have severe rheumatoid arthritis. The same is true for individuals over the age of 60, regardless of gender. 

Signs and Symptoms

While all forms of arthritis present with joint pain, swelling, and eventual deformity rheumatoid arthritis has several unique signs and symptoms that sets it apart. The most common signs and symptoms of rheumatoid arthritis are:

• Pain in the joints, most commonly the fingers and hands. 

• Tenderness and swelling of the joints

• Stiffness and limited mobility in the affected joints

These joint symptoms almost always begin in the small joints of the fingers and are equal in severity on both sides of the body. These symptoms are almost always worse in the morning upon waking or after a long period of not using the affected joints. The inflammation that causes rheumatoid arthritis also affects the body as a whole, this leads to symptoms such as fever, fatigue, and weakness which tend to be absent in other forms of arthritis.

Long-term untreated rheumatoid arthritis results in the destruction of the cartilage and bone that makes up the joint and the accumulation of scar tissue in and around the joint. This leads to the signs and symptoms of advanced rheumatoid arthritis, the most common of which are:

• Deformity of the fingers in the hands.

• Inability to grasp, hold, or manipulate objects with the hands.

• Formation of tumor-like nodules next to the affected joints.

• General disability: 35% of patients with rheumatoid arthritis report severe work-related disability. 

In rare cases the autoimmune response that attacks the joints can also affect other organs in the body, this is most common in severe and/or untreated rheumatoid arthritis. Pericarditis - Inflammation of the lining of the heart, scleritis - inflammation of the eye, and neuropathy - damage to the sensory nerves of the skin are all seen in association with severe rheumatoid arthritis. 

Diagnosis

Your physician will generally suspect rheumatoid arthritis based on your risk factors and history of symptoms alone. In some cases, the symptoms of rheumatoid arthritis will mimic other causes of arthritis, and specialized testing will be required to rule out other more acutely dangerous conditions.

The formal diagnosis of rheumatoid arthritis is not as straightforward as other medical conditions. In order to be diagnosed, you must have at least one joint with swelling not explained by another disease. In order to rule out other diseases, the following are generally obtained:

• X-rays of the affected joints

• Complete blood count (CBC)

• Comprehensive metabolic panel (CMP)

• Blood coagulation studies 

If you have a joint that suddenly becomes red, swollen, and warm your physician may perform a test known as arthrocentesis, commonly called a “joint tap.” This allows a direct look at the fluid in the joint and helps to rule out an infection caused by bacteria in the joint. 

There are several special tests that are done in all patients suspected of having rheumatoid arthritis. These tests detect inflammation throughout the body and the presence of antibodies that are associated with autoimmune conditions. 

• Erythrocyte sedimentation rate (ESR)

• C-reactive protein (CRP)

• Anti-nuclear antibody (ANA)

• Rheumatoid factor (RF)

• Anti-citrullinated peptide antibodies (anti-CCP)

If these tests are positive it does not mean that you have rheumatoid arthritis but it will increase the confidence your physician has in your diagnosis. If you are diagnosed with rheumatoid arthritis these tests are used to monitor the severity of your disease and change treatment plans.

Rheumatoid Arthritis Treatment

Rheumatoid arthritis is treated with a combination of lifestyle changes and medical therapy. All patients with rheumatoid arthritis should be referred to a rheumatologist, a physician that specializes in the treatment of autoimmune diseases. 

The cornerstone of rheumatoid arthritis treatment is the disease modifying anti rheumatic drug (DMARD). This class of medications reduces inflammation throughout the body and limits the ability of the immune system to attack the cells in your joints. All patients can benefit from a DMARD unless they do not tolerate them or have some special contraindications that will be reviewed by your physician. The most common DMARDs are:

• • Methotrexate 

• Hydroxychloroquine

• Minocycline

• Sulfasalazine

Methotrexate is the most effective and best studied and is generally prescribed first. If this medication is ineffective another will be added to it. Patients on two DMARDs generally have fewer RA symptoms but have a greater risk of side effects. Damage to the liver and intestines are most common, regular blood tests will be ordered by your physician to watch for these complications. 

DMARDs are the only long-term therapy that is effective in rheumatoid arthritis. In some cases your physician will prescribe short term medications such as NSAIDS and corticosteroids to reduce pain and swelling during flare-ups of your arthritis symptoms. 

The most commonly prescribed NSAIDS are:

• Advil (Ibuprofen)
• Naprosyn (Naproxen)
• Celebrex (Celecoxib)
• Mobic (Meloxicam)

Corticosteroids are generally injected directly into the affected joint by your physician but may be prescribed as an oral medication to be taken daily. The most common corticosteroids are: 

• Prednisone

• Solumedrol (Medrol)

NSAIDS and corticosteroids should not be used long-term due to their significant risk of side effects when used daily. NSAIDS may result in stomach ulcers and low bone density. Corticosteroids may result in weight-gain, diabetes, and low bone density.

Finally, if the above medications do not control your symptoms there are advanced agents known as “biologics” that deactivate some of the key proteins and cells that are required for inflammation. These medications are used with caution as they increase the risk of bacterial and viral infections. The most common biologics are:

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

If all of these treatments fail to adequately control your arthritis there are some options to help you remain mobile and limit the disability that can result from the disease. The most common option is surgery to replace any damaged joints in the knees and hips. While this will not help with the pain and deformity in the hands it is a critical step for some patients with severe rheumatoid arthritis.