What Is Rheumatoid Arthritis?

Rheumatoid arthritis (RA for short) is a chronic disease that causes pain, stiffness, swelling, and limitation in the motion and function of multiple joints. If left untreated, or improperly treated, RA can produce serious destruction of one or more joints which frequently leads to permanent disability. Though the joints are the principal body part affected by RA, inflammation can develop in other body organs as well.

What Is The Cause Of RA?

RA is classified as an autoimmune disease in which certain cells of the immune system malfunction and attack healthy joints. While the cause of RA remains unknown, exciting, rapidly advancing research is revealing the factors that are important in producing inflammation, and giving us a better understanding of the genetic factors that may be involved in the disease. As a result of this work, new medications have been developed that specifically block certain reactions in the body that are important in causing the symptoms and joint damage of RA. These medications are useful additions to the treatments available for RA.

Who Develops RA?

More than 2 million Americans suffer from RA. Most, about 75% or 3 out of 4 patients, are women. The peak onset is between 20 and 45 years of age.

What Are The Symptoms Of RA?

Pain, stiffness, swelling, redness and difficulty moving the joints through a full range of motion are most commonly reported. The stiffness seen in active RA is typically worst in the morning and lasts anywhere from 1-2 hours to the entire day. This long period of morning stiffness is an important diagnostic clue as not many other arthritic diseases behave this way. While RA can affect just about any joint, some joints, especially those of the hands and feet, tend be involved more frequently than others. This produces a pattern of joint disease that rheumatologists regard as characteristic of RA. In addition to the above complaints, other symptoms that can occur in RA include:

- loss of energy
- low-grade fevers
- loss of appetite
- dry eyes and mouth producing a condition known as Sjogren’s (pronounced “show-grens”) Syndrome
- soft skin lumps in areas such as the elbow and hands called rheumatoid nodules
How Is RA Diagnosed?

RA can be difficult to diagnose because it may begin gradually with subtle symptoms. Many diseases, especially early on, can behave similarly to RA. For this reason, patients suspected as suffering from RA should be evaluated by a rheumatologist – a physician with the necessary skill and experience to reach a precise diagnosis and develop the most appropriate treatment plan.

The diagnosis of RA is based on the symptoms described and typical physical examination findings characterized by warmth, swelling and pain in the joints. Additionally, certain laboratory abnormalities such as anemia (low red blood cells), a positive rheumatoid factor (an antibody found in approximately 80% of RA patients), and an elevated erythrocyte sedimentation rate or “sed rate” (a blood test that in most patients with RA tends to correlate with the amount of inflammation in the joints) are commonly found in RA and are utilized by physicians as diagnostic aids. X-rays can be very helpful in diagnosing RA and are useful in determining if the disease is progressing.

It is important to remember that for the majority of patients with this disease (especially those who’ve had symptoms of 6 months or less in duration), there is no single test, whether of the blood or an X-ray, which “confirms” a diagnosis of RA. Rather, the diagnosis is typically established when the physician skillfully combines the appropriate symptoms, physical examination findings, laboratory tests and X-rays.

What Is The Treatment Of RA?

Therapy for patients with RA has improved dramatically over the past 25 years. Current treatments offer most patients good to excellent relief of symptoms and the ability to continue to function at or near normal levels. Since there is no cure for RA, the goal of treatment is to minimize patients’ symptoms and disability by introducing appropriate drug therapy early in the course of the disease before permanent damage to the joints has occurred. No one treatment is effective for all patients, and many patients will need to change therapies during the course of their disease.

Successful management of RA requires early diagnosis and, at times, aggressive treatment. Non-steroidal anti-inflammatory drugs (most commonly referred to as NSAIDs, such as ibuprofen or naproxen), and/or corticosteroids (such as prednisone) given orally at low doses or via injection into the joints may be used first with the primary aim of quickly reducing joint inflammation.

However, all RA patients with persistent swelling in the joints are candidates for treatment with disease-modifying anti-rheumatic drugs (called DMARDs for short) that are typically used in conjunction with NSAIDs and/or low dose corticosteroids. The DMARD class of drugs has greatly improved the symptoms and function as well as the quality of life for the vast majority of patients with RA. DMARDs include: methotrexate (Rheumatrex ® and Folex ®), hydroxychloroquine (Plaquenil ®), sulfasalazine (Azulfidine ®), gold given orally (Auranofin ®) or intramuscularly (Myochrisine ®), minocycline (Minocin ®, Dynacin ® and Vectrin ®), azothiaprine (Imuran ®), cyclosporine (Sandimmune ® and Neoral ®), leflunomide (Arava ®).

A new class of medications, referred to as biologic disease response modifiers or “biologic agents” can specifically target parts of the immune system that lead to joint and tissue damage in RA. FDA approved treatments include agents etanercept (Enbrel ®), infliximab (Remicade ®), adalimumab (Humira ®), and anakinra (Kineret ®). The optimal treatment of RA requires comprehensive coordinated care, patient education and the expertise of a number of providers, including rheumatologists, primary care physicians, and physical and occupational therapists.

What Is The Role Of The Rheumatologist In The Diagnosis And Management Of RA?

RA has been a primary focus of rheumatologic research. The chronic nature of RA, along with its diagnostic and treatment complexity, have made the rheumatologist’s special skills and advanced training critically important in providing optimal care to people suffering from this disease.

Expertise is particularly needed to establish a diagnosis of RA early, to exclude diseases that mimic RA (thereby avoiding unnecessary testing, drug therapy and costs) and to design a treatment plan that is best suited and customized for the patient and addresses the need for and the risks and benefits of DMARD therapy. Accordingly, the rheumatologist, working in concert with the primary care physician and other health care givers, should play the major role in outlining, implementing and supervising the management of the patient with RA.

Studies have shown that people who receive early treatment of RA feel better, are likely to be able to be lead an active life, and are less likely to have joint damage that leads to joint replacement.