Rheumatoid Arthritis

What is rheumatoid arthritis?

Rheumatoid arthritis (RA) is a form of inflammatory arthritis caused by an autoimmune disorder. This means that your immune system mistakenly recognises some tissue or organ as foreign or potentially threatening, and inadvertently attacks it. During RA, this tissue is the synovium, a fibrous membrane that coats the inside of your joint cavities. As a consequence, severe inflammation is initiated. This results in significant corrosive damage to the interior of a joint through the release of several highly caustic protein-dissolving enzymes. Besides damaging the synovium, these enzymes also progressively degrade all other adjacent joint components, such as cartilage, tendons, ligaments and bone. In a more advanced stage, progressive tissue destruction can cause a joint to lose its shape and alignment, and become visibly distorted.

What causes rheumatoid arthritis?

Although the underlying mechanism involves the body’s immune system attacking the joints, the exact trigger is still not clearly understood and is generally believed to involve a combination of genetic and environmental factors:

• Family history – if a direct member of your family has had rheumatoid arthritis, you are at an increased risk. While your genes don’t directly cause rheumatoid arthritis, they can make you more prone to environmental factors such as infection, which may activate your immune system.
• Smoking – cigarette smoke is the most significant non-genetic risk factor. Rheumatoid arthritis is three times more common in smokers than non-smokers, particularly among men.
• Infections – certain viruses and bacteria are suspected to increase the risk. Epidemiological studies have confirmed a potential association between rheumatoid arthritis and two viral infections, namely Epstein-Barr virus (EBV) and Human Herpes Virus 6 (HHV-6).
• Gender – women are more likely to develop rheumatoid arthritis. The disease may improve during pregnancy and flare up afterwards, while breastfeeding may aggravate the disease. Additionally, a person’s likelihood of developing RA may be increased slightly by hormonal contraceptive use. These observations suggest that certain female hormones, or possibly deficiencies or changes in the response to hormones, promote the development of rheumatoid arthritis in a genetically susceptible woman who has been exposed to an environmental trigger.
• Age – although rheumatoid arthritis can occur at any age, it is more common after the age of 40.

What are the symptoms of rheumatoid arthritis?

Rheumatoid arthritis typically manifests with signs of inflammation in the joint. Specifically, the affected joint becomes swollen, warm, painful and stiff. A prominent feature which distinguishes RA from osteoarthritis is increased morning stiffness upon waking, which typically lasts for up to an hour. The small joints of the hands, feet and cervical spine, are most commonly affected, but larger joints like the shoulders, elbows, hips, knees, and ankles can also be involved. Gentle movements may relieve symptoms in early stages of the disease. The following symptoms are common:

• Swollen, tender, warm, and stiff joints.
• More than one joint involved at the same time (polyarthritis).
• Both large- and small-joints (fingers) involved at the same time.
• Symmetrical pattern, namely similar joints on both sides of the body are simultaneously involved.
• Inflammation in the fingers mostly affects the finger-joints closest to the hand (Osteoarthritis affects the opposite joints).
• Morning stiffness which lasts more than 30 minutes.
• General symptoms such as fatigue, low grade fever, malaise, loss of appetite and loss of weight.
• Deformity of joints and fingers in more advanced cases.

What are the common complications of rheumatoid arthritis?

Although rheumatoid arthritis predominantly affects the synovium and therefore causes joint disease, the inflammatory process activated by the immune system may have a detrimental effect on other organs. Examples are:

• Skin – the appearance of subcutaneous lumps called rheumatoid nodules. These range from a few millimetres to a few centimetres in size and are usually found over bony prominences, such as the elbow, the heel, the knuckles, or other areas of skin exposed to repeated mechanical stress.
• Lungs – fibrosis or scaring of the lungs may occur, either as a direct result of the disease or as consequence of treatment (methotrexate and leflunomide).
• Kidneys – chronic damage from inflammation. Treatment with penicillamine and gold salts may also lead to renal disease.
• Heart and blood vessels – individuals with rheumatoid arthritis are more prone to hardening of the arteries (atherosclerosis). Risk of heart attack (myocardial infarction) and stroke is therefore markedly increased.
• Eyes – inflammation of the sclera (episcleritis) and dry eye syndrome.
• Blood – anaemia caused by a variety of mechanisms.
• Neurological – peripheral neuropathy and carpal tunnel syndrome.
• Bones – osteoporosis, both local (around inflamed joints) and systemic. This is caused by immobility, inflammation (as a result of certain inflammatory signalling molecules called cytokines), as well as corticosteroid therapy.

How is rheumatoid arthritis treated?

The goals of treatment are:

• To relieve pain.
• To reduce inflammation.
• To slow or stop joint damage.
• To improve a person’s sense of well-being and ability to function.

Current treatment approaches are:

• Medication
• Lifestyle strategies
• Surgery
• Routine monitoring and ongoing care

Medication:

• Disease-modifying anti-rheumatic drugs (DMARDs) – these are the primary treatment for RA and have been found to improve symptoms, decrease joint damage, and improve overall DMARDs should ideally be started early in the disease since they result in disease remission in approximately half of patients. They comprise a diverse collection of different drugs grouped according to their pharmaceutical function. Common DMARDs include methotrexate, hydroxychloroquine, leflunomide, and sulfasalazine. Other DMARDs, called biologic response modifiers, may be used in people with more serious disease. These are genetically engineered medications that reduce inflammation and structural damage to the joints by interrupting the cascade of events that cause inflammation. Examples are abatacept, adalimumab, anakinra, certolizumab, etanercept, golimumab, infliximab, rituximab, tocilizumab, and tofacitinib. (Ask your rheumatologist for advice).
• Anti-inflammatory drugs (NSAID’s) – these include the COX-2 inhibitors and reduce both pain and stiffness in those with RA. Generally, no effect on people’s long term disease course is observed and are therefore no longer first line agents. NSAIDs should be used with caution in those with increased risk of gastrointestinal, cardiovascular, or kidney disease. (Ask your doctor or pharmacist for advice).
• Steroids – glucocorticoids can be used over the short term for acute flare-ups, especially when waiting for slow-onset drugs to take effect. Injections of glucocorticoids into individual joints are also effective. While long-term use reduces joint damage, it also results in osteoporosis and an increased susceptibility to infections. (Ask your doctor for advice).
• Analgesics – paracetamol (acetaminophen) and opiates or opiate derivatives are often required to help alleviate acute pain. These drugs serve as symptomatic relief, lowering the sensation of pain, but do not combat the underlying cause. Opiates may cause drowsiness, constipation and addiction. (Ask your doctor or pharmacist for advice).

Lifestyle strategies:

• Exercise – regular exercise is recommended as both safe and useful to maintain muscle strength and overall physical function. However, individuals with rheumatoid arthritis need to balance rest and exercise, with more rest during stages when the disease is active and more exercise when it is not. Rest reduces active joint inflammation, pain, and fatigue. Resting time varies from person to person, but shorter rest breaks are generally more helpful than long times spent in bed. Exercise is important for maintaining healthy and strong muscles, preserving joint mobility, maintaining flexibility, improving sleep better, reducing pain, maintaining a positive attitude, and managing weight. Exercise programs should take into account the person’s physical abilities, limitations, and changing needs. Contracting muscles also release substances called myokines, which promote the growth of new tissue and facilitate tissue repair. Myokines have multiple anti-inflammatory effects, which in turn reduce your overall risk of developing various other inflammatory diseases such as cardiovascular disease.
• Use supplements that combat inflammation – various natural molecules derived from plants are highly effective in suppressing pathways involved in chronic inflammation. These generally have a low side-effect risk, making the approach attractive when compared to other pharmaceuticals. RheumaLin™ is a novel multi-modal, multi-target anti-inflammatory supplement that consists of two plant extracts, Boswellia bark extract and resveratrol. These naturally derived phytochemical (plant based) compounds are widely recognised, and combat inflammation via different biochemical mechanisms compared to existing anti-inflammatory drugs. [read more about RheumaLin …]
• Hot or cold packs – applying a heat pack to inflamed joints can help to ease pain. You can use a microwavable heat pad or hot-water bottle. Heat alters the sensation of pain. Cold (for example a bag of frozen peas) may reduce inflammation by decreasing the size of blood vessels and the flow of blood to the area, and may reduce the sensation of pain through reducing nerve activity.
• Rehabilitation therapies – Physiotherapy, biokinetics, or occupational therapy will prove helpful.
• Joint care – supporting an inflamed joint and allowing it to rest often reduces pain and swelling. Splints are useful for wrists, hands, ankles, and feet. Other ways to reduce stress on joints include self-help devices such as zipper pullers and long-handled shoe horns. Devices to assist with getting on and off chairs, toilet seats, and beds may also be required.
• Stress reduction – besides physical hardship, individuals with rheumatoid arthritis face several emotional challenges as well. Distress, anger, and frustration stem from the disease itself, aggravated by chronic pain and physical limitations. These increase levels of stress which also increase the amount of pain that one experiences. There are a number of successful techniques for coping with stress.