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Arthritis Library

Rheumatoid Arthritis

Symptoms

Early symptoms, preceding obvious joint involvement: fatigue and weakness; low-grade fever; general feeling of poor health; loss of appetite and weight loss.

Red, swollen, painful joints that may be warm to the touch. With long-term rheumatoid arthritis, joints may become bent and gnarled.

Stiffness (often the second manifestation), especially after awakening in the morning.

Red, painless skin lumps, known as rheumatoid nodules, on the elbows, knees, or toes.

Chest pain and breathing difficulty.

Dry mouth and dry, painful eyes.

When To Call Your Doctor

Make an appointment with a doctor if painful joints interfere with normal activities.


What Is It?

Rheumatoid arthritis is a common, persistent systemic disorder that can cause inflammation of joints throughout the body. Joints contain a number of structures that allow for ease of movement. The ends of the bones in a joint are protected from rubbing together by an elastic cushioning material, known as cartilage. The entire joint is surrounded by a capsule known as the synovial sac. A thin layer of tissue (synovial membrane) lines the sac and secretes synovial fluid, which provides lubrication to ease movement.

In the early stage of rheumatoid arthritis, the synovial membrane becomes inflamed and thickened, causing pain and limiting joint movement. As the disease progresses, the cartilage and the ends of the bones erode. The result is severe joint damage and deformity. Joint pain is often preceded by general, nonspecific symptoms, such as fever, fatigue, and loss of appetite. It may also be prefaced by stiffness in the joints, particularly in the morning.

The hallmark of the disorder is involvement of the small joints of the hands and wrists with painful, warm, swollen, tender, and reddish joints. The process can also involve the elbows, shoulders, knees, hips, ankles, feet, and neck. Symptoms tend to occur symmetrically; that is, joints on both sides of the body are usually affected at the same time. In some cases other organ systems of the body—including the eyes, heart, and lung—may become inflamed too. Symptoms occur in lengthy episodes that may be separated by remission periods of reduced or total absence of pain and stiffness. Between 50 and 75 percent of patients experience a remission within one to two years after the first episode.

Current research suggests that rheumatoid arthritis is an autoimmune disorder caused by an attack of the immune system on some of the body's own cells. The disease usually develops between the ages of 20 and 50, and its prevalence increases with age. Women are affected approximately three times more frequently than men. Treatment is aimed at relieving pain and inflammation, preventing joint deformity, and preserving function.

What Causes It?

The cause of rheumatoid arthritis is unknown.

Genetic factors play a role.

Some theories suggest that a virus may be associated with the development of rheumatoid arthritis.

Flare-ups of rheumatoid arthritis may be triggered by emotional stress or other concurrent illness.

Prevention

There is no known way to prevent rheumatoid arthritis.

Diagnosis

Patient history and physical examination. There is no specific diagnostic test for rheumatoid arthritis; long-term observation of joint changes may be necessary for definitive diagnosis.

Blood tests for autoimmune rheumatoid factors; anemia may be found in almost half of patients. The white blood cell count is usually normal, but may be high (in active inflammation) or low (in the variant called Felty's syndrome).

X-rays of the affected joints.

Synovial fluid analysis. Under local anesthetic, synovial fluid is drawn from the affected joint.

How To Treat It

To reduce fever and treat pain, your doctor may prescribe large doses of aspirin, or one of the many other nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, naproxen, nabumetone, salsalate, or COX-2 inhibitors.

The current trend is to move patients more rapidly to other, more potent antirheumatic drugs if initial anti-inflammatories fail to control symptoms. Because of potential side effects, patients receiving such therapy must be closely monitored.

Hydroxychloroquine, a drug used to treat malaria, may also be prescribed to relieve symptoms of rheumatoid arthritis. The drug's effects may not be felt for three to six months.

A solution containing gold salts may be taken orally or injected to reduce inflammation and pain.

Methotrexate, an antimetabolite drug, may be prescribed to subdue the immune system. If symptoms persist, immunosuppressants such as azathioprine or cyclophosphamide may be tried.

Penicillamine, a penicillin derivative, may be prescribed to relieve symptoms if other drugs are ineffective (though its use is limited by a large number of side effects).

Sulfasalazine appears to work by suppressing the immune response that is active in rheumatoid arthritis, and also as an anti-inflammatory agent.

Minocycline is an antibiotic that acts more as an anti-inflammatory; it has modest benefit in some patients with early disease.

Oral corticosteroids, such as prednisone, offer quick relief from symptoms of rheumatoid arthritis. Because prednisone has serious side effects when used for extended periods, it is often reserved for severe flare-ups of the disease or when other treatments are ineffective. Injection of corticosteroids into an affected joint may also be helpful.

Researchers are developing drugs that target the mechanisms in the disease process and have the potential to prevent joint damage. Recent drug treatment advances include: Leflunomide, an immunomodulator that has antiproliferative activity as well as an anti-inflammatory effect, and etanercept and infliximab, which inhibit the action of tumor necrosis factor (TNF), a naturally occurring substance that is overproduced in people with rheumatoid arthritis. Another advance is anakinra, which inhibits the activity of a protein called interleukin-1 that invades the joints of people with RA. In addition, innovative strategies such as combination therapy are being applied with encouraging results.

Hot or cold compresses may provide pain relief.

Get plenty of rest. People with rheumatoid arthritis often need over 10 hours of sleep a night, or eight hours a night and a two-hour nap during the day, and may need more during severe episodes.

Creams or lotions containing capsaicin may be applied to relieve minor joint pain. Those containing camphor, menthol, or turpentine oil may mask pain and provide some relief from minor symptoms.

Contrary to popular belief, there is no evidence that bee venom relieves or cures rheumatoid arthritis.

Splints may be prescribed to relieve pain by immobilizing the joints during severe episodes.

Your doctor may prescribe an exercise program or may advise you to see a physical therapist. While exercise that is too vigorous may worsen symptoms, some regular activity is necessary to maintain full range of motion of the joints and to prevent muscle deterioration (atrophy). Such programs outline gentle exercises that can be done to increase the range of motion of the joints.

Some exercises are easier to perform in a pool or hot tub, because water helps support the body; these techniques should be discussed with your doctor or physical therapist.

Surgery to remove the diseased synovial membrane from affected joints (synovectomy) may be performed in advanced cases.

Surgery to remove the damaged joint and replace it with a mechanical joint (arthroplasty, or total joint replacement) may be performed in advanced cases. Almost 90 percent of the 150,000 joint replacements each year are of the hip or knee, but the shoulders, elbows, and joints in the hands and feet may be replaced as well. Discussion of the types of activities the patient would like to continue after joint replacement aids the surgeon in selecting the appropriate type of prosthesis and implantation technique, while making the patient more aware of the risks and limitations of surgery.

 

From Johns Hopkins Symptoms and Remedies, the complete home medical reference. You can order this book now on our secure server.

 


 


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