Rheumatoid Arthritis

Rheumatoid Arthritis
Definition
Rheumatoid arthritis (RA) is an autoimmune disease that causes pain, swelling, stiffness, and loss of function in the joints. RA usually affects the same joint on both sides of the body. It occurs most frequently in the:
• Fingers
• Wrists
• Elbows
• Shoulders
• Jaw
• Hips
• Knees
• Toes
Rheumatoid Arthritis

Causes
Rheumatoid arthritis is likely to be caused by a combination of genetic and environmental factors that trigger an abnormal immune response. Possible causes include:
• Genetic Factors–certain genes that play a role in the immune system are associated with the development of RA
• Defects in the immune system, which cause ongoing inflammation
• Environmental Factors–certain infectious agents, such as some viruses or bacteria, may increase susceptibility to RA
• Other Factors–some evidence suggests that hormonal factors may promote the development of RA in combination with genetic factors and environmental exposure
Risk Factors
A risk factor is something that increases your chance of getting a disease or condition.
Risk factors include:
• Family members with rheumatoid arthritis
• Sex: Female
• Ethnic background: Pima Indians
• Heavy or long-term smoking
Symptoms
When RA first begins, symptoms may include:
• Joint pain and stiffness that is:
o Symmetrical
o Most prominent in the morning
o Lasts for at least half an hour
• Red, warm, or swollen joints
• Joint deformity
• Mild fever, tiredness
• Loss of appetite
• Small lumps or nodules under the skin
As RA progresses, it may cause complications with the:
• Heart
• Lungs
• Eyes
• Skin
• Liver
• Kidneys
• Blood
• Nervous system
• Blood vessels
• It is also associated with the development of early cardiovascular disease and death
Diagnosis
There is no single test for RA. The doctor will ask about your symptoms and medical history. Physical exam will include an examination of your joints, skin, reflexes, and muscle strength.
Tests may include:
• Measuring rheumatoid factor (RF) level in the blood
• Measuring erythrocyte sedimentation rate (ESR) of the blood to measure inflammation in the body
• Measuring C-reactive protein (CRP)–an indicator of active inflammation in the blood
• White blood cell count
• X-rays of affected joints (especially dual energy x-ray absorptiometry)
Treatment
There is no treatment to cure RA. The goals of treatment are to:
• Relieve pain
• Reduce inflammation
• Slow down joint damage
• Improve functional ability
Treatments include:
Medications
• Disease-modifying Antirheumatic Drugs (DMARDS)–to slow the course of the disease. These medications are used early in the course of the disease to prevent long-term damage:
o Methotrexate (Rheumatrex)
o Hydroxychloroquine (Plaquenil)
o Sulfasalazine (Azulfidine)
o Leflunomide (Arava), cyclosporine (Neoral)
o Penicillamine (Cuprimine)
o Gold (Ridaura)–gold can also be given as an injection
o Minocycline (Minocin)
• Immunosuppressive drugs (only used when other DMARDS are ineffective):
o Azathioprine (Imuran)
o Cyclophosphamide (Cytoxan)–rarely used
o Chlorambucil (Leukeran)–rarely used
• Biologic response modifiers–drugs that interfere with the autoimmune response associated with RA.
o Etanercept (Enbrel)
o Infliximab (Remicade)
o Adalimumab (Humira)
o Abatacept (Orencia)
o Rituximab (Rituxan)
• Adjunctive medications include:
o Acetaminophen (Tylenol)
o Non-steriodal anti inflammatory medications including ibuprofen and naproxen
A study showed a small but significant increased risk of cardiovascular events (such as heart attack) in patients taking the prescription medication. Vioxx(R) is a so-called "selective" nonsteroidal anti-inflammatory drug (NSAID) specially designed to lower the risk of stomach irritation. It is commonly used in the treatment of acute and chronic pain associated with arthritis, menstruation, and other conditions. Since Merck's withdrawal of Vioxx(R), evidence has come to light regarding similar dangers posed by the other popular selective NSAID, Celebrex(R) (cefecoxib), which is produced by Pfizer. Most physicians now question the wisdom of prescribing any medications from the COX-2 class, particularly in patients with known cardiovascular disease.
Steroids
Low-dose corticosteroids (prednisone 10mg or the equivalent) are often used initially, and may be tapered when other drugs gain efficacy. Long-term steroid use should be avoided. Corticosteroid injections to individual inflamed joints may also be used.
Rest and Exercise
Rest helps reduce active joint inflammation and pain, and fight fatigue. Exercise is important for maintaining muscle strength and flexibility, as well as preserving joint mobility.
Joint Care
Splints applied to painful joints may reduce pain and swelling. Devices that assist in activities of daily living can also reduce stress on joints, such as:
• Zipper extenders
• Long-handled shoehorns
• Specially designed kitchen tools
Stress Reduction
Stress reduction can ease the difficulties of living with a chronic, painful disease. Exercise programs, support groups, and open communication with healthcare providers can all help reduce stress.
Surgery
Joint replacement and tendon reconstruction help alleviate severe joint damage.
Lifestyle Measures
The following measures may relieve stiffness and weakness and reduce inflammation:
• Maintain a balance between rest and exercise
• Attempt mild strength training
• Aerobic exercise (walking, swimming, dancing)
• Avoid heavy impact exercise
• Stop smoking
• Control weight
• Physical therapy
Prevention
There are no guidelines for preventing rheumatoid arthritis.