Rheumatoid Arthritis

Issue

Vol. 1 No. 1 (2024)

Date Log

Submitted
May 23, 2024
Accepted
June 29, 2024
Published
June 28, 2024

Rheumatoid Arthritis - Symptoms and Treatment Demystified

https://doi.org/10.69512/ajphi.v1i01.41
Gauri Adhikari, MD
Nepalese Army Institute of Health Sciences-College of Medicine, Kathmandu, Nepal
Binaya Dhakal, MD
Nepalese Army Institute of Health Sciences-College of Medicine, Kathmandu, Nepal
Saloni Shrestha, MD
Nepal Medical College, Kathmandu, Nepal
https://orcid.org/0000-0001-9919-6864

Corresponding Author(s) : Gauri Adhikari, MD

gauryadhikary@gmail.com

The American Journal of Patient Health Info, Vol. 1 No. 1 (2024)

Abstract


  1. Rheumatoid Arthritis is characterized by the body's immune system mistakenly attacking its own tissues, particularly the synovium, which lines the joints.

  2. It commonly presents joint pain, swelling, stiffness, and reduced mobility, which affect multiple joints symmetrically.

  3. Beyond joint involvement, RA can impact various organs and systems throughout the body, leading to symptoms like fatigue, fever, and weight loss.

  4. Early diagnosis and aggressive treatment can slow down disease progression and mitigate joint damage.

  5. While there's no cure, numerous treatment modalities exist to alleviate symptoms, reduce inflammation, and maintain joint function.

Keywords

Arthritis Anti-cyclic citrullinated peptide antibody Joint Pain Rheumatoid Factor
Adhikari, MD, G., Dhakal, MD, B., & Shrestha, MD, S. (2024). Rheumatoid Arthritis - Symptoms and Treatment Demystified. The American Journal of Patient Health Info, 1(1). https://doi.org/10.69512/ajphi.v1i01.41
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References
  1. World Health Organization. Rheumatoid arthritis. www.who.int. 2023. Available from: https://www.who.int/news-room/fact-sheets/detail/rheumatoid-arthritis
  2. Kurkó J, Besenyei T, Laki J, Glant TT, Mikecz K, Szekanecz Z. Genetics of Rheumatoid Arthritis — A Comprehensive Review. Clinical Reviews in Allergy & Immunology. 2013 Jan 5;45(2):170–9. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3655138/
  3. Deane KD, Demoruelle MK, Kelmenson LB, Kuhn KA, Norris JM, Holers VM. Genetic and environmental risk factors for rheumatoid arthritis. Best Pract Res Clin Rheumatol 2017;31(1):3–18.
  4. CDC. Rheumatoid arthritis | CDC [Internet]. www.cdc.gov. 2021. Available from: https://www.cdc.gov/arthritis/types/rheumatoid-arthritis.html
  5. Mayo Clinic. Rheumatoid arthritis - Symptoms and causes [Internet]. Mayo Clinic. 2023. Available from: https://www.mayoclinic.org/diseases-conditions/rheumatoid-arthritis/symptoms-causes/syc-20353648
  6. Forslind K. Prediction of radiological outcome in early rheumatoid arthritis in clinical practice: role of antibodies to citrullinated peptides (anti-CCP). Annals of Rheumatic Diseases. 2004 Sep 1;63(9):1090–5.
  7. Pope JE, Choy EH. C-reactive protein and implications in rheumatoid arthritis and associated comorbidities. Semin Arthritis Rheum 2021;51(1):219–29.
  8. Cleveland Clinic. Magnetic Resonance Imaging (MRI) [Internet]. Cleveland Clinic. 2022. Available from: https://my.clevelandclinic.org/health/diagnostics/4876-magnetic-resonance-imaging-mri
  9. Mayo Clinic. Rheumatoid arthritis - diagnosis and treatment [Internet]. Mayoclinic.org. 2023. Available from: https://www.mayoclinic.org/diseases-conditions/rheumatoid-arthritis/diagnosis-treatment/drc-20353653
  10. Law ST, Taylor PC. Role of biological agents in treatment of rheumatoid arthritis. Pharmacological Research. 2019 Dec;150(4887324):104497. Available from: https://www.sciencedirect.com/science/article/pii/S1043661819310266
  11. Efthimiou P, Kukar M, MacKenzie CR. Complementary and Alternative Medicine in Rheumatoid Arthritis: No Longer the Last Resort! HSS Journal. 2009 Sep 26;6(1):108–11.
  12. Klein A, Molad Y. Hematological Manifestations among Patients with Rheumatic Diseases. Acta Haematol 2021;144(4):403–12.
  13. Varshney M, Ray S, Reddy M, Chatterjee D, Chakravarty K, Bhatia V, et al. A Neurological Complication in Rheumatoid Arthritis – A Scenario of Catastrophic Proportions. Ann Indian Acad Neurol 2023;26(4):560–3.
  14. Schäfer C, Keyßer G. Lifestyle Factors and Their Influence on Rheumatoid Arthritis: A Narrative Review. J Clin Med 2022;11(23):7179.
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Gauri Adhikaria, Binay Dhakala, Saloni Shresthab

a Nepalese Army Institute of Health Sciences-College of Medicine, Kathmandu, Nepal

b Nepal Medical College, Kathmandu, Nepal

Background

Rheumatoid arthritis (RA) is a chronic, autoimmune disease in which the immune system unintentionally attacks its own healthy cells, leading to inflammation of the joints and periarticular soft tissues. About 18 million people worldwide are living with rheumatoid arthritis, and about 70% of them are women. About 55% of these individuals are older than 55 years of age. Similarly, about 13 million people with rheumatoid arthritis experience severity that could benefit from rehabilitation. 1

Etiology and Risk Factors of Rheumatoid Arthritis

Figure 1.

  • Genetic Predisposition: Some people with genetic variation, particularly with the human leukocyte antigen (HLA) gene complex, have an increased risk of developing RA. 2
  • Environmental Triggers: While genetics contribute to susceptibility, environmental factors trigger the onset of RA in genetically predisposed individuals. Environmental triggers such as smoking, infection, hormonal factors, and exposure to certain pollutants or toxins have been implicated in the development of RA. 3
  • Gender and Age: RA is more common in women than in men, and it often develops between the ages of 30 and 60. However, RA can affect individuals of any age, including children (juvenile idiopathic arthritis).
  • Family History: If you have a family history of RA, your risk of developing the condition increases. Individuals with first-degree relatives who have RA are at a higher risk compared to those without a family history. 3
  • Obesity: There is some evidence to suggest that obesity may be a risk factor for RA, as excess body weight can contribute to inflammation and may exacerbate the symptoms of RA in those who already have the condition. 4
  • Other Autoimmune Diseases: Individuals with autoimmune diseases, such as lupus or inflammatory bowel disease, may have an increased risk of developing RA.

Clinical Presentation (Symptoms) of Rheumatoid Arthritis

Symptoms of RA can be different among individuals, and they can be as follows:

Figure 2.

  • Joint Symptoms: RA typically presents joint pain, swelling, stiffness, and warmth. These symptoms often affect multiple joints, especially the hands, wrists, elbows, knees, and feet. The joint involvement is usually symmetrical, affecting both sides of the body equally.
  • Joint Stiffness: One of the hallmark symptoms of RA is joint stiffness, which is especially pronounced in the morning or during a period of inactivity. This stiffness can even last for more than 30 minutes.
  • Fatigue: Many individuals with RA experience persistent fatigue and general tiredness. The fatigue is often exacerbated by inflammation and the body’s immune response and can significantly impact daily activities and quality of life.
  • Systemic Symptoms: RA is considered a systemic disease because it can affect other organs and systems in the body. Systemic symptoms may include fever, weight loss, and generalized weakness.
  • Rheumatoid Nodules: Some people with RA develop firm bumps under the skin, known as rheumatoid nodules. These nodules usually occur near joints affected by RA but can also appear in other body areas. 5
  • Joint Deformities: Over time, untreated RA can lead to joint deformities, such as joint malalignment, subluxation (partial dislocation), and even joint destruction. This can result in significant functional impairment.
  • Symmetrical Pattern: Unlike osteoarthritis, which often affects one joint asymmetrically, RA usually affects joints symmetrically. This means if you have one knee or hand affected, the corresponding one on the other side will also be likely affected.
  • Extra-articular Manifestations: RA can also involve organs and systems outside of the joints, leading to complications such as inflammation of the eyes (uveitis), inflammation of blood vessels (vasculitis), and inflammation of the lining of the heart (pericarditis). 5

Diagnosis of Rheumatoid Arthritis

Early diagnosis can help prevent joint damage and improve long-term outcomes for individuals with RA. The diagnostic steps involved are:

Figure 3.

1. Laboratory Tests

  • Rheumatoid Factor (RF): This blood test detects the presence of antibodies called rheumatoid factor, which are often elevated in individuals with RA. However, not all people with RA have positive RF.
  • Anti-cyclic citrullinated peptide (anti-CCP) Antibodies: Another blood test that checks for antibodies directed against cyclic citrullinated peptides. Anti-CCP antibodies are more specific to RA and can help confirm the diagnosis. 6
  • Inflammatory markers: The markers like C-reactive protein (CRP) and Erythrocyte Sedimentation Rate (ESR) measure the degree of inflammation. These markers are often elevated in RA and can help assess disease activity. 7
  • Complete Blood Count (CBC): This test may reveal anemia, which is common in RA, and other abnormalities, such as thrombocytosis (elevated platelet count).

2. Imaging Studies

  • X-rays: X-rays of the affected joints can reveal joint damage, erosion, and narrowing of joint spaces. These changes may not be apparent in the early stages of RA but can become more pronounced over time.
  • Ultrasound: This imaging technique can detect synovitis (synovial membrane inflammation) and joint effusion (fluid accumulation within the joint) with high sensitivity. It can help assess disease activity and guide treatment decisions.
  • Magnetic Resonance Imaging (MRI): MRI may be used to assess joint inflammation, soft tissue involvement, and bone marrow edema in more detail, particularly in early or aggressive forms of RA. 8

Treatment of Rheumatoid Arthritis

The treatment of RA aims to reduce inflammation, alleviate symptoms, prevent further joint damage, and improve the quality of life.

Figure 4.

1. Medications

  • Disease-Modifying Antirheumatic Drugs (DMARDs): These drugs, such as methotrexate, hydroxychloroquine, sulfasalazine, and leflunomide, are the cornerstone of RA treatment. They slow down the progression of the disease and reduce joint damage. 9
  • Biologic DMARDs: Biologic drugs include TNF inhibitors (e.g., adalimumab, etanercept), IL-6 inhibitors (e.g., tocilizumab), and other targeted therapies. They target specific components of the immune system involved in the pathogenesis of RA. They are used for individuals who do not respond adequately to traditional DMARDs. 10
  • Corticosteroids: Corticosteroids such as prednisone or methylprednisolone are used briefly to reduce inflammation and suppress the immune system. However, they are not used for long-term use due to potential side effects.
  • Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): NSAIDs, such as ibuprofen and naproxen, help relieve pain and inflammation in RA. They are often used as adjunctive therapy to DMARDs but are not typically used as long-term maintenance therapy due to potential side effects.

2. Physical Therapy

Physical therapy and exercise programs built to meet an individual's needs can help improve joint flexibility, strength, and range of motion. They can also alleviate pain and prevent disability.

3. Occupational Therapy

Occupational therapists can provide techniques and assistive devices to help individuals with RA perform daily tasks more easily and reduce strain on affected joints.

4. Lifestyle Modifications

Maintaining a healthy lifestyle with regular exercise, a balanced diet, and adequate rest can help manage RA symptoms and improve overall well-being.

5. Surgery

In severe cases of RA where joint damage is significant and unresponsive to other treatments, surgery becomes the last resort. In some patients, joint replacement surgery (arthroplasty) may be necessary to restore the function of the joint. 9

6. Complementary and Alternative Therapies

Some people with RA find relief from symptoms with the help of alternative therapies such as acupuncture, massage therapy, and dietary supplements. 11

Complications of Rheumatoid Arthritis

RA is not limited to joint inflammation; it can affect various organs throughout the body, leading to systemic complications. Here are some systemic complications associated with RA:

Figure 5.

  • Cardiovascular: RA increases the risk of cardiovascular diseases such as heart attack, stroke, and atherosclerosis. Chronic inflammation in RA can damage blood vessels, leading to accelerated thickening of the blood vessels and increased cardiovascular risk. 5
  • Pulmonary: RA can affect the lungs, leading to conditions such as interstitial lung disease, pleurisy (inflammation of the lining of the lungs), and rheumatoid nodules in the lungs. These complications can cause cough, shortness of breath, and reduced lung function. 5
  • Ocular: RA can lead to eye inflammation, resulting in conditions such as scleritis, episcleritis, and uveitis. If left untreated, these eye complications can cause redness, blurred vision, and even vision loss.
  • Hematologic: RA can affect the blood, leading to abnormalities such as anemia (due to chronic inflammation or medication side effects), thrombocytosis, and neutropenia. 12
  • Neurological: RA can rarely affect the nervous system, leading to conditions such as peripheral neuropathy, vasculitis of the nervous system, and compression neuropathies (e.g., carpal tunnel syndrome). 13
  • Renal: While less common, RA can affect the kidneys, leading to glomerulonephritis and amyloidosis. These complications can impair kidney function and lead to kidney damage or failure.
  • Osteoporosis: Chronic inflammation and long-term use of corticosteroids in RA can increase the risk of osteoporosis. Osteoporosis is a condition that leads to reduced bone density and increased risk of fractures. 5

Prevention of Rheumatoid Arthritis

Currently, there are no known strategies to prevent the development of rheumatoid arthritis (RA) entirely. However, there are some lifestyle factors and behaviors that may help reduce the risk of developing RA or delay its onset:

Figure 6.

  • Maintain a Healthy Weight: You can reduce the risk of RA by keeping a healthy weight with the help of regular exercise and a diet rich in fruits, green vegetables, and omega-3 fatty acids. 14
  • Quit Smoking: Smoking not only raises the risk of developing RA but also contributes to more severe disease and poorer treatment outcomes in those already diagnosed with RA. By quitting smoking, you can reduce your risk of developing severe RA and improve treatment. 14
  • Regular Exercise: Physical activity can help to keep your joints flexible, build muscle strength, and improve overall health. One can start with low-impact walking, swimming, and cycling exercises.
  • Manage Stress: Chronic stress can increase the ongoing inflammation and autoimmune conditions like RA. You should find healthy ways to manage stress, such as mindfulness techniques, relaxation exercises, or engaging in hobbies and activities you enjoy, which may be beneficial.
  • Limit Alcohol Consumption: Excessive consumption of alcohol has been associated with an increased risk of RA. Limiting alcohol intake to moderate levels or leaving alcohol altogether may help reduce the risk. 14
  • Early Treatment of Infections: Some research suggests that certain infections may trigger the onset of RA in genetically susceptible individuals. In some cases, prompt treatment of infections may help reduce the risk of RA development.
  • Genetic Counseling: While genetics play a role in RA, not everyone with a family history of the disease will develop it. However, if you have a family history of RA or other autoimmune diseases, you may consider genetic counseling to understand your risk factors better.

Questions To Ask Your Doctor

  1. What are the benefits and risks associated with each treatment option?
  2. Are there any lifestyle changes or modifications I should consider to help manage my condition?
  3. How often should I schedule follow-up appointments to monitor my condition and treatment progress?
  4. Are there any specific dietary recommendations or supplements that may help alleviate symptoms?
  5. How does rheumatoid arthritis affect daily activities and overall quality of life?
  6. Are there any new developments or research findings in rheumatoid arthritis that I should be aware of?

References

  1. World Health Organization. Rheumatoid arthritis. www.who.int. 2023. Available from: https://www.who.int/news-room/fact-sheets/detail/rheumatoid-arthritis
  2. Kurkó J, Besenyei T, Laki J, Glant TT, Mikecz K, Szekanecz Z. Genetics of Rheumatoid Arthritis — A Comprehensive Review. Clinical Reviews in Allergy & Immunology. 2013 Jan 5;45(2):170–9. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3655138/
  3. Deane KD, Demoruelle MK, Kelmenson LB, Kuhn KA, Norris JM, Holers VM. Genetic and environmental risk factors for rheumatoid arthritis. Best Pract Res Clin Rheumatol 2017;31(1):3–18. Available from: https://pubmed.ncbi.nlm.nih.gov/29221595/
  4. CDC. Rheumatoid arthritis | CDC [Internet]. www.cdc.gov. 2021. Available from: https://www.cdc.gov/arthritis/types/rheumatoid-arthritis.html
  5. Mayo Clinic. Rheumatoid arthritis - Symptoms and causes [Internet]. Mayo Clinic. 2023. Available from: https://www.mayoclinic.org/diseases-conditions/rheumatoid-arthritis/symptoms-causes/syc-20353648
  6. Forslind K. Prediction of radiological outcome in early rheumatoid arthritis in clinical practice: role of antibodies to citrullinated peptides (anti-CCP). Annals of Rheumatic Diseases. 2004 Sep 1;63(9):1090–5. Available from: https://pubmed.ncbi.nlm.nih.gov/15308518/
  7. Pope JE, Choy EH. C-reactive protein and implications in rheumatoid arthritis and associated comorbidities. Semin Arthritis Rheum 2021;51(1):219–29. Available from: https://pubmed.ncbi.nlm.nih.gov/33385862/
  8. Cleveland Clinic. Magnetic Resonance Imaging (MRI) [Internet]. Cleveland Clinic. 2022. Available from: https://my.clevelandclinic.org/health/diagnostics/4876-magnetic-resonance-imaging-mri
  9. Mayo Clinic. Rheumatoid arthritis - diagnosis and treatment [Internet]. Mayoclinic.org. 2023. Available from:https://www.mayoclinic.org/diseases-conditions/rheumatoid-arthritis/diagnosis-treatment/drc-20353653
  10. Law ST, Taylor PC. Role of biological agents in treatment of rheumatoid arthritis. Pharmacological Research. 2019 Dec;150(4887324):104497. Available from: https://www.sciencedirect.com/science/article/pii/S1043661819310266
  11. Efthimiou P, Kukar M, MacKenzie CR. Complementary and Alternative Medicine in Rheumatoid Arthritis: No Longer the Last Resort! HSS Journal. 2009 Sep 26;6(1):108–11. Available from:https://pubmed.ncbi.nlm.nih.gov/19784703/
  12. Klein A, Molad Y. Hematological Manifestations among Patients with Rheumatic Diseases. Acta Haematol 2021;144(4):403–12. Available from: https://pubmed.ncbi.nlm.nih.gov/33221805/
  13. Varshney M, Ray S, Reddy M, Chatterjee D, Chakravarty K, Bhatia V, et al. A Neurological Complication in Rheumatoid Arthritis – A Scenario of Catastrophic Proportions. Ann Indian Acad Neurol 2023;26(4):560–3. Available from:https://pubmed.ncbi.nlm.nih.gov/37970250/
  14. Schäfer C, Keyßer G. Lifestyle Factors and Their Influence on Rheumatoid Arthritis: A Narrative Review. J Clin Med 2022;11(23):7179. Available from: https://pubmed.ncbi.nlm.nih.gov/36498754/

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