Rheumatoid Arthritis

Rheumatoid Arthritis (RA) is an autoimmune disease of unknown cause. It manifests itself as an inflammatory arthritis involving multiple joints. However, RA actually involves a person’s entire system, so that symptoms of fatigue, low-grade fever, and malaise may accompany the joint symptoms. Likewise, inflammation of other body parts can result in pleurisy, scars in the lung (interstitial lungdisease) pericarditis, or formation of inflammatory nodules in and around joints (as well as other tissues.) Or the salivary and tear glands may become inflamed resulting in dryness. The bone marrow may become sluggish in its production of blood cells, so that anemia results. The eye may become red and inflamed. Sometimes arthritic changes in the neck can impinge on the spinal cord causing weakness. A widespread aggressive inflammation called ãvasculitisäcan occur, causing severe skin lesions or loss of nerve function in the arms and legs.
 
What Are The Symptoms of RA?
The most common manifestation of RA, however, is the finding in the joints. Usually, the small joints of the hands and feet become involved first. Joint involvement is characterized by stiffness, redness, swelling, and pain in the joints. Typically a person will be stiff for several hours upon awakening in the morning, or after sitting for prolonged periods of time. The stiffness usually subsides with movement, but returns during rest. The joint pain and swelling occurs symmetrically. It is rare for RA to involve an isolated joint. The onset of RA is usually slow and insidious, but may also be dramatic. All synovial joints may be involved in the process. Synovial joints are those lined by a thin layer of connective tissue called synovium and include wrists, hands, elbows, shoulder, neck, jaw, hips, knees, ankles, and feet. Low back pain is not a common feature of RA. The synovium is a very active tissue and responds briskly to a disturbance in its immune environment. Whatever the inciting agent/event/stimulus is in RA, the synovium becomes inflamed and produces proteins in the joint space, which can be very destructive. These proteins cause tissue and bone destruction. Overgrowth of the synovium is called pannus and can actually be felt by the examining physician. Pannus is painful and prevents normal joint motion. Inflamed joints over time become weak and deformed and surrounding bone develops erosions (holes in the bone). Tendons nearby inflamed joints may become weak and rupture. A major goal of medical therapy is to curtail this synovial overgrowth and to prevent deformity, destruction, and erosions. In some patients, surgical correction of the effects of RA or even replacement of destroyed joints becomes necessary.
 
RA occurs worldwide and it is estimated that 1-2% of adults have the disease. It is more common in women of childbearing years, however both men and women may develop the disease. Juvenile arthritis may occur at any age in childhood, even as young as one-year-old. (The disease in children may present differently than in adults and be associated with symptoms not seen in adults.) Race does not seem to be a contributing factor to the development of RA, but other genetic factors may play a role. A specific genetic defect or mutation associated with RA has not been found, but there is evidence that parts of the sixth chromosome may code for predisposing genes. We know from observational studies, however, that RA does occur in siblings and does, indeed, run in families. More research on the genetics of RA is ongoing and may help us with our understanding of the disease in the future.
 
How Is The Diagnosis Of RA Made?
The diagnosis of RA is called a clinical diagnosis. That is, based upon a typical history and physical examination, a trained physician can make the diagnosis, even without xrays or blood work. It is important to remember, however, that joint pain and swelling may be associated with many types of illness and may mimic other disorders, even cancer. Therefore, the physician typically performs additional tests to help her better define the disease. One of these tests is the rheumatoid factor. It is seen in most cases of RA, but not necessarily so. It is a nonspecific test and can be seen in the normal population. It can also be present in cases of infection, or malignancy, or even other autoimmune disease. The physician must interpret the rheumatoid factor in the clinical setting in which it occurs. Other laboratory tests might include a blood count looking for anemia. An erythrocyte sedimentation rate (ESR) might be performed to look for other signs of inflammation. Usually chemical tests are performed, as well. Early in RA, xrays do not usually reveal any signs of the disease. But as early as one year from the start of the disease, subtle signs of joint inflammation and destruction can be seen.
 
Treatment Options
The treatment of RA is individualized to the needs of each patient. Almost always, however, physical therapy and exercise programs can be incorporated into a treatment plan. The goal of therapy is to reduce inflammation, improve function, and relieve pain. Several medications have anti-inflammatory potential, the most effective of which is cortisone. However, cortisone products may have several untoward side effects, so that their use is not desirable in many patients. Most of the time, physicians use cortisone in low doses and for a short period of time in order to help the patient while a disease-modifying agent (DMARD) has time to work. There are several nonsteroidal anti-inflammatory medications (NSAIDS) available, as well. These medications are prescription drugs since their usage requires close monitoring by the physician. These types of medications can cause gastrointestinal side effects or kidney side effects, which must be recognized promptly. Both cortisone and NSAIDS are anti-inflammatory medications, but they do not induce a remission in RA. DMARDS are the medications which induce remission, so that the joint pain and stiffness is reduced, and it is almost as if the RA was gone! DMARDS are extremely potent medications and require close monitoring by the physician. Patient education as to the effects and side effects of these medications is an integral part of the close patient-physician relationship needed to use these drugs safely and effectively. The choice of a DMARD depends on the patientâs needs and a consideration of the patientâs entire medical condition beyond her RA. DMARDS may have deleterious effects on the bone marrow, liver, kidney, etc. On the other hand, the improvement in RA symptoms from successful treatment with a DMARD are worth the risk of treatment. Through research and development, new and better DMARDS are now being developed for the treatment of RA. For example, theories of blocking inflammatory proteins at their very start have allowed the development of substances genetically engineered and injected into the patient for sometimes-dramatic results. Combinations of medications may also be recommended by the physician with benefits greater than with one medication alone. A crucial part of any management program for RA is to maintain a healthy lifestyle, with proper nutrition and weight control, routine exercise, osteoporosis prevention, and expert handling of any accompanying medical disorders.
 
Authored by: Carolyn Smith, M.D.

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