Rheumatoid Arthritis
Rheumatoid arthritis is a long term disease that causes inflammation and deformity of the joints. In New Zealand the disease affects 1-2% of the population and is three times more common in women than men.
Rheumatoid arthritis is a consequence of changes in the body's immune system which, for reasons not fully understood, attacks the soft tissue of the joints. The result is inflammation of the joints, particularly the synovial membrane that lines them, and an over-production of synovial (joint) fluid. These effects cause the joints to become swollen and painful. If the process continues, damage to the cartilage and other soft tissue can cause joint deformities.
In a healthy joint, cartilage lines the end of the bones. The cartilage acts as a cushion and allows the bones within the joint to glide smoothly over one another. The joint is contained within a joint capsule, which is lined by a synovial membrane (synovium). The synovial membrane produces synovial fluid – a clear fluid that lubricates and nourishes the joint. Surrounding muscles, tendons and ligaments support the joint allowing it to move smoothly and without pain.
Rheumatoid arthritis causes the normally thin synovial membrane (synovium) to become inflamed and thickened, leading to an accumulation of synovial fluid and causing pain and swelling. Also, the cartilage and bone ends within the joint may become damaged and eroded leading to loss of function and deformity of the joint.
Rheumatoid arthritis can affect any joint in the body but usually affects the small joints in the hands and feet before any of the larger joints such as hips, knees, shoulders and elbows are affected. Joints are usually affected symmetrically (both the left and the right side of the body).
The condition can develop at any age, though it is most likely to develop between the ages of 35 and 45 years. Rarely, children under the age of 16 can develop a form of rheumatoid arthritis known as juvenile rheumatoid arthritis or Still’s disease.
Rheumatoid arthritis occurs in all ethnic groups, climates and altitudes. In New Zealand it affects about 1-2% of the population. It is three times more common in women than it is in men.
Rheumatoid arthritis can develop gradually or very quickly. Signs and symptoms can vary greatly between individuals and can range from mild to very severe. Rheumatoid arthritis is characterised by periods of remission (absence of symptoms) and exacerbation (when symptoms are problematic).
Often the first symptoms experienced are:
- Pain in the joints
- Swelling (often accompanied by warmth and redness) of the joints
- Stiffness in the joints (generally worse in the mornings and after periods of rest)
- Because rheumatoid arthritis is a systemic condition, meaning that it can have an effect on the whole body, the following “flu like” symptoms may also be experienced:
- Fatigue
- Muscle pain
- Mild fever
- Loss of appetite (with resulting weight loss)
- Anaemia can also occur, often compounding the feeling of fatigue and the feeling of being generally unwell.
Rarely, rheumatoid arthritis causes problems with other parts of the body. These include:
- Inflammation of the blood vessels (vasculitis)
- Inflammation of the linings of the lung or the heart
- Dryness of the eyes and mouth.
One quarter of people with rheumatoid arthritis develop small, firm movable lumps under the skin called rheumatoid nodules. These usually appear under the skin around the joints and on the top of the arms and legs. Rarely, rheumatoid nodules can occur on the tissue membranes that cover the lungs and on the lining of the brain and spinal cord. Rheumatoid nodules do not usually cause any problems and usually do not require treatment.
Approximately one in six people with rheumatoid arthritis will develop significant joint deformity as a result of damage to the cartilage, bones and supporting structures such as the ligaments and tendons.
The cause of rheumatoid arthritis is unknown. It is clear, however, that many factors are involved in the development of the condition.
Possible factors in the development of rheumatoid arthritis include:
Genetic (inherited) factors:
The condition appears to run in families giving rise to the theory that genetic factors may influence its development.
Infectious agents:
It is possible that rheumatoid arthritis is triggered by the abnormal response of the body’s immune system (autoimmune response) to some infections.
Hormonal factors:
Changes or deficiencies in certain hormones may be involved in the development of rheumatoid arthritis.
There is no single test that diagnoses rheumatoid arthritis. In its initial stages it may be difficult to distinguish rheumatoid arthritis from other forms of arthritis.
In order to diagnose rheumatoid arthritis a doctor will usually undertake the following:
- A full medical history, including any family history of rheumatoid arthritis
- Discussion of current symptoms
- Physical assessment eg: of the joints, skin, reflexes and muscle strength
- X-rays and MRI (of the feet/hands). MRI detects joint damage (erosions) much earlier than plain x-rays.
- Blood tests
Two blood tests commonly performed to assist in the diagnosis of rheumatoid arthritis are:
Rheumatoid factor
A protein produced by the immune system that is present in up to 80% of people with rheumatoid arthritis. CCP antibody is a newer, more accurate but expensive test. It can help to detect rheumatoid arthritis in its early stages, before it becomes full blown.
Erythrocyte sedimentation rate (ESR)
An elevated ESR indicates the presence of inflammation in the body. CRP (C reactive protein) is also used as a masker of acute inflammation.
Treatment for rheumatoid arthritis is aimed at treating the symptoms. Goals of treatment are to:
- Reduce pain
- Reduce inflammation
- Minimise and/or prevent joint damage
- Maximise joint movement
To achieve these goals a combination of treatments is usually recommended. These include:
MEDICATIONS
Common types of medications used to treat the symptoms of rheumatoid arthritis include:
Non-steroidal anti-inflammatory drugs (NSAIDs)
These medications work by treating pain and inflammation. A newer class of NSAID, the COX II inhibitor, reduces pain and inflammation without the damage to the stomach lining that was problematic with older NSAIDs. However some COX II inhibitors have been linked to an increased risk of heart attacks and stroke.
Corticosteroids
These medications eg: prednisone, work to reduce inflammation.
Disease modifying antirheumatic drugs (DMARDs)
These medications are commonly used to treat moderate to severe rheumatoid arthritis. Types of medications in this category include those used to suppress the immune system (eg: Imuran), anti-malarial medications (eg: Plaquenil), gold preparations (eg: Auranofin), Penicillamine and some medications normally used to treat cancer (eg: Methotrexate). Methotrexate is considered by many to be the anchor drug in managing severe rheumatoid arthritis.
Tumor Necrosis Factor–alpha (TNF-a)
These medications work by inhibiting an inflammatory chemical called tumor necrosis factor. The medication used will depend on the seveity of the arthritis. If effective, the medication may be continued for a number of years. One type of TNF inhibiting medication available in New Zealand is called Hurima.
PHYSIOTHERAPY
A range of physiotherapy treatments are used to reduce pain, improve movement, strengthen muscles, and maintain independence.
EXERCISE AND REST
A balance should be reached between exercise and rest. When the disease is active more rest may be appropriate. Rest will help reduce fatigue, pain and inflammation. Exercise is important to increase muscle strength, decrease joint deformities and stiffness, and to maintain mobility. A physiotherapist can recommend an appropriate exercise regime.
CARE OF JOINTS
Joint protection and work simplification methods can be effective in decreasing joint pain and fatigue. An occupational therapist or physiotherapist can give advice on these. The use of splints or joint-sparing devices such as zipper pullers or long-handled shoehorns may be suggested.
SURGERY
When pain is severe or deformities disabling, surgery may be indicated. Commonly this involves hip and knee joint replacements but it may be necessary to perform other joint replacements. The repair of tendons, nerves or joint structures such as the synovial membrane may also be required.
Rheumatoid arthritis cannot be prevented but in most cases an independent life can be maintained. Research is continuing to try to understand the development of the disease so that in time a cure may be possible.
For further information and support please contact Arthritis New Zealand:
Arthritis New Zealand.
PO Box 10-020
Wellington
Tel (04) 472 1427
Fax (04) 472 7066
Website: www.arthritis.org.nz
For branch offices please refer to the local telephone directory or the Arthritis New Zealand website.
Arthritis New Zealand (2007) Rheumatoid arthritis Wellington: Arthritis New Zealand (Inc)
http://www.arthritis.org.nz/index.php?section=arth&chapter=rheumatoid_arthritis
Everybody (2005) Rheumatoid arthritis Auckland: CMPMedica (NZ) Ltd. http://www.everybody.co.nz/page-75d2b8b9-9b93-4e99-9274-171b33e156dc.aspx
Meszaros, L. (2006) Rheumatoid arthritis. The Gale Encyclopedia of Medicine. Third Edition. Jacqueline L. Longe, Editor. Farmington Hills, MI. Thompson Gale.
Nuki, G., Ralston, S.H. & Luqmani, R. (1999) Disease of the connective tissues, joints and bones. In C.Haslett, E.R. Chilvers, J.A.A. Hunter & N.A. Boon (eds.) Davidson’s principles and practice of Medicine (18th ed.) (pp801 – 876) Edinburgh: Churchill Livingstone
Last Reviewed – 3/10/07
Go to our Medical Library Index Page to find information on other medical conditions.