What Is It?
Rheumatoid arthritis is a chronic (long-lasting) inflammatory disease that causes pain, stiffness, warmth, redness and swelling in joints. Over time, the affected joint can become misshapen, misaligned and damaged. Tissue lining the joint can become thick, and may wear away surrounding ligaments, cartilage and bone as it spreads. Rheumatoid arthritis usually occurs in a symmetrical pattern, meaning that if one knee or hand has it, the other usually does, too.
Symptoms
Symptoms include:
* Pain, swelling, limited motion, warmth and tightness around affected joints, which most commonly include the hands and wrists, feet and ankles, elbows, shoulders, neck, knees and hips, usually in a symmetrical pattern. Over time, joints may develop deformities.
* Fatigue, soreness, stiffness and aching, particularly in the morning and afternoon (described as morning stiffness and afternoon fatigue)
* Lumps or rheumatoid nodules below the skin
* Weight loss
* Low-grade fever and sweats
* Trouble sleeping
* Weakness and loss of mobility
* Depression
Treatment
The treatment of rheumatoid arthritis has improved dramatically in the past 50 years. A comprehensive approach that combines medications, rest balanced with exercise, lifestyle modifications, and sometimes surgery, can help many people to lead normal lives. The most important goals in treating rheumatoid arthritis are maintaining your ability to move and function, reducing pain, and preventing future joint damage. If these are achieved, quality of life and length of life may be normal. The treatments themselves may cause problems. You and your doctor will have to weigh the risks and benefits of any medication or other treatment that is available for this disease.
MedicationCertain medications relieve the symptoms of rheumatoid arthritis (such as pain and swelling), while other medications slow the progress of the disease.
Nonsteroidal anti-inflammatory drugs (NSAIDs), including prescription aspirin, ibuprofen (Motrin and other brand names) and naproxen (Aleve, Naprosyn), can help relieve symptoms. Side effects occur in a minority of patients. These include upset stomach, ulcers, reduced kidney function or allergic reactions.
Newer NSAIDs, including celecoxib (Celebrex) and valdecoxib (Bextra), may provide the same benefits as older medications but with less risk of ulcers. However, the risk may be less but it is not zero. One study showed that for people at highest risk (those with recent bleeding ulcer), up to 10% of those treated with celecoxib developed a new ulcer. In addition, the risk was similar for these high-risk patients when taking an older agent (diclofenac) combined with a medication to protect the stomach (omeprazole).
The newer drugs cost more and have other possible side effects. Alert: Please read this important notice about COX-2 inhibitors including rofecoxib (Vioxx), which has been voluntarily withdrawn from the market.
Other pain relievers, such as acetaminophen (Tylenol) or tramadol (Ultram), may provide additional pain relief when taken with an NSAID.
Corticosteroids, such as prednisone (Deltasone and other brand names), reduce inflammation. They also may slow joint damage, although whether they do this is controversial. However, they have little lasting benefit and come with a long list of troubling side effects, such as easy bruising, thinning of the bones, cataracts, weight gain, puffy face, diabetes and high blood pressure, among others. If you do use corticosteroids, follow your doctor's recommendations closely. Your doctor may prescribe a corticosteroid to relieve occasional flare-ups, and then gradually taper you off the medication. Stopping corticosteroid therapy suddenly can be dangerous.
Disease-modifying antirheumatic drugs (called DMARDs, second-line drugs or remittive therapies) appear to slow or halt the progression of rheumatoid arthritis by altering the function of your body's immune system. Most experts recommend that all people with rheumatoid arthritis take a DMARD soon after being diagnosed to reduce the chances of joint damage.
These drugs include methotrexate (Folex, Methotrexate LPF, Rheumatrex), hydroxychloroquine (Plaquenil) or sulfasalazine (Azulfidine). Each of these comes with a small risk of serious side effects. Your doctors will review them with you.
Newer medications include leflunomide (Arava) in pill form, and abatacept (Orencia), adalimumab (Humira), etanercept (Enbrel), infliximab (Remicade) and rituximab (Rituxan) by injection. These can be highly effective, but because they are new and more expensive, most doctors recommend other treatments first. Another of the newest medical therapies approved by the U.S. Food and Drug Administration (FDA) for rheumatoid arthritis is anakinra (Kineret), an injectable drug that appears to be only modestly effective but may be a reasonable option if other treatments have failed. Other therapies include minocycline (Minocin), cyclosporine (Neoral, Sandimmune), immunoadsorption (a blood-filtering procedure), gold and penicillamine (Cuprimine, Depen), although these treatments are used much less often because most experts find that they are not as effective or safe
Because the newest medications have been studied only in selected, and often the healthiest, people, they may have side effects that are not yet well known. For example, new risks were discovered for infliximab a year or two after it was approved for use. Studies found that tuberculosis, although rare, was more common than expected among those receiving treatment. In addition, in a trial of infliximab treatment for congestive heart failure, a higher death rate was observed compared with those not receiving the drug. These findings have led to new recommendations about how patients should be screened before treatment begins. Because these medications take some time to start working, your doctor probably will advise you to take an NSAID, a corticosteroid or both during the early weeks or months of treatment with a DMARD.
Diet, Exercise and Rehabilitation ServicesFinding a balance between rest and exercise is crucial to managing rheumatoid arthritis. When your symptoms flare up — when your joints are sore, warm and swollen — take it easy and rest. You can continue to do range-of-motion exercises to keep your joints mobile, but be careful not to tire yourself or aggravate your joints. Avoid unnecessary walking, housework or other activities. When your joints feel better and when other symptoms, including fatigue and morning stiffness, are less noticeable, increase your activity. Weight-bearing exercises such as walking and lifting weights can strengthen weakened muscles without risking additional joint damage. If exercise produces more pain or joint swelling, cut back a bit.
Despite many claims, there are no dietary changes, supplements, herbs or other alternative therapies known to improve the symptoms of rheumatoid arthritis over a long period of time.
Having rheumatoid arthritis often means that you have to pay special attention to the way you move. An occupational therapist or physical therapist can offer suggestions and guidance as you manage ordinary tasks around your home and work. In addition, a therapist can provide special devices that can help you conserve energy and protect your joints during your daily activities. A splint, brace, sling or Ace bandage worn when your joints are especially tender can take the pressure off the joints and protect them from injury. A podiatrist may provide shoe inserts (orthotics) or even suggest surgery to improve pain and function in arthritic feet.
SurgeryIn some cases, surgery is needed to remove inflamed tissue, or to reconstruct or replace the affected joint. When rheumatoid arthritis causes significant destruction and pain in the hip or knee, arthroplasty, a surgical procedure to replace the joint, may be an effective option. Because rheumatoid arthritis may cause tendon damage, especially in the hand and wrist, surgical tendon repair may be recommended.
