Rheumatoid Arthritis

rheumatoid arthritis What is rheumatoid arthirits?

Arthritis means inflammation of joints. Rheumatoid arthritis (RA) is a common form of arthritis. (There are various other causes of arthritis and RA is just one cause).

Who are prone to get the infection?

The incidence of RA is 1 in 100 people. Any person can be affected and it is not a hereditary disease. People develop RA at any age, but most commonly starts between the ages of 40 and 60. It is seen to be three times more common in women than in men.

What do you understand by a joint?

A joint is where two bones meet. Each joint in the body involves muscles which are required for their movement, the cartilage and the thick fluid (the synovial fluid secreted by synovial cells which surround the joint, this is called as synovium) in them is there to provide lubrication, and the outer layer called as capsule, which is thick and along with the ligaments and surrounding muscles, provides stability to the joint.

How is it caused?

The main cause of rheumatoid arthritis is autoimmune problem. Normally, the immune system of the body protects itself from infection by producing proteins or antibodies against bacteria causing infection. In people suffering from autoimmune disease, the immune system starts producing antibodies against ones own body. The reason is not clear, there is a triggering agent, which initiates the disease, but still it is not known.

In people with RA, develop antibodies against the synovium (the tissue that surrounds each joint), causing, inflammation in and around affected joints and with time, the inflammation can damage the joint, the cartilage, and parts of the bone near to the joint.

The joints commonly affected are the small joints of the fingers, thumbs, wrists, feet, and ankles. However, any joint may be affected. The knees are quite commonly affected. Less commonly, the hips, shoulders, elbows, and neck are involved. It is often symmetrical. In some people, just a few joints are affected. In others, many joints are involved.

How does it present?

Symptoms of rheumatoid Arthritis mostly involve joint symptoms like pain and stiffness of the affected joints. The stiffness is usually worse in the morning, or after you have been resting. Other symptoms include extra-articular symptoms of RA (meaning outside of the joints) like; Small painless lumps (nodules) develop in about 1 in 4 cases. These commonly occur on the skin over the elbows and forearms, but usually do no harm.Inflammation around tendons may also occur; this is due to the tissue which covers tendons are similar to the synovium around the joints. Patient also suffers from anaemia and tiredness. Sometimes patient suffer from fever, feeling unwell, weight loss, and muscle aches and pain.In a few cases, inflammation develops in other parts of the body, such as the lungs, heart, blood vessels, or eyes. This is uncommon but, if it occurs, can cause various symptoms and problems, which are sometimes serious.

The symptoms develop gradually - over several weeks or so, first todevelop is the stiffness in the hands, wrists, or soles of the feet in the morning, which eases by mid-day, these may come and go for a while, but then becomes a regular occurrence. After that, one may have some pain and swelling in the same joints. More joints such as the knees may then become affected.

The severity of RA can vary greatly from person to person. It is usually a persistent relapsing condition, which means that at times, the disease flares up (relapses), and at other times it settles down with no apparent reason. During each flare up of the disease joint is affected and this in minority of cases could lead to disability.

How do you diagnose it?

It is quite difficult to diagnose definitely,RA, this is because there are many causes of joint pains. But a confidant diagnosis is made if the patient presents with typical symptoms, blood test shows positive for a protein called as rheumatoid factor , x-rays show characteristic early damage to joints and if the patient has associated problems like cardiac problems, anemia, infections and osteoporotic changes.

Rheumatoid factor in the blood is present in about 2 of the 3 patients with RA. However it is also present in 1 out of 20 normal people. So a person with positive rheumatoid factor is suggestive of RA but is not conclusive. A more recently developed test that detects the presence of an antibody to a substance called cyclic citrullinatedpeptide (CCP) in a blood sample,has been found to be more specific than rheumatoid factor in the diagnosis of RA. This blood test may become more commonly done to help diagnose RA.

How do you treat it?

There is no cure for RA , however , symptomatic treatment can make a big difference.

The main aims of treatment are:

  • To decrease disease activity and prevent joint damage medicines called as disease-modifying antirheumatic drugs (DMARDs) are given. These medicines ease symptoms and also reduce the damaging effect of the disease on the joints. They work by blocking the way inflammation develops in the joints. DMARDs include: methotrexate, sulfasalazine, gold injections, gold tablets, penicillamine, leflunomide, hydroxychloroquine, azathioprine, ciclosporin, and mycophenolatemofetil (MMF). It is these medicines that have improved the prognosis (outlook) in recent years for many people with RA.
  • Biological medicines which have been introduced more recently and also have a disease-modifying effect against RA. They are sometimes called cytokine modulators or monoclonal antibodies. Biological therapies include: adalimumab, certolizumabpegol, etanercept, golimumab, infliximab, anakinra, abatacept, rituximab and tocilizumab.They are called biological medicines because they mimic substances produced by the human body such as antibodies. Also, they are made by living organisms such as cloned human white blood cells. This is unlike most medicines that are made by chemical processes. Biological medicines work in RA by blocking chemicals that are involved in inflammation. For example, some of these biological medicines block a chemical called TNF-alpha, which plays an important role in causing inflammation in joints in RA.

    One problem with biological medicines is that they need to be given by injection. They are also expensive. Recent guidelines state that two trials of six months of traditional DMARD monotherapy or combination therapy (at least one including methotrexate) should fail to control symptoms or prevent disease progression before one of these newer biological medicines are recommended. Biological medicines may also be used in combination with methotrexate (a DMARD).

  • Maintaining good oral hygiene may help To reduce pain and stiffness again, DMARDs and biological medicines can be given to control the activity of the disease.
  • During a flare-up of inflammation, if you rest the affected joint(s) it helps to ease pain. Special wrist splints, footwear, gentle massage, or applying heat may also help. Medication is also helpful.

    Medicines advised by your doctor to ease pain and stiffness include the following:

    • Non-steroidal anti-inflammatory drugs (NSAIDs) They help to reduce inflammation. There are many types and brands. The leaflet which comes with the tablets gives a full list of possible side-effects. The most common side effect is stomach pain (dyspepsia). An uncommon but serious side effectis bleeding from the stomach, during which one should stop taking the tablets and see a doctor urgently.
    • Painkillers- Paracetamol often helps. This does not have any anti-inflammatory action, but is useful for pain relief in addition to, or instead of, an anti-inflammatory tablet. Codeine is another painkiller that is sometimes used.
    • Steroids are good at reducing inflammation. It is common practice to advise a short course of steroids to damp down a flare-up of symptoms, which has not been, helped much by an NSAID. Also, when RA is first diagnosed, a short course of steroids is commonly used to control symptoms whilst waiting for DMARDs to take effect. An injection of steroid directly into a joint is sometimes used to treat a bad flare-up in one particular joint.

To minimise disability one has to try to keep active. The muscles around the joints will become weak if they are not used. Regular exercise may also help to reduce pain and improve joint function. Swimming is a good way to exercise many muscles without straining joints too much. A physiotherapist can advise on exercises to keep muscles around joints as mobile and strong as possible. They may also advise on splints to help rest a joint if needed.

Treating other symptoms of the disease, helps people treat with RA, example anaemia.Better lifestyle would decrease incidence of cardiovascular problems and immunisation to diseses would decrease infections.

What is the prognosis of the disease?

The prognosis regarding joint damage is perhaps better than many people think, about 2 in 10 people with RA have a relatively mild form of the disease, and can continue to do most normal activities for many years after the condition first starts.About 1 in 10 people with RA becomes severely disabled.About 7 in 10 people with RA fall somewhere in between with varying degrees of difficulties and disability. Most will have to modify their lifestyle to some extent, but can expect to lead a full life.However, these figures are probably becoming out-of-date, as treatment has improved in recent years.

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