Rheumatoid arthritis (RA) is a systemic, inflammatory disease in which joint disease is center-stage, with a background of constitutional and internal manifestations. Systemic means that many parts of the body can be involved. Inflammatory means that the patient presents with redness, warmth, swelling and functional limitation in the joints. This can lead to joint damage, a major focus of the newer therapies for RA. Constitutional and internal manifestations mean that the body's immune and inflammatory systems of the body are activated, can affect various tissues throughout the body, and can cause fatigue and weight loss.
We now know a great deal about what causes RA and how to control it. While we cannot cure it at present, joint damage can now be prevented -- with early use of disease-modifying drugs that are essential in order to avoid joint erosions and limitation in function. The rate at which new advances in care are occurring in RA is mind-boggling!
The actual cause of RA is unknown, but it is thought to be triggered by environmental factors, such as infections with viruses or bacteria, in people with a genetic predisposition to the disease. However, while some patients do remember a viral-type illness when RA began, most do not. To date, no specific infectious agent has been found. (Some antibiotics may improve RA a bit, but their benefits seem to come from their anti-inflammatory action, not their bacteria-killing actions.) Genetic factors appear to play as much as a 50% role in the development of RA. But it is the contact with an environmental agent in the genetically-predisposed person that seems to initiates the self-perpetuating inflammation characteristic of RA. While it is clear that genetics are important, if you have RA, this does not at all mean that your child or grandchildren will develop it. Actually, the risk is very small.
Diet may play a role in some patients with RA. However, in most, a well-balanced diet is the correct prescription. Patients should keep a diary to determine whether eating one type of food is commonly associated with a flare of RA. If that is the case, a trial of avoiding that food is reasonable. Optimal weight is always appropriate, especially patients with joint inflammation in the legs.
Patients commonly report that stress, either physical or emotional, was present or severe when their RA began. This is true in other autoimmune disorders as well. Since the mind-body connection is real, most physicians appreciate the linkage between stress and disease onset or exacerbation. Because there are clear interactions between the nervous, immune and endocrine systems, the impact of stress on disease presentation and severity is explainable in physiologic terms. Obviously, life is stressful. Thus, how to employ stress reduction in a therapeutic regimen is up to the individual patient, in concert with the physician.
The immune system plays a major role in development of joint inflammation and damage, fatigue, and the feeling that you have a chronic viral illness. The immune system is made up of body-protecting cells and antibodies. In normal people, these help to fight off invading infectious agents. In RA, however, something goes awry, and immune system appears to be directed against the person's tissues. Thus, it is called an autoimmune disorder.
The main joint symptoms are related to the state of inflammation and include pain, swelling, redness, warmth and limitation in range of motion of the involved joints The joint pains in RA behave in a specific manner and affect multiple joints on both sides of the body in what is called a symmetric pattern. That is, if your left knee is affected, your right knee will likely also be affected. The joints most likely to be affected are the small joints of the hand and feet, elbows, knees, and ankles. The external signs of inflammation reflect a potentially-damaging disease process that can lead to injury to bone, cartilage, and soft tissues such as tendons. If left untreated, this can cause deformities and limitation in function. Fortunately, today we have excellent treatments that can stop this inflammation and avoid further damage.
Some patients with RA develop more generalized disease in which internal organs can be inflamed and damaged. This is quite rare, and rarer still today with our new therapies. Some of the patients who develop this problem have little nodules under the skin of their forearms. Internal problems can include: lung inflammation; nerve irritation called neuropathy; eye inflammation called scleritis; and dry eyes or dry mouth due to Sjogren's syndrome. Each of these problems can be treated with many of the newer medications available for RA.
The diagnosis of RA is based on clinical signs and symptoms, but it is supported by laboratory tests. If someone presents with a clinical pattern suggestive of RA, a variety of blood tests and X-rays will be performed.
Today, we are blessed with a deeper understanding of the pathogenesis and characteristics of RA and the availability of safe and effective medications that can alter the natural history of RA and improve function. We start with the premise that RA is eminently controllable, and the goal of our therapies is "no evidence of disease." That means no signs of redness, warmth, swelling or tenderness and normal function. Since we would not accept uncontrolled illness in angina, chronic obstructive lung disease, hypertension or diabetes, we should similarly not accept it in RA. Luckily, today, we have the therapeutic tools to make this happen. Early treatment with disease-modifying drugs is mandatory in order to prevent joint damage and dysfunction (i.e. within the first two to three months after disease onset). Treatment will continue for at least five years and possibly throughout life. Medications, physical and occupational therapy, and education for patients and their families should be important components of every regimen.
A multidisciplinary team that includes the primary care physician, the rheumatologist, the physical therapist, and other members of the health care system will bring about a coordinated treatment program that is both safe and effective. The primary care physician or internist commonly works in partnership with a rheumatologist. Referral to a specialist in rheumatology most commonly occurs in the following situations: