Rheumatoid arthritis is a systemic, autoimmune, inflammatory disease. It chiefly affects the joints, often many joints throughout the body at the same time. But "systemic" means that many other parts of the body can also be affected.
In medical terms, rheumatoid arthritis (RA) is usually described as “a systemic, inflammatory disease in which joint disease takes center-stage against a background of constitutional and internal manifestations.”
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 the immune system appears to be directed against the person's tissues. This is why RA is called an autoimmune disorder. In people with RA, the immune system plays a major role in the development of joint inflammation and damage, fatigue, and the feeling that they have a chronic viral illness.
The major focus of treatment is modifying these immune responses inside joints so that damage can be halted, symptoms controlled or resolved, and function restored.
Medical textbooks about RA will talk about “constitutional and internal manifestations” of the disease. This means that the body's immune and inflammatory systems of the body are activated and can affect various tissues throughout the body. Most people who develop RA will experience this as fatigue.
Arthritis caused by inflammation often results in pain and stiffness after periods of rest or inactivity, particularly in the morning. The swelling, redness, and warmth may be present in the affected joints, but other areas in the body can be affected by the inflammation as well, such as the eyes and the lining around the heart.
Rheumatoid arthritis is caused by a problem with the immune system, which mistakes your own body tissue as if it were an outside harmful invader (like a virus or bacteria). The immune system attacks your own joints, causing inflammation.
The precise cause of the immune system problems that lead to RA is unknown, but it is thought that they are triggered by environmental factors – such as infections with viruses or bacteria – in people who have some genetic (inherited) predisposition to the disease. However, although some patients do remember having viral-type illness when their RA symptoms first started, most do not. No specific infectious agent has been found that triggers the immune system's response. (Some antibiotics may improve RA a bit, but their benefits seem to come from their anti-inflammatory effects, rather than their bacteria-killing actions.) Some evidence points to cigarette smoking and oral inflammation (gingivitis) as triggers for the early development of rheumatoid arthritis.
Genetic factors play a significant role in the development of RA. Genetic factors means that a person has genes that place him or her at risk for RA, and that those genes have been “turned on” (meaning expressed in cells). 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.
The chief symptom of RA is inflammation (swelling, redness, warmth) of joints in the body, which cause pain and stiffness. Patients also often feel fatigue during RA flares.
The main joint symptoms are related to the inflammation and include pain, swelling, redness, warmth, weakness and limitation in range of motion of the affected joints. These joints will be tender to pressure and can occasionally appear red. Inside the joints, the immune system has been activated, and many cells proliferate in the joints – producing fluid, and mediators of pain. If left untreated, this process can lead to joint damage.
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:
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.
When the disease is very active, one may also experience weight loss, loss of muscle mass and immune response effects on other organs.
Diet may play a role in some patients, but most patients should maintain a well-balanced diet rather than avoid specific foods. Keep a diary to determine whether certain foods are associated with your disease flares and then see if removing them from your diet is helpful.
Some studies do suggest that eating fish two or more times per week may be associated with fewer disease-related symptoms, and there is increasing evidence that achieving and maintaining a healthy weight is helpful for managing RA.
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 very real, most doctors agree that there is a link between stress and disease onset or flares.
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. Many patients have found benefits from mindfulness programs that facilitate learning tools to reduce the impact of stress.
Some patients with RA develop more generalized disease in which internal organs can be inflamed and damaged. This is quite rare, especially 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:
Each of these problems can be treated with many of the newer medications available for rheumatoid arthritis.
The diagnosis of RA is based on a person's clinical signs and symptoms, but it is supported by laboratory tests, including X-rays and various blood tests, including but not exclusively the rheumatoid factor, anti-CCP.
If a person exhibits a clinical pattern of symptoms and signs that suggestive they have rheumatoid arthritis, a variety X-rays and blood tests will be performed. Certain blood tests (such as rheumatoid factor, anti-CCP) can help to confirm the diagnosis, but a negative test does not necessarily mean a person does not have RA it.
Approximately half of people developing rheumatoid arthritis will have blood test results that demonstrate inflammation. These tests are called acute phase reactants. Examples of these are an erythrocyte sedimentation rate (ESR) and a C-reactive protein (CRP). These tests are performed to assess the activity of the disease in combination with an assessment of the patients symptoms and physical findings.
There is no cure yet, however, we now know a great deal about what causes RA, and how to control it and prevent joint damage. This is achieved by the early implementation of disease-modifying antirheumatic drugs (DMARDs). These are essential to gain rapid control of the disease, in order to avoid joint erosions and long-term limitation of function.
RA is usually treated with a combination of medications to relieve swelling and pain while regulating the immune system. Joint surgery to relieve pain and disability, including joint replacement, may also be considered when these nonsurgical methods have failed to provide lasting benefit.
With early detection and intervention, RA and other forms of inflammatory arthritis can be treated very effectively. The HSS Inflammatory Arthritis Center connects patients quickly and efficiently with a rheumatologist who can evaluate their joint pain and get each patient started on an appropriate course of treatment. HSS also offers specialized support and education programs for people with RA.
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 (ie, within the first two to three months after disease onset). Current treatments are often very effective at controlling the disease and achieving a medication controlled remission. Cessation of therapy is associated with flares and return of disease manifestations for most. Thus treatment is usually continued throughout life, but doses and types of medication may be reduced over time. Medications, physical and occupational therapy, and education for patients and their families should be important components of every regimen.
In general, patients with RA will benefit from seeing a specialist as early as possible. Most often the specialists treating this disease are trained in rheumatology. Their knowledge of medications to treat this disease can help patients make informed decisions consistent with their values and goals. These specialists can also help provide a balanced perspective on the benefits of treating the disease well vs. any potential side effects.
Patients diagnosed with RA are encouraged to become the “captain” of their multidisciplinary team of health providers. These include the primary care physician, the rheumatologist, the physical therapist, social worker, education programs 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:
Learn more from the content below, or find the best rheumatologist HSS for your particular rheumatoid arthritis condition and insurance.
Get more information on the basics of rheumatoid arthritis.
Learn about nonsurgical treatments for rheumatoid arthritis.
Read about surgical treatments for rheumatoid arthritis and considerations for RA patients who choose to have orthopedic surgery unrelated to their chronic disease.
These articles can help people with rheumatoid arthritis understand ways that diet, nutrition, psychology and medical issues can positively or negatively affect the management of their chronic disease.
Read educational content adapted from live presentations given at HSS patient support and education programs.
These articles are designed to provide helpful information to primary care and rheumatology medical professionals.
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