Rheumatoid Arthritis

Joint involvement in RA tends to 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 (although initially only one side may be involved).

The joints most likely to be affected are the:

• small joints of the hands and feet (fingers and toes)
• elbows
• knees
• ankles

However, many other joints can be affected, such as the neck joints in the cervical spine, the shoulders, hips or temporo-mandibular joints (at the angle of the jaw).

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 in most people. In some people, the fatigue is the worst of their symptoms. Fortunately, our present medications for RA can often significantly improve this symptom as well.

How can you tell if you have rheumatoid arthritis or osteoarthritis?

People often ask how to distinguish rheumatoid arthritis (which occurs in less than 1% of the population) from the more common osteoarthritis. Rheumatoid arthritis is more inflammatory, and it is a systemic disease. If arthritis is accompanied by low-grade fever, weight loss or fatigue, that points to a possible diagnosis of RA, since osteoarthritis is a localized process affecting individual joints rather than a systemic disease. Morning stiffness is present in osteoarthritis, but often it lasts just 5 or 10 minutes, whereas in RA it often lasts for hours (related to the degree of inflammation). In addition, particular joints are more commonly affected by RA than in osteoarthritis. For example, the knuckles, where the fingers meet the hands, are more likely to be involved in RA, while in osteoarthritis, the joints at the tips of the fingers are more commonly affected.

What are the early signs of rheumatoid arthritis?

Treatments for RA are especially effective if started early, so getting an early diagnosis is important. One clue to a possible RA diagnosis is joint swelling, especially in the small joints of the hands or feet. In the hands, this will most commonly be at the joints in the middle of the fingers or where the fingers meet the hand, and not at the tip joints near the nails. Morning stiffness, especially if it lasts a half an hour or more, is another clue. If the joint symptoms are accompanied by fatigue, weight loss or malaise, these all suggest that this is a systemic problem and, therefore, possibly rheumatoid arthritis.

If you have signs and symptoms that may suggest you have RA, it is important to consult a rheumatologist promptly, since early detection is key to disease management and prevention of joint damage. (Find a doctor at HSS who diagnoses and treats rheumatoid arthritis.)

What are rheumatoid nodules?

Rheumatoid nodules are “bumps” on the skin that are related to the inflammatory process in rheumatoid arthritis. A common spot would be at the tip of the elbow or on the forearm (especially on the side of the forearm extending from the point of the elbow (funny bone). Fortunately, these are much less commonly seen than they used to be. The general belief is that they are less common now because our treatments are much better than they were prior to the 1990s.

Rheumatoid nodules are not dangerous in themselves. If they are bothersome to a patient, they can be taken in consideration when treatments are chosen, since some medications for RA seem to have a better chance of decreasing nodules than other treatments.

What causes rheumatoid arthritis?

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 determined to have triggered the immune system's RA 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 gum 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). It appears that a number of genes are involved in increasing the risk of RA. However, 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.

How do you test 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. No single blood test makes the diagnosis, but rather it is the pattern of the arthritis, in combination with blood testing and X-ray findings.

If a person has an elevation of one or both of two blood tests − sedimentation rate and CRP − this suggests the presence of an inflammatory process that could be rheumatoid arthritis. A positive blood test for the rheumatoid factor suggests RA, but this test can also be positive in people who have other disorders. The CCP antibody is more specific to RA than is the rheumatoid factor, but just having the CCP antibody positive does not by itself confirm a diagnosis of RA. Also, it is possible for a person to have RA but still have a normal sedimentation rate and CRP test results, and to test negative for rheumatoid factor or CCP antibody. A diagnosis is made by taking into account the whole picture – symptoms, patient history and blood test results.

For example, the tests for RA discussed above are much more meaningful if a patient also has multiple swollen and tender joints, and even more so if the joint swelling is accompanied by fatigue or weight loss. Rheumatologists put all these elements on the scale to make a final diagnosis.

Is there a cure for rheumatoid arthritis?

There is no cure yet, however, we now know a great deal about what causes RA, as well as 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.

What are the treatments for rheumatoid arthritis?

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. Fortunately, treatments have improved over the years, and fewer and fewer patients are needing joint replacement due to RA. (Most joint replacements are done to treat advanced stage osteoarthritis.)

Early detection and intervention is key

With early detection and intervention, RA and other forms of inflammatory arthritis can be treated very effectively. It’s important to see a rheumatologist soon if you have early signs of rheumatoid arthritis. Early treatment with disease-modifying drugs (DMARDs) is generally mandatory in order to prevent joint damage and dysfunction (ideally, starting within three months after disease onset).

Current treatments are often very effective at controlling the disease. Most patients who cease therapy experience flares and return of disease symptoms, but there are some people who can eventually discontinue their medications and still experience a remission. There is evidence that such drug-free remissions are more likely in people who start treatment during early onset of their disease.

Currently, in most cases, treatment continues indefinitely, with efforts over time to reduce doses or modify the medication. Fortunately, we have a concept that RA medications get “safer over time.” This is because we have seen that patients who have no problem with a medication early in treatment seem to do quite well over the long-term. We watch RA patients closely when they first start treatment so that any side-effects can be addressed.

Continuing medical research advances clinical care

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 for our patients to exhibit "no evidence of disease" whenever possible. That means no signs of redness, warmth, swelling or tenderness, and having normal joint function with no stiffness. In some cases, bringing a patient to “low disease activity” (minimized symptoms), with the patient able to be fully active, may be acceptable, but the goal is to achieve full remission. As therapies for RA keep improving, that goal is reached by more patients.

HSS researchers have recently found evidence to suggest that RA can be characterized into at least four distinct subtypes, based on molecular patterns found in patients’ joint biopsies. These distinctions may one day enable doctors to personalize treatment options, depending on which subtype a patient has.

Currently, there are numerous medications available, but the chance the most appropriate one will be chosen the first time is only about 40%. By understanding the unique features of a patient's condition, doctors may soon be able to make more informed decisions on which specific medications are likely to produce more successful outcomes for each patient from the start.

In addition to taking medications for RA, whether pills or injections, other treatments are important. Occupational Therapy and physical therapy are important for most patients with RA, along with a home exercise program. Patients with RA need to be educated about the pros and cons of various treatments, so that the best choice can be made in concert with their rheumatologist. There is not one absolute best route for an individual patient, so that “joint decision making” with the rheumatologist is very important in RA.

HSS also offers specialized support and education programs for people with RA.

How serious is rheumatoid arthritis?

RA is a condition that certainly needs to be taken seriously, and if it is not treated it can have major impact on quality of life. There is even data now that untreated inflammation over time can increase the risk of heart disease, which is one more reason to get RA under control. Patients with RA now are very fortunate that there are now many effective treatment options, with the potential to give them back an excellent quality of life.

Rheumatologists think of RA differently than they did 30 or 40 years ago. Back then, “gold shots” (various types of injection compositions that contained gold) were the main available treatment, and many patients either did not respond to treatment or could not tolerate it. This led to a number of people with uncontrolled RA, which can be a serious situation. Patients can have chronic pain, disability, fatigue and may go on to need joint surgery. Now, however, there is a wide variety of medications for RA which are able to stop the inflammatory process.

Substantial ongoing research is helping rheumatologists pick the right treatment for each patient, and we do have some early guidelines which are helpful. Still, an individual person may need to try several different medications before finding the best one for them. Once they find the right medication, their situation is much improved, and RA is not the same serious condition it could have been.

When should I see a specialist for rheumatoid arthritis?

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 a fully involved member of their multidisciplinary team of health providers. These include the primary care physician, the rheumatologist, the physical or occupational therapist, social worker, health educators and other members of the healthcare system associated with care. The primary care physician or internist commonly works in partnership with a rheumatologist. Note that every RA patient’s healthcare team is a little different, so it’s important for the patient to understand what role each member plays. For example, in many situations all medication changes will need to be cleared with the rheumatology, and sometimes the primary care physician may be taking a more active role. Referral to a specialist in rheumatology most commonly occurs in the following situations:

• when the diagnosis is in question
• at the start of therapy, in order to provide expert input into the optimal medication and physical therapy regimen
• during the course of the illness to define response to or alteration in the treatment regimen
• in the setting of possible medication side effects
• progressive disease despite therapy
• a single joint that is leading to significant functional limitation
• the presence of fever, marked fatigue, or weight loss
• prior to orthopedic surgery

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