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.”
“Systemic” means that many parts of the body can be involved. “Inflammatory” means that the patient presents with joints that have signs of inflammation (think of it as a “fire in the joints”). Symptoms and signs can include pain, stiffness and a feeling that the areas where joints are affected feel weak. There will also be warmth, swelling and limitation of range of movement in the joints. They 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 major focus of RA therapy is to modify this immune response inside joints so that damage can be halted, symptoms controlled or resolved, and function restored. Textbooks about RA will also 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. When the disease is very active, one may also experience weight loss, loss of muscle mass and immune response effects on other organs.
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. 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. 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.) Cigarette smoking and oral inflammation (gingivitis) have been implicated in 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.
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. Evidence is mounting to support achieving a healthy weight. Some studies suggest that eating fish two or more times per week is associated with less disease related symptoms.
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. Many patients have found benefits from mindfulness programs that facilitate learning tools to reduce the impact of stress.
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 the 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:
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 of symptoms and signs suggestive of RA, a variety of blood tests and X-rays will be performed. Certain blood tests (rheumatoid factor, anti-CCP) can help to confirm the diagnosis, but a negative test does not exclude it. Approximately half of people developing rheumatoid arthritis will have tests that reflect 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.
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 2 to 3 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, and these specialists can 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:
Reviewed and updated by Vivian P. Bykerk, BSc, MD, FRCPC.