What is rheumatoid arthritis?
Rheumatoid arthritis (RA) is an autoimmune disorder characterized by joint inflammation, which can lead to progressive joint damage, deformities and disability if left untreated.
Who is affected by rheumatoid arthritis?
Rheumatoid arthritis can occur at any age, but the peak onset is between the ages of 50 and 75. Disease prevalence is about 1 percent in Caucasians, but ranges between 0.1-5 percent in other ethnic groups. Women are affected two to three times more often than men.
What are risk factors for developing rheumatoid arthritis?
The causes of RA remain unclear, but certain genes have been identified that make certain individuals more prone to developing disease. Cigarette smoking and obesity have also been identified as risk factors. It has been hypothesized that certain environmental triggers, such as bacterial or viral infections, may contribute to the development of RA, but no specific organisms have been identified.
What are symptoms of rheumatoid arthritis?
Patients with rheumatoid arthritis typically present with symmetrical joint pain, swelling and prolonged stiffness in the morning. The joint stiffness usually improves with activity, but it may take up to several hours. Small joints (hands, wrists) are more frequently affected than large joints (knees, hips). The cervical spine is occasionally involved, resulting in neck pain and stiffness. Many patients complain of decreased handgrip strength and limitations in hand function, so it may be difficult to open jars, turn doorknobs and perform fine motor tasks, such as fastening buttons.
On occasion, rheumatoid arthritis can involve other areas of the body aside from the joints (known as “extra-articular” symptoms). Extra-articular manifestations are more frequently seen in patients with severe, active disease. Patients may develop rheumatoid nodules on their elbows or other extensor surfaces. Patients who have rheumatoid arthritis-related eye disease may complain of dry eyes, eye pain or redness, and those with rheumatoid lung disease may present with a dry cough or shortness of breath.
How is rheumatoid arthritis diagnosed?
The diagnosis of rheumatoid arthritis is based predominantly on the presence of clinical symptoms. The presence of a positive rheumatoid factor (RF) or anti-cyclic citrullinated peptide (anti-CCP Ab) is useful in confirming the diagnosis. However, the absence of a positive RF or anti-CCP Ab does not exclude the possibility of RA in a patient with convincing clinical symptoms. Similarly, the presence of a positive RF or anti-CCP Ab does not guarantee a diagnosis of RA, as false positive tests can be seen in healthy individuals as well as patients with other autoimmune disorders, such as Sjogren’s syndrome. Other laboratory abnormalities seen in RA include elevated inflammatory markers (ESR, CRP) or anemia. X-rays of affected joints may show abnormalities typical of RA, such as erosions, joint space narrowing or peri-articular osteopenia. An MRI or ultrasound can be performed to look for subtle joint inflammation or damage if xrays are normal.
How is rheumatoid arthritis treated?
Early initiation of appropriate therapy is critical in the management of rheumatoid arthritis, as this will decrease the risk of developing irreversible joint damage.
Mild to moderate RA can be managed with non-steroidal anti-inflammatories (NSAIDs) and traditional disease-modifying anti-rheumatic drugs (DMARDs). Xeljanz is the newest oral medication to be approved for patients who fail to respond to these therapies. Patients with severe disease are often treated with biologic agents, such as anti-tumor necrosis factor inhibitors (anti-TNFs). Frequently, oral steroids are used to control the joint pain and inflammation until the long-term medications take effect. If a patient suffers from joint pain related to irreversible joint damage, then local steroid injections can be performed, but joint replacement surgery may be warranted.
Because the biologic medications are immunosuppressive, it is important that patients are screened appropriately and adequately immunized prior to initiating therapy. Rheumatoid arthritis patients are at increased risk for cardiovascular disease, so aggressive management of hypertension, hyperlipidemia and other cardiovascular risk factors is necessary. Rheumatoid arthritis patients are also predisposed to developing osteoporosis, so a baseline bone density should be performed in post-menopausal females or patients on chronic steroid therapy.
Are there any useful lifestyle modifications that I can make?
Several lifestyle modifications have been shown to be beneficial in rheumatoid arthritis, including cutting out smoking, losing weight and increasing exercise. The benefits of various diets have been investigated, but the effects remain uncertain with the exception of diets rich in fish oil, which have been shown to correlate with a decrease in arthritic symptoms.
Dr. Dee Dee Wu is a rheumatologist who specializes in the treatment of rheumatoid arthritis, psoriatic arthritis, osteoarthritis and osteoporosis. She practices at both the HSS Outpatient Center in Paramus and the hospital’s main campus in New York.