Rheumatoid arthritis (RA) is an autoimmune disease in which the body’s immune system – which normally protects its health by attacking foreign substances like bacteria and viruses – mistakenly attacks the joints. This creates inflammation that causes the tissue that lines the inside of joints (the synovium) to thicken, resulting in swelling and pain in and around the joints. The synovium makes a fluid that lubricates joints and helps them move smoothly.
According to the Arthritis Foundation, RA affects about 1.3 million Americans, mostly women; two to three times more women have RA than men, and the number of women with the disease appears to be increasing. The age of onset can vary, but it typically occurs between ages 30 and 60, with the risk increasing as a person ages. The good news is that new advancements in treatment have made it possible to slow or stop the progression of RA.
Unlike the more common osteoarthritis, which is mainly a disease of the cartilage in joints, RA occurs when the body’s immune system attacks and damages the joints and, sometimes, other organs. RA often occurs in a symmetrical pattern, meaning that if one knee or hand is involved, the other one is, too.
If inflammation goes unchecked, it can damage cartilage, the elastic tissue that covers the ends of bones in a joint, as well as the bones themselves. Over time, there is loss of cartilage, and the joint spacing between bones can become smaller. Joints can become loose, unstable, painful and lose their mobility. Joint deformity also can occur. Joint damage cannot be reversed, and because it can occur early, doctors recommend early diagnosis and aggressive treatment to control RA.
Rheumatoid arthritis most commonly affects the joints of the hands, feet, wrists, elbows, knees and ankles. The joint effect is usually symmetrical. That means if one knee or hand if affected, usually the other one is, too. Because RA also can affect body systems, such as the cardiovascular or respiratory systems, it is called a systemic disease. Systemic means “entire body.”
The condition is considered an autoimmune disease. Such diseases are characterized by an immune-system attack on the body’s healthy tissues. In RA, white blood cells travel to the synovium (the membranes that line the inner surface of the joint capsule) and cause inflammation, namely synovitis. The ensuing warmth, redness, swelling and pain are typical symptoms of RA, which usually affects the wrists, fingers, knees, feet and ankles.
The continuous inflammation associated with RA gradually destroys cartilage- the specialized tissue that coats and cushions the bony ends in the joints. The loss of cartilage leads to narrowing and loss of joint space and, eventually, damage to the bone. The surrounding muscles, ligaments and tendons that support and stabilize the joint also become weak and unable to work normally.
Systemic symptoms often include fatigue, general sense of malaise, low-grade fever, morning joint stiffness and difficulty moving a joint or several joints. Pain and signs of inflammation such as redness and warmth in or around a joint are often severe.
RA varies from person to person, but most cases are chronic, meaning they never go away. Some people have mild or moderate disease, with flares (periods of worsening symptoms) and remissions. For others, the disease is active most of the time. The resulting joint damage can be disabling.
The disease can affect more than just the joints, bones and surrounding muscle. About one-quarter of those with RA develop rheumatoid nodules. These are bumps under the skin that often form close to the joints. Many people with rheumatoid arthritis develop anemia. Other effects, which occur less often, include neck pain and dry eyes and mouth. Very rarely, RA results in inflammation of the blood vessels, the lining of the lungs, or the sac enclosing the heart. If you have RA, you may also be at increased risk for infections and gastrointestinal ailments.
Diagnosing and treating rheumatoid arthritis can sometimes be difficult. It may require a team effort between you and several types of health care professionals, including arheumatologist, a physician who specializes in arthritis and other diseases of the joints, bones and muscles. Physical therapists, psychologists and social workers can also play a role.
RA can be devastating, but current treatment strategies can help you cope and possibly reduce the impact of the disease. These strategies can include pain relievers and other medications, rest, appropriate exercise, education and support programs. Involvement of the rheumatology health care professional is essential in the care of RA.
The psychological element is important: Some studies indicate that if you are well informed about your condition and participate in your own treatment plan, you will probably have less pain and make fewer visits to your health care professional than otherwise. You can find treatment support groups in many cities.
Signs and symptoms of rheumatoid arthritis may include:
- Tender, warm, swollen joints
- Joint stiffness that is usually worse in the mornings and after inactivity
- Fatigue, fever and weight loss
Early rheumatoid arthritis tends to affect your smaller joints first — particularly the joints that attach your fingers to your hands and your toes to your feet.
As the disease progresses, symptoms often spread to the wrists, knees, ankles, elbows, hips and shoulders. In most cases, symptoms occur in the same joints on both sides of your body.
About 40 percent of the people who have rheumatoid arthritis also experience signs and symptoms that don’t involve the joints.
Rheumatoid arthritis can affect many nonjoint structures, including:
- Salivary glands
- Nerve tissue
- Bone marrow
- Blood vessels
Rheumatoid arthritis signs and symptoms may vary in severity and may even come and go. Periods of increased disease activity, called flares, alternate with periods of relative remission — when the swelling and pain fade or disappear. Over time, rheumatoid arthritis can cause joints to deform and shift out of place.
What You Can Do to Combat RA Symptoms
While health care professionals must be involved in your care, there are a number of lifestyle changes you can make to help manage RA. Experts suggest that eating a healthy diet can enhance your overall health and thus help you better manage your RA.
Although drinking has no known impact on the disease itself, you may need to avoid alcoholic beverages, depending on the RA medications you are taking, especially the often-prescribed methotrexate. Check with your health care professional. Stress reduction is also important, since your stress level may affect the amount of pain you feel.+
Rest and exercise—seemingly opposite ends of the spectrum—are important to your health. When your RA is active, you will want more rest. But moderate exercise is critical to healthy muscles, joint mobility and flexibility.
While exercise may seem unappealing if you’re experiencing frequent pain, there are a number of techniques to help you get through a program:
- Moist heat supplied by warm towels, hot packs, a bath or a shower can be used at home for 15 to 20 minutes three times a day to relieve symptoms. Applying heat before exercise can be a good way to start. A health care professional can apply deep heat using short waves, microwaves and ultrasound to relieve pain.
- Cold supplied by a bag of ice or frozen vegetables wrapped in a towel helps stop pain and reduce swelling when used for 10 to 15 minutes. This treatment often is recommended for acutely inflamed joints. Do not use cold treatments if you have numbness or poor circulation.
- Hydrotherapy (water therapy) can decrease pain and stiffness. Exercising in a large pool may be easier because water takes some weight off painful joints. Many community centers, YMCAs and YWCAs have water exercise classes developed for people with arthritis. You may also find relief from the heat and movement of a whirlpool.
- When performed by a trained professional, massage and manipulation (using the hands to restore normal movement to stiff joints) can help control pain and increase joint motion and muscle and tendon flexibility.
Although these types of physical therapy can temporarily relieve symptoms, none have documented anti-inflammatory effects or affect the rate of joint damage that can occur in RA.
Alternative Therapies for RA Pain Relief
- Relaxation techniques: Deep breathing, guided imagery and visualization (where you focus on “seeing” pleasant pain-free scenes or activities in your mind) and stress reduction help provide some pain relief. Physical therapists can teach relaxation techniques. The Arthritis Foundation has a self-help course that includes relaxation therapy; find out more about the Arthritis Foundation Self-Help Program at
- Acupuncture: Acupuncture is an important component of traditional Chinese medicine that involves the insertion of thin needles at specific points, which are mostly along the body’s nerve pathways, to improve health. A handful of small studies have been conducted on the use of acupuncture in RA, and the findings do not clearly answer the question of whether or not it works. Individuals who want to use acupuncture should discuss their interest with their health care team. Only a licensed acupuncturist should be used.
- Thunder god vine: Studies indicate that preparations made from the peeled root of this plant, used in traditional Chinese medicine to treat inflammatory and autoimmune disorders, may be helpful in the treatment of RA. Possible side effects include menstrual changes, hair loss and diarrhea.
- Nutritional supplements: A few studies have shown that the nutritional supplement gamma-linolenic acid (GLA) and the fish oils eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) may help reduce some of the symptoms of RA.Discuss your interest or questions about such products and reports with your health care professional.
- Biofeedback: Biofeedback is a way to enhance an awareness of your body so that you become focused on how your body functions; usually this enhanced focus is turned toward something—such as muscle control—that typically occurs at a subconscious level. During biofeedback, an electronic device provides information about a body function (such as heart rate) so you can learn to control that function.
- Biofeedback may help people with arthritis learn to relax their muscles. In this case, an electronic device amplifies the sound of a muscle contracting, so you know that the muscle is not relaxed. The therapy is typically learned with the help of a health care professional and then may be practiced at home once you have mastered the technique, either with a biofeedback machine or without one.
- Some additional techniques under investigation include tai chi (a movement- based form of meditation) and cognitive behavioral therapy (a method of anticipating and preparing yourself for situations and bodily sensations that will cause pain).
- With all of these treatments—lifestyle, medical and surgical—monitoring which treatments work and which don’t and watching for side effects is critical. Monitoring can involve regular consultations with your health care professional as well as blood, urine and other laboratory tests and X-rays.
Rheumatoid arthritis vs. osteoarthritis
Rheumatoid arthritis occurs when your immune system attacks the synovium — the lining of the membranes that surround your joints.
The resulting inflammation thickens the synovium, which can eventually destroy the cartilage and bone within the joint.
The tendons and ligaments that hold the joint together weaken and stretch. Gradually, the joint loses its shape and alignment.
Doctors don’t know what starts this process, although a genetic component appears likely. While your genes don’t actually cause rheumatoid arthritis, they can make you more susceptible to environmental factors — such as infection with certain viruses and bacteria — that may trigger the disease.
Rheumatoid arthritis affects around 400,000 people in the UK. It can affect adults at any age, but most commonly starts between the ages of 40 and 50. About three times as many women as men are affected.
Rheumatoid arthritis is an autoimmune disease. This means that your immune system starts attacking your body’s own tissues instead of germs and viruses, which causes inflammation. Inflammation normally dies down fairly quickly but in rheumatoid arthritis it becomes a long-term (chronic) process. We don’t yet know exactly what sets off the inflammation in rheumatoid arthritis. There’s some evidence that lifestyle factors may affect your risk of developing the condition.
Rheumatoid arthritis is more common in people who:
- eat a lot of red meat
- drink a lot of coffee.
Rheumatoid arthritis is less common in people who:
- have a high vitamin C intake
- drink alcohol in moderation.
The genes you inherit from your parents may increase your chances of developing rheumatoid arthritis, but genetic factors alone do not cause it. Even if you have an identical twin, who shares all the same genetic material as you, and they have rheumatoid arthritis, you only have a 1 in 5 chance of developing it too. And if some of your family have it, the severity can be very different from person to person.
Some people find that the weather, especially cold, damp conditions, seems to make their symptoms worse but the weather doesn’t cause the condition itself.
The new Arthritis Research UK Rheumatoid Arthritis Pathogenesis Centre of Excellence will look into where and why rheumatoid arthritis starts. Researchers at King’s College London and the University of Manchester, funded by Arthritis Research UK, have also recently developed a new method to identify people that are at a very high-risk of developing rheumatoid arthritis, using a simple blood test and information about their smoking habits.
Rheumatoid arthritis (RA) can be difficult to diagnose in its initial stages, but an early diagnosis can be crucial to limiting its progress and severity. Some studies indicate that rheumatoid arthritis causes the most joint damage in the first two years.
There is no single test to determine if you have RA. The symptoms often are similar to those of other types of arthritis and joint conditions. The types of symptoms you experience—and the severity—may differ markedly from those of another person with RA. To make matters more confusing, symptoms can vary in the same person: Symptoms develop over time, and only a few may be present in the early stages of RA.
Often, RA is diagnosed by recognizing the type and pattern of joint involvement; it is a hallmark of RA, for example, if the same areas are affected symmetrically on both sides of the body.
The typical symptoms of RA include:
- tender, warm and swollen joints
- symmetrical pattern
- joint inflammation often affecting the wrists, fingers, knees, feet and ankles
- occasional fever
- a general sense of malaise
- pain and stiffness lasting for more than 30 minutes in the morning or after a long rest
- rheumatoid nodules (bumps under the skin—often formed close to the joints—that affect about a quarter of those with RA)
Less common symptoms can include neck pain and dry eyes and mouth. Very rarely, RA may cause inflammation of the blood vessels, the lining of the lungs or the sac enclosing the heart. If you have any of these symptoms, you should visit a health care professional.
He or she will take several factors into consideration before rendering a diagnosis:
- Medical history. Your description of the symptoms—including their duration and intensity—can help with the diagnosis.
- Physical examination. Your health care professional will do a physical exam and pay particular attention to your joints, skin, reflexes and muscle strength.
- Laboratory tests. Some lab tests can help establish the presence of RA. Your health care professional will probably order a test to detect rheumatoid factor (an antibody eventually present in the blood of most people with rheumatoid arthritis). It’s inconclusive, however, since not all people with RA test positive for rheumatoid factor, especially in the early stages.
- Some people with other types of rheumatic disease and a small number of healthy individuals also have a positive rheumatoid factor test, so you could test positive and never develop the disease. A test called anti-cyclic citrullinated peptide, or anti-CCP, is now available and is more specific than rheumatoid factor tests. Specificity is even higher when both of the tests are positive.
- Other common tests include one that indicates the presence of inflammation in the body (the erythrocyte sedimentation rate, or ESR, and the C-reactive protein, or CRP), a test for antinuclear antibodies (antibodies that appear in about 30 percent to 40 percent of people with RA), a white blood cell count and a blood test for anemia.
- X-rays. These can help determine the extent of joint destruction. If you identify RA in its early stages, X-rays may not be helpful in diagnosis. However, they can be used to monitor the disease’s progress. Other imaging techniques, such as MRI and particularly joint ultrasound, have been shown to be very useful in assessment of the extent of inflammation and joint damage in RA.
The main goals of rheumatoid arthritis (RA) treatment are to relieve symptoms of inflammation and to significantly slow the progression of joint damage. Although there is no cure, you and your health care professional can develop strategies for keeping the disease under good control. You may need to try several approaches and different types of medication before you can satisfactorily relieve pain, reduce inflammation, slow joint damage and improve your ability to function.
In addition to the guidance of your primary health care professional, you may need care from a physical therapist, a rheumatologist (a physician who specializes in diagnosing and treating disorders that affect the joints, muscles, tendons, ligaments and bones) or an orthopedist.
When symptoms occur, you can take steps to lessen their severity. Protecting your joints from undue stress can help. Your health care professional can help you obtain a properly fitting splint. You may want to talk to him or her about self-help devices that can reduce stress on the joints while you participate in everyday activities. Zipper pullers, long-handled shoehorns and products that help you get on and off chairs, toilet seats and beds can all ease the strain on your joints.
Most likely, your treatment plan will include medications to relieve pain and/or reduce inflammation. Although there is no cure, disease-modifying antirheumatic drugs (DMARDs) may slow or stop the course of the disease. In the past, health care professionals often hesitated to prescribe these strong drugs until the disease had become relatively advanced. However, this approach has changed, especially for those who suffer from severe, rapidly progressing RA.
Most rheumatologists believe that early treatment with more powerful drugs and the use of drug combinations is the best way to halt RA’s progression and to reduce or prevent joint damage. It is therefore important to establish care of RA with a rheumatologist as early as possible.
There is no cure for rheumatoid arthritis. But recent discoveries indicate that remission of symptoms is more likely when treatment begins early with strong medications known as disease-modifying antirheumatic drugs (DMARDs).
The types of medications recommended by your doctor will depend on the severity of your symptoms and how long you’ve had rheumatoid arthritis.
- NSAIDs. Nonsteroidal anti-inflammatory drugs (NSAIDs) can relieve pain and reduce inflammation. Over-the-counter NSAIDs include ibuprofen (Advil, Motrin IB) and naproxen sodium (Aleve). Stronger NSAIDs are available by prescription. Side effects may include ringing in your ears, stomach irritation, heart problems, and liver and kidney damage.
- Steroids. Corticosteroid medications, such as prednisone, reduce inflammation and pain and slow joint damage. Side effects may include thinning of bones, weight gain and diabetes. Doctors often prescribe a corticosteroid to relieve acute symptoms, with the goal of gradually tapering off the medication.
- Disease-modifying antirheumatic drugs (DMARDs). These drugs can slow the progression of rheumatoid arthritis and save the joints and other tissues from permanent damage. Common DMARDs include methotrexate (Trexall, Otrexup, Rasuvo), leflunomide (Arava), hydroxychloroquine (Plaquenil) and sulfasalazine (Azulfidine).
Side effects vary but may include liver damage, bone marrow suppression and severe lung infections.
- Biologic agents. Also known as biologic response modifiers, this newer class of DMARDs includes abatacept (Orencia), adalimumab (Humira), anakinra (Kineret), certolizumab (Cimzia), etanercept (Enbrel), golimumab (Simponi), infliximab (Remicade), rituximab (Rituxan), tocilizumab (Actemra) and tofacitinib (Xeljanz).
These drugs can target parts of the immune system that trigger inflammation that causes joint and tissue damage. These types of drugs also increase the risk of infections.
Biologic DMARDs are usually most effective when paired with a nonbiologic DMARD, such as methotrexate.
Your doctor may send you to a physical or occupational therapist who can teach you exercises to help keep your joints flexible. The therapist may also suggest new ways to do daily tasks, which will be easier on your joints. For example, if your fingers are sore, you may want to pick up an object using your forearms.
Assistive devices can make it easier to avoid stressing your painful joints. For instance, a kitchen knife equipped with a saw handle helps protect your finger and wrist joints. Certain tools, such as buttonhooks, can make it easier to get dressed. Catalogs and medical supply stores are good places to look for ideas.
If medications fail to prevent or slow joint damage, you and your doctor may consider surgery to repair damaged joints. Surgery may help restore your ability to use your joint. It can also reduce pain and correct deformities.
Rheumatoid arthritis surgery may involve one or more of the following procedures:
- Synovectomy. Surgery to remove the inflamed synovium (lining of the joint). Synovectomy can be performed on knees, elbows, wrists, fingers and hips.
- Tendon repair. Inflammation and joint damage may cause tendons around your joint to loosen or rupture. Your surgeon may be able to repair the tendons around your joint.
- Joint fusion. Surgically fusing a joint may be recommended to stabilize or realign a joint and for pain relief when a joint replacement isn’t an option.
- Total joint replacement. During joint replacement surgery, your surgeon removes the damaged parts of your joint and inserts a prosthesis made of metal and plastic.
Surgery carries a risk of bleeding, infection and pain. Discuss the benefits and risks with your doctor.
Some common complementary and alternative treatments that have shown promise for rheumatoid arthritis include:
- Fish oil. Some preliminary studies have found that fish oil supplements may reduce rheumatoid arthritis pain and stiffness. Side effects can include nausea, belching and a fishy taste in the mouth. Fish oil can interfere with medications, so check with your doctor first.
- Plant oils. The seeds of evening primrose, borage and black currant contain a type of fatty acid that may help with rheumatoid arthritis pain and morning stiffness. Side effects may include nausea, diarrhea and gas. Some plant oils can cause liver damage or interfere with medications, so check with your doctor first.
- Tai chi. This movement therapy involves gentle exercises and stretches combined with deep breathing. Many people use tai chi to relieve stress in their lives. Small studies have found that tai chi may reduce rheumatoid arthritis pain. When led by a knowledgeable instructor, tai chi is safe. But don’t do any moves that cause pain.
The following are commonly used rheumatoid arthritis medications:
Analgesics are drugs that provide pain relief, and they can be used either orally or topically in people with RA. Analgesics include topical capsaicin (Capsagel), oral acetaminophen (Tylenol), tramadol (Ultram) and the more potent narcotics oxycodone (OxyContin) and hydrocodone (Vicodin). Narcotics are usually discouraged in the treatment of rheumatoid arthritis, however, because of the long-term nature of the condition and the danger of dependence.
2.] Nonsteroidal anti-inflammatory drugs (NSAIDs).
NSAIDs such as aspirin, ibuprofen, ketoprofen and naproxen help diminish pain, swelling and inflammation. However, each NSAID is a different chemical and can have different effects in the body.NSAIDs may cause side effects including ringing in your ears, bruising, heart problems, gastric ulcers, stomach irritation, and liver and kidney damage. The longer you use NSAIDs, the more likely you are to have side effects, and the more serious those effects can be. Many other drugs cannot be taken with NSAIDs—in particular, the blood thinner warfarin (Coumadin).
NSAIDS should be used with caution in people over 65 and in those with any history of ulcers or gastrointestinal bleeding, congestive heart failure, renal insufficiency and hypertension. Even the nonprescription, over-the-counter forms of these medications have the same risks. It’s important to ask your health care professional for safety information associated with pain relievers with your personal health history in mind.
A newer NSAID (called a COX-2 specific inhibitor) inhibits an enzyme (COX-2), which triggers pain and inflammation, while sparing an enzyme called COX-1, which helps maintain the normal stomach lining. The COX-2 inhibitor celecoxib (Celebrex) is sometimes prescribed for RA, osteoarthritis and other pain-causing conditions, such as acute pain and menstrual cramps.
Celebrex is currently the only COX-2 inhibitor on the market. Celebrex may increase the risk of heart attack and stroke; discuss these risks with your health care professional. And if you are currently taking Celebrex and think you are having an allergic reaction or have other severe or unusual symptoms while taking any NSAID, call your health care professional immediately. For more information on the risks associated with Celebrex.
3.] Disease-modifying antirheumatic drugs (DMARDs).
These are slower-acting drugs, which work by altering the natural course of the disease and therefore slow or even prevent joint and cartilage destruction. They can produce significant results. You may need to wait weeks—even months—before seeing any effect, and you may use some or all of these, depending on the specifics of your condition. In some cases, one DMARD is used by itself. In other cases, more than one DMARD may be prescribed at the same time.
You may have to try different medicines or combinations to find one that works best with the fewest side effects.Common DMARDs include: methotrexate (Rheumatrex, Trexall), sulfasalazine (Azulfidine), hydroxychloroquine (Plaquenil), leflunomide (Arava), cyclosporine (Sandimmune, Neoral), and azathioprine(Imuran, Azasan).
People taking methotrexate and most other DMARDs need periodic monitoring to make sure that toxicity to the liver or bone marrow does not occur. Although there is clearly a potential for toxicity of a powerful drug like methotrexate, it actually has a remarkable safety profile in RA and can be taken continuously for many years.
Side effects of DMARDS vary greatly but may include nausea or vomiting, diarrhea, heartburn, high blood pressure, sun sensitivity, rash, temporary hair loss, damage to the retina, liver or kidney damage, lung infections and bone marrow suppression.
Pay attention to how your body responds to these drugs. Not only do you need to make sure the medications are effective (since efficacy can occasionally diminish over time), you also need to be alert to any problems arising from the drugs.
Also known as glucocorticoids, corticosteroids such as prednisone and methylprednisolone (Medrol) reduce inflammation and pain and may slow joint damage from RA. Because they can cause dramatic improvements in a very short time, health care professionals often use them while waiting for DMARDs to kick in, and then may gradually discontinue use.
They may be an option if your RA doesn’t respond to NSAIDs and DMARDs. These medications also have serious side effects, especially at high doses, including increased bruising, thinning of bones, increased appetite, weight gain, worsening of diabetes and cataracts. RA can increase bone loss, leading to osteoporosis. This bone loss is more likely in people who use corticosteroids for longer periods of time.
To keep your bones as strong as possible, use the lowest possible dose of corticosteroids for the shortest amount of time, consume at least 1,000 to 1,200 milligrams of calcium and 400 to 1,000 IUs of vitamin D a day and talk to your doctor about medications called bisphosphonates, such as alendronate sodium (Fosamax) and ibandronate sodium (Boniva), that can help reduce bone loss.
5.] Biologic response modifiers.
These are protein drugs that must be administered by subcutaneous injection or intravenous infusion. These drugs help to reduce joint-damaging inflammation by interfering with the inflammation process. The most commonly used short-acting drugs in this category are adalimumab (Humira), etanercept (Enbrel) and infliximab (Remicade). The longer-acting drugs in this category are certolizumab pegol (Cimzia) and golimumab (Simponi).
They all target and inactivate a protein called tumor necrosis factor, or TNF-alpha, which is involved in the cascade of immune responses that cause inflammation in people with RA. Other biologic response modifiers target different molecules involved in the inflammation process. For instance, the drug anakinra (Kineret) blocks a cytokine called interleukin-1 (IL-1). Abatacept (Orencia) blocks the activation of T cells, and rituximab (Rituxan) blocks B lymphocytes. Tocilizumab (Actemra) is a biologic response modifier that inhibits interleukin-6.
The biologic response modifiers are used as a second line drugs in individuals who do not respond to one or several TNF-alpha blocking agents.There have been very rare reports of serious nervous system disorders such as multiple sclerosis, seizures or inflammation of the nerves of the eyes, and serious infections, including sepsis and tuberculosis, with the TNF-inhibitors. The risk of tuberculosis has been greatly decreased with pre-therapy screening of TB skin tests and/or chest X-rays and treating with anti-TB drugs if these tests are positive.
Additionally, there is some evidence that people treated with TNF inhibitors might have a somewhat higher risk of lymphomas. Although you need to be aware of these risks, it is equally important to recognize that the benefits can be substantial
6.] Non-biological DMARD.
Recently, the U.S. Food and Drug Administration approved a new non-biological DMARD for RA treatment named tofacitinib (Xeljanz). This medication is the first in the new category of RA drugs that work by inhibiting intracellular enzymes called kinases. Tofacitinib is a JAK (Janus kinase) 1 and 3 inhibitor.
Kinases are involved in generation of inflammation in RA. Tofacitinib has been approved as a second-line drug for RA patients who have inadequate response or are intolerant to a first- line DMARD methotrexate. Similarly to biologic response modifiers, Tofacitinib may increase risk for infection and cause liver abnormalities. In addition, in clinical trials, it has been associated with lipid and various blood cell count abnormalities in a small percentage of people. Your health professional will be able to tell if and when this new drug would be appropriate for treatment of your RA.
If you are taking a biologic response modifier and have an infection severe enough to require antibiotics, the biologic should not be given until the infection is gone.
If you are using DMARDs or biologics, you should not receive live-virus vaccinations. Discuss how to handle live-virus vaccinations with your health care provider.
Surgery may be an option if you have severe joint damage. In the right circumstance, it can help reduce pain, improve the affected joint’s function and appearance and enhance your ability to perform daily activities. However, surgery is not right for everyone, and you and your health care professional need to discuss the best approach. Factors to consider include your overall health, the condition of the joint or tendon that will be operated on and cost of the surgery.
A common type of surgery prescribed for people with RA is joint replacement, which replaces your damaged joint with an artificial one. One thing to consider is that the artificial joints can wear out, necessitating additional surgery.
Tendon repair, most frequently performed on the hands, is a surgery that repairs overly loose or tight tendons around a joint.
In synovectomy, the inflamed synovial tissue is removed. Synovectomy is performed if the lining around your joint (synovium) is inflamed and causing pain, joint damage and loss of function that do not respond to conventional treatments.
RA may also require joint fusion (arthrodesis) or the surgical fusion of a joint to stabilize or realign it for pain relief in cases where joint replacement isn’t possible.
ClinicalTrials.gov, a service of the National Institute of Health, provides easy access to information on clinical trials for a wide range of diseases and conditions, including rheumatoid arthritis. The website is located.
Factors that may increase your risk of rheumatoid arthritis include:
- Your sex. Women are more likely than men to develop rheumatoid arthritis.
- Age. Rheumatoid arthritis can occur at any age, but it most commonly begins between the ages of 40 and 60.
- Family history. If a member of your family has rheumatoid arthritis, you may have an increased risk of the disease.
- Smoking. Cigarette smoking increases your risk of developing rheumatoid arthritis, particularly if you have a genetic predisposition for developing the disease. Smoking also appears to be associated with greater disease severity.
- Environmental exposures. Although uncertain and poorly understood, some exposures such as asbestos or silica may increase the risk for developing rheumatoid arthritis. Emergency workers exposed to dust from the collapse of the World Trade Center are at higher risk of autoimmune diseases such as rheumatoid arthritis.
- Obesity. People who are overweight or obese appear to be at somewhat higher risk of developing rheumatoid arthritis, especially in women diagnosed with the disease when they were 55 or younger.
Rheumatoid arthritis increases your risk of developing:
- Osteoporosis. Rheumatoid arthritis itself, along with some medications used for treating rheumatoid arthritis, can increase your risk of osteoporosis — a condition that weakens your bones and makes them more prone to fracture.
- Rheumatoid nodules. These firm bumps of tissue most commonly form around pressure points, such as the elbows. However, these nodules can form anywhere in the body, including the lungs.
- Dry eyes and mouth. People who have rheumatoid arthritis are much more likely to experience Sjogren’s syndrome, a disorder that decreases the amount of moisture in your eyes and mouth.
- Infections. The disease itself and many of the medications used to combat rheumatoid arthritis can impair the immune system, leading to increased infections.
- Abnormal body composition. The proportion of fat compared to lean mass is often higher in people who have rheumatoid arthritis, even in people who have a normal body mass index (BMI).
- Carpal tunnel syndrome. If rheumatoid arthritis affects your wrists, the inflammation can compress the nerve that serves most of your hand and fingers.
- Heart problems. Rheumatoid arthritis can increase your risk of hardened and blocked arteries, as well as inflammation of the sac that encloses your heart.
- Lung disease. People with rheumatoid arthritis have an increased risk of inflammation and scarring of the lung tissues, which can lead to progressive shortness of breath.
- Lymphoma. Rheumatoid arthritis increases the risk of lymphoma, a group of blood cancers that develop in the lymph system.
Prevention and Risk Reduction
Genetic, environmental and hormonal factors probably all play a role in the development of rheumatoid arthritis (RA). However, there is no known way to prevent RA. Cigarette smoking is one environmental risk factor for RA that you can avoid.
Certain genes involved in immune system responses are associated with a predisposition for developing RA, although there is no single “rheumatoid arthritis gene.” People with RA are more likely to have human leukocyte antigen (HLA) genes than people without the disease, and other genes also play roles in the development of RA.
Having any of these genes is no guarantee that you’ll develop RA (in fact, many individuals with this common gene do not develop the disease); likewise, the absence of these genes doesn’t rule out the possibility of developing the disease. It appears that a person’s genetic make-up is an important part of the story, but not the whole answer.
Recent research shows that tobacco smoking can increase risk for RA. One study was conducted in Sweden and specifically looked at a population of more than 30,000 women. The study found significant association between development of RA and both smoking intensity and duration of smoking in women.
The same study showed that such risk decreases over time, but it may take up to 15 years after smoking cessation to significantly reduce the risk. More and more studies seem to indicate that dental health is another important factor associated with RA. These are important advances in understanding the role of environmental factors in RA, because these factors can be avoided by not smoking and by flossing and brushing your teeth.
Self-help and daily living for rheumatoid arthritis
Self-help tips for rheumatoid arthritis include striking a balance between rest and exercise, especially when you’re having a flare-up, and protecting your joints from unnecessary strain.
Managing a flare-up of rheumatoid arthritis
The symptoms of rheumatoid arthritis tend to come and go with no particular pattern. Sometimes flare-ups will have an obvious cause, such as another illness or stress, but usually there’s no obvious trigger. This unpredictability makes it difficult to plan ahead.
It’s tempting to do all your jobs when you’re having a good day, but overdoing things on the good days can be counter-productive, causing a flare-up of symptoms the next day. Pacing yourself is important. Make it clear to your family and friends that not all days are the same. It’s important they realise that activities you enjoy on a good day may be impossible on a bad one.
Diet and rheumatoid arthritis
No specific diet will cure rheumatoid arthritis, although there’s some scientific evidence that certain diets may help the symptoms in some people. The diets most likely to help have:
- low in saturated fats
- high in unsaturated fats, especially omega-3 fatty acids, which are found in oily fish
- a good supply of vitamin C.
In the UK, dietary guidelines recommend two portions of fish a week, including one of oily fish (for example, mackerel, pilchards, salmon). But you can top up your omega-3 levels with fish body oil (not fish liver oil) supplements.
There’s some evidence that a very strict vegetarian diet can help, though the reasons for this aren’t clear. People who eat a lot of red meat may have a slightly increased risk of rheumatoid arthritis. Speak to your doctor or a dietitian before starting any strict diet as the disadvantages may outweigh the advantages.
Occasionally some people find that a specific type of food upsets them, but this is quite unusual. If you think you may have an intolerance to a particular food try removing it from your diet for about 3–4 weeks and then reintroducing it. If you do have an intolerance you will notice a flare-up in your arthritis within a few days.
Exercise and rheumatoid arthritis
Strike a balance between rest and exercise. Rest will make inflamed joints feel more comfortable, but without movement your joints will stiffen and your muscles will become weaker. You need to find out what the right balance is for you.
It’s possible to exercise the muscles without even moving the joint by doing isometric exercises. These are done in static positions so the joint angle and muscle length don’t change. Many yoga positions are isometric – a physiotherapist may be able to suggest some of these exercises
Many people with rheumatoid arthritis try different types of complementary medicine. Most types haven’t proven effective, but there are a couple that have some scientific evidence to support their use, including:
- fish body oil
- evening primrose oil
- borage seed oil
- acupuncture (generally available on the NHS)
- Massage– though there’s little evidence that specific oils have particular benefits.
Support aids and rheumatoid arthritis
It’s very important to protect your joints from unnecessary strain. An occupational therapist can give you advice about changing the way you do some tasks and on using simple aids or adaptations to make them easier.
A huge variety of gadgets are available to help with daily tasks, whether you’re at work, around the home or in the garden.
Sleep and rheumatoid arthritis
You may experience severe tiredness (fatigue) and suffer disturbed sleep. Lack of restful sleep can make it all the more difficult to cope with the pain of arthritis. Try the following tips:
- Painkillers or a warm bath can help ease pain or stiffness before going to bed.
- Check that your bed is supportive and comfortable, and if your neck and shoulders are stiff or painful try experimenting with different pillows.
- Try to establish a relaxing bedtime routine – avoid eating, drinking tea, coffee or alcohol, and smoking close to bedtime.
- Regular exercise should help you to sleep but don’t exercise within three hours of going to bed.
Sex, pregnancy and rheumatoid arthritis
- Sex and rheumatoid arthritis:- There’s no reason why rheumatoid arthritis should you should stop having sex. You may find that some positions are more comfortable than others, so experiment to find out what works for you. Tiredness may affect your desire for sex, so talk to your partner. Good communication is the key to resolving any difficulties. The contraceptive pill won’t make a difference to your arthritis or its treatment so it’s fine to keep taking it.
- Pregnancy and rheumatoid arthritis:-If you want a baby, discuss your plans with your doctor before you want to start a family as some drugs can temporarily reduce fertility. Other drugs, such as methotrexate and, leflunomide ,can affect the baby’s development so it’s important to use reliable contraception while you’re taking these – this applies to men wanting to father a child as well as to women.
Work and rheumatoid arthritis
It’s usually possible to keep on working unless it involves a lot of manual labour. If your workplace needs to be adapted because of your condition your local Jobcentre Plus office can put you in touch with a Disability Employment Adviser. They can advise on workplace adaptions and give you information if you need to change jobs or retrain.
Facts to Know
- According to the Arthritis Foundation, rheumatoid arthritis affects approximately 1.3 million Americans, and two to three times more women have RA than men.
- RA is considered an autoimmune disease. Such diseases are characterized by the immune system attacking the body’s healthy tissues. Although RA affects other parts of the body, joint inflammation is the hallmark of this disease.
- Although no one knows the precise causes of rheumatoid arthritis, it seems to develop as a result of an interaction of several factors, including genetics, environmental factors and hormones. A virus or bacterium could serve as the environmental trigger in people genetically susceptible to the disease.
- Many researchers think a viral or bacterial infection may help trigger the development of RA. However, this remains unproven.
- Tobacco smoking may increase risk for developing RA.
- Rheumatoid arthritis appears to cause considerable joint damage in the first two years. An early diagnosis can be crucial in preventing the worst effects of the disease, especially since there are more effective treatment options today.
- Common RA symptoms can include fatigue, occasional fever, morning stiffness, difficulty moving a joint or several joints, pain and inflammation in or around a joint and a general sense of malaise.
- There is no single test you can take to find out if you have RA, although tests are used as part of the diagnosis.
- Arthritis literally means joint inflammation, but the term often is used to refer to more than 100 rheumatic diseases that can affect children and adults. Osteoarthritis is the most common form.
- Why is rheumatoid arthritis (RA) sometimes called an autoimmune disease? Autoimmune diseases are characterized by an immune system attack on healthy tissues. In RA, white blood cells travel to the synovium (the membranes that surround joints) and cause inflammation, or synovitis. The ensuing warmth, redness, swelling and pain are typical symptoms of rheumatoid arthritis, which usually affects the wrists, fingers, knees, feet and ankles.
- What causes rheumatoid arthritis? A combination of factors—genetic, environmental and hormonal—probably plays a role in the onset of the disease. Those with a genetic susceptibility may develop RA when it is triggered by an environmental agent, perhaps a virus or bacterium, although no pathogenic agent has yet been identified. Hormones also appear to play a role. Tobacco smoking may increase risk for RA.
- Is RA preventable? No one has found a way to prevent RA.
- What can be done to reduce the pain or slow the disease? The symptoms of RA are highly treatable in most cases, and new research shows that the long-term outcome can be affected by how quickly the disease is diagnosed and treatment initiated. Consulting with your health care professional, you will find that there is a wide range of options—medical, surgical and lifestyle—available for modifying the disease and treating pain, swelling and other symptoms.
- How can I find out if I have RA? The symptoms you describe to a health care professional are the foundation of an RA diagnosis. The most common symptoms are tender, warm, swollen joints; symmetrical pattern of pain; joint inflammation; fatigue; occasional fever; a general sense of malaise; pain and stiffness lasting for more than 30 minutes in the morning or after a long rest; and rheumatoid nodules (bumps under the skin). Because many of these symptoms are also indicative of other diseases (for example, lupus), your health care professional may recommend lab tests for those diseases or for confirmation of an RA diagnosis, as well as X-rays and/or joint ultrasound to detect any joint damage. A full medical history and physical exam are also part of a typical diagnostic workup for RA.
- Is it safe to exercise if I have RA? Yes, moderate exercise is good for RA. However, you should consult with a health care professional before beginning any new exercise regimen and make sure that inflammation is reasonably well controlled. Moist heat applied before an exercise session and a cold pack applied afterward can help alleviate pain. Exercising in a swimming pool is also a good option for preventing joint stress during a workout.
- Can diet make a difference in preventing or managing RA? There is no scientific evidence that any specific food or nutrient helps or harms most people with rheumatoid arthritis. However, an overall nutritious diet with enough—but not an excess of—calories, protein and calcium is important. Some studies have shown that the omega-3 fatty acids in certain fish or plant seed oils also may reduce rheumatoid arthritis inflammation.
However, many people are not able to tolerate the large amounts of oil necessary for any benefit, and both fish oils and plant oils have side effects, including risk of bleeding and interactions with certain medications, including blood pressure medications and psychiatric drugs. More research is necessary to find the optimal dosage of fish and plant seed oils for the management of RA.
Some people may need to be careful about drinking alcoholic beverages because of the medications they take for rheumatoid arthritis. Those taking methotrexate may need to avoid alcohol altogether. You should ask your health care professional or a registered dietitian for guidance on the issue of diet.
If I have the “RA gene,” does that mean I will develop the disease? There is no single RA gene. People with specific human leukocyte antigen (HLA) genes are more likely to develop RA than people without them, and other genes also play a role in the onset of disease. Having any of these genes is no guarantee that you’ll develop RA, and their absence doesn’t rule out the possibility of developing the disease. It appears that a person’s genetic makeup is an important part of the story but not the whole answer.
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