Update on Rheumatoid Arthritis

Despite a host of recent advances during the last century in treating and preventing many formerly debilitating and/or crippling diseases —in fact, rendering many of them nearly obsolete in the Western world — rheumatoid arthritis (RA) continues to inflict disabling pain and, in many cases, disfigurement on men and women of all ethnicities and socioeconomic classes in the United States and Europe.

Distinct in both cause and physiology from the more common osteoarthritis, RA not only can cause chronic pain, bringing about a diminished quality of life, but also can, if left untreated, slowly destroy the joints in the hands and feet, leading to physical damage that cannot be reversed.¹ As the disease progresses, it may spread to the legs and arms, and then the hips, shoulders and spine. Advanced or severe cases can even cause damage to other tissues of the body, including the eyes, lungs, skin and circulatory system.² The condition is also linked to early mortality.³

The causes of RA remain unclear, with most research now indicating a possible genetic predisposition that can be triggered by an unknown number of combinations of catalysts.⁴ And, while there is neither prevention nor cure currently available, there are many treatments that can ease the pain and slow or even halt the destruction of joint structures.

What Is RA?

RA is an autoimmune disease in which the body’s defenses attack the lining that surrounds the joints of the hands and feet.² Specifically, the body’s immune system attacks the synovial membranes, the tissue that surrounds joints with capsules — in the fingers and toes, for instance. As the membrane is attacked by the immune system, it swells, causing pain and loss of flexibility. Over time, the pressure from the swollen synovium causes the cartilage and bone in the joints to begin to break down, causing disfigurement and further loss of function.⁵

Advanced cases can cause other health problems as the body struggles to deal with the autoimmune attacks on itself. The lungs may develop fibrosis, the kidneys may begin to develop amyloid deposits, the eye sockets can dry out making them more susceptible to infection and other vision problems, and the swollen joints may cause a rise in blood pressure that can raise the patient’s risk of heart attack or stroke.⁶

RA can occur at any stage of life, but most commonly it is seen in patients age 40 and older. The Mayo Clinic estimates that between 3 percent and 4 percent of people will develop RA at any point in their life. Women are statistically two to three times as likely as men to develop RA. In addition, women who have given birth and breast-fed are at slightly lower risk of developing RA, although researchers do not understand why this is true.³ Smokers are also at heightened risk of contracting RA — again, for reasons not yet understood.

Symptoms of RA

The earliest symptoms of RA are often similar to or the same as those for the more common age- and injury-related osteoarthritis: stiffness and pain in the joints, particularly upon waking in the morning.⁷ However, depending on the specific progression and the stage at which symptoms are first noticed, RA also may cause small, noticeable bumps (known as rheumatoid nodules) under the skin of the arms. Fingers or toes also may be swollen and warm to the touch, and patients may notice fatigue or have a fever. It is recommended that anyone suffering chronic joint paint see a doctor to get an early and accurate diagnosis.

Diagnosing RA

Physicians seeing a patient will often face several challenges in accurately diagnosing RA if the disease is still in its early stages. There is currently no single test that will positively identify a case of RA. As previously mentioned, the early symptoms are similar to osteoarthritis and other joint diseases: pain and swelling in the joints. X-rays or other scans taken during the early stages of the disease will not yet reveal joint damage, as that takes time to develop.

Doctors may order one or more of several blood tests to determine if certain factors associated with RA are present. A test for the rheumatoid factor (RF) will detect if a patient’s bloodstream contains an antibody consistent with RA. However, many patients with RA never show RFs, and others with RF present never develop RA.5 Anti-cyclic citrullinated peptides also can be looked for, as they often show up in patients with RA. Another test, for erythrocyte sedimentation rate, can help confirm the presence of inflammation in the patient’s body.⁸ While none of these tests is as clear-cut as, say, a biopsy confirming a tumor is benign or a culture indicating an infection, a combination of them will give a physician a fairly good indication of whether a patient has RA.

Treating RA

Currently, there is no cure for RA. Doctors do, however, have numerous options available to help ease a patient’s discomfort and to slow the progression of the disease. For most patients, this will be a combination of behavior (diet and exercise), medication (immune suppression, swelling reduction, pain control) and equipment (braces).

Patients with RA can almost universally benefit from a carefully monitored regimen of exercise and rest. Regular exercise will strengthen the musculature around the joints, providing additional stability and support. However, when RA is flaring and there is significant inflammation, rest is indicated.⁹ The use of a brace or splint can help provide additional support to joints affected by RA. In addition, the use of self-help devices such as zipper pullers or long-handle shoe horns can relieve pain and wear on joints.⁷

While exercise and reducing stress on joints are important components of treating RA, modern medications also are an important part of most treatment programs. Among the types of medications used in treating RA are:

• Nonsteroidal anti-inflammatory drugs (NSAIDs) are used to reduce swelling and alleviate pain. Over-the-counter varieties include ibuprofen (Advil, Motrin) and naproxen sodium (Aleve). Prolonged usage can increase the risk of liver damage or kidney damage, cardio issues or stomach irritation.⁹
• Corticosteroids may be used for short durations to provide quick relief, but carry the risk of more severe side effects such as diabetes, loss of bone density and cataracts.⁹
• Disease-modifying antirheumatic drugs (DMARDs) help prevent serious joint deterioration and permanent disfigurement, but need an even higher level of monitoring due to the risks associated with them —from liver failure to lung infections.⁹ Among the DMARDs used in treating RA are hydroxychloroquine, leflunomide, methotrexate and sulfasalazine. While they work in different ways, each slows the disease by interfering with the way the body’s immune system is attacking the joints.⁵
• Immunosuppressants are used to weaken the immune system as a whole. The risk of acquiring other infections when using drugs such as azathioprine and cyclosporine means they are generally reserved for severe cases of RA when other treatments are not providing effective relief.⁹
• TNF-alpha inhibitors slow the production of certain substances that cause inflammation. Again, these increase the risk of other infections in the patient.⁹ When behavior modification and medications are not enough to stop the progression of the disease, a physician may recommend surgery to restore function and/or ease pain. Joint replacement surgery, tendon reconstruction and joint fusion are all strategies employed as a last resort to help patients with RA.⁹

Research

Current research into RA is focused in four main areas: locating the genes that may predispose some people to developing RA; uncovering the specific triggers that cause RA to develop; understanding the specific molecular processes that occur in the joints of patients with RA; and finding more effective treatments.

Until we understand exactly how RA develops, prevention is not possible.However, as our understanding of the processes of RA grows, so do the possibilities for treatment. In 2012, the drug tofacitinib was approved for treatment of RA. It works by blocking a specific activity of the immune system that leads to joint destruction. Similar research is looking into other facets of the immune system to develop drugs that will slow or stop RA without compromising a patient’s overall immune protection.

Any prevention or cure is likely decades away given the complexity of RA. However, treatments continue to improve all the time, providing physicians a growing array of resources to assist them in helping their patients.