Rheumatoid Arthritis

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Published: June 10, 2016
Last reviewed: April 28, 2017

What is rheumatoid arthritis?

Rheumatoid arthritis is a chronic inflammatory disease that affects the joints, mainly in the hands and feet.

Causes and Risk Factors

Rheumatoid arthritis is considered an autoimmune disease in which antibodies attack your own tissues, mainly the membranes (synovial sheaths) that line the joints [1]. The synovial sheath and later the joint cartilage and nearby bone become inflamed.

The cause of the disease is not known but genetic predisposition, increased levels of the hormone prolactin, smoking, infection or trauma may increase the risk [2]. In women, the disease can improve during pregnancy and worsen during breastfeeding [1].

Symptoms and Signs

The disease is more frequent in women than in men [2]. The onset of the disease is usually gradual with morning stiffness, fatigue and low-grade fever: in women usually between 30 and 60 years of age and in men after 50, but sometimes in early adulthood [1]. Children before 16 may have a similar condition called juvenile idiopathic arthritis [2]. Typical symptoms and signs [3]:

  • Pain, tenderness, swelling, redness, warmth and stiffness–usually symmetrical–in the joints between the hands and fingers, the first knuckles of the fingers, wrists, joints between the feet and toes, and, sometimes, in shoulders, ankles, cervical spine, hips, elbows and the joints between the jaw and skull, which are worse in the morning or after a prolonged rest, last for more than 30 minutes and improve through the day
  • Weakness in the hands
  • Dry mouth and eyes (keratoconjunctivitis)
  • Rheumatoid nodules — firm lumps, mainly near the elbows or on the upper side of the fingers

Symptoms can appear in flares or change with the weather [1].

Complications

  • Tenosynovitis – inflammation of the muscle tendons and their sheaths
  • Carpal tunnel syndrome (tingling and numbness in the thumb, index and middle finger)
  • Wrist and finger deformities
  • Baker cyst (a swelling behind the knee)
  • A compression of one or more nerves in the neck spine (cervical radiculopathy)
  • Osteoporosis
  • Rarely:
    • An inflammation of the lung membranes (pleurisy) or heart sac (pericarditis)
    • Inflammation of the blood vessels (vasculitis) and coronary heart disease
    • Felty syndrome (enlarged spleen and low white blood cell count)
    • Lymphoma
  • Reference: [1,3]

Diagnosis

A doctor–an internist or rheumatologist–can make a diagnosis of rheumatoid arthritis from a combination of symptoms, signs and blood tests that show increased levels of the antibodies rheumatoid factor (RF), anti-CCP and ANA [2]. RF factor can be sometimes increased in healthy individuals (false positive test) or negative in individuals with rheumatoid arthritis (false negative test). RF is not specific for rheumatoid arthritis [5].

Sedimentation rate and CRP levels and anemia increase with the disease activity [5].

In later stages, an X-ray can show the degree of bone damage in the joints and MRI the damage of the spinal vertebra [5].

Differential Diagnosis

Diseases similar to rheumatoid arthritis [4,22]:

  • Osteoarthritis (pain is not symmetric and affects the last rather than the first finger knuckles; pain increases through the day)
  • Psoriatic arthritis (symmetrical; rash may be present or not)
  • Systemic lupus erythematosus (SLE) (symmetrical; rash)
  • Sjögren’s syndrome (symmetrical; dry eyes and mouth)
  • Rheumatic fever
  • Acute viral polyarthritis (parvovirus, hepatitis B and C virus, alphavirus)
  • Gout (asymmetric, mainly affects the big toe)
  • Reactive arthritis after genitourinary or bowel infection
  • Arthritis associated with inflammatory bowel disease
  • Dermatomyositis
  • Infectious arthritis (usually in a single joint)
  • Polymyalgia rheumatica (pain around the shoulders and hips)
  • Fibromyalgia (no swelling, tender points in the upper back and chest, hips, elbows and knees)
  • Lyme disease
  • Paraneoplastic syndromes in lung or other cancers
  • Sarcoidosis

Treatment

Medications

Main points [6]:

    • Emedicine.com recommends methotrexate as the first drug (or, when not tolerated, sulfasalazine or leflunomide).
    • Methotrexate in combination with a biological DMARD drug, such as adalimumab, is more effective than either drug alone. Methotrexate and other DMARDs may need few months to take effect, so analgesics, NSAIDs and steroids can be used together with them in meantime.
    • In pregnancy, azathioprine and sulfasalazine are considered low-risk.

Chart 1. Medications for Rheumatoid Arthritis

MEDICATION SIDE EFFECT
Non-biologic DMARDs for prevention of disease progression
Azathioprine, cyclosporine, D-penicillamine, gold salts, hydroxychloroquine, leflunomide, methotrexate, minocycline, sulfasalazine Bone marrow or kidney toxicity, increased risk of infections or sunburn, pneumonitis (methotrexate), fatigue, lymphoma, headache, fever, nausea, metallic taste, itch
Analgesics for pain relief
Acetaminophen Liver toxicity (together with alcohol)
Opioids: codeine, tramadol Constipation, drowsiness, addiction
NSAIDs to reduce inflammation
Aspirin, celecoxib, diclofenac, ibuprofen, ketoprofen, naproxen Water retention, high blood pressure, stomach bleeding, kidney damage
Steroids to reduce inflammation
Prednisone, prednisolone Weight gain, increased blood pressure, osteoporosis, skin thinning, hair growth
Biologic DMARDs when other drugs do not work
TNF inhibitors: certolizumab, adalimumab, golimumab Infections, heart failure
Non-TNF agents: abatacept, anakinra, etanercept, infliximab, rituximab, tocilizumab Infections, headache
JANUS kinase inhibitors: tofacitinib Infections, lymphoma

Chart 1 sources: [6,7,8,9,10]

Home Remedies

  • Applying heat by heat pads, showering, spas, paraffin, ultrasound or diathermy relieves pain; it can be used before stretching.
  • Ice packs, ice water or cooling sprays can relieve pain in acute inflammation.
  • Custom insoles can reduce pain in the feet.
  • Hand splints can improve functions of the hand.
  • Reference: [6]

Physical Therapy

Physical therapy can include resistance exercise to increase muscle strength (in the absence of pain) [6].

There is INSUFFICIENT EVIDENCE about the effect of hydrotherapy (balneotherapy) or using magnets in relieving pain in rheumatoid arthritis [12,21].

Surgery

  • Severely and repeatedly inflamed joints can be treated by a surgical removal of the synovial sheaths, joint fusion, joint replacement, etc.
  • A compression of the spinal nerves in the neck can be treated by decompression therapy [6].

Supplements and Herbs

There is CONFLICTING EVIDENCE of the effectiveness of Evening primrose, borage and blackcurrant oil (which contain gamma-linolenic acid (GLA) [14,17,18,19]Tripterygium wilfordii Hook F [14,16] and fish oil (which contains omega-3 fatty acids) [11,12,19,20] in the prevention or treatment of rheumatoid arthritis.

There is INSUFFICIENT EVIDENCE of the effectiveness of acupuncture, tai chi, yoga, Ayurvedic medicine, traditional Chinese medicine, thunder god vine, Boswellia, ginger, green tea, turmeric, beta-cryptoxanthin in the prevention or treatment of rheumatoid arthritis [12,13,14,15,16,18].

There seem to be NO HUMAN TRIALS about the effectiveness of glucosamine and chondroitin sulfate in the treatment or prevention of rheumatoid arthritis [21].

Special Diets

There is INSUFFICIENT EVIDENCE about the effectiveness of fasting, elimination, vegetarian, high-fruit, high-vegetable, Mediterranean or other special diets in the treatment of rheumatoid arthritis [12,21].

There is NO EVIDENCE about the effectiveness of homeopathy in relieving pain [21].

Prognosis

Early diagnosis can greatly improve the effectiveness of treatment [2].

In some individuals, rheumatoid arthritis is self-limiting disease and in others a chronic disease, which can be life-long [2]. RA factor levels that remain increased for more than 1 year increase the risk of joint deformities [2].

  • References

      1. 2016, Handout on health: rheumatoid arthritis  National Institute of Arthritis and Musculoskeletal and Skin Diseases
      2. Rheumatoid arthritis, overview  Emedicine
      3. Rheumatoid arthritis, clinical presentation  Emedicine
      4. Rheumatoid arthritis, differential diagnosis  Emedicine
      5. Rheumatoid arthritis, workup  Emedicine
      6. Rheumatoid arthritis, treatment & management  Emedicine
      7. Rheumatoid arthritis, medications  Emedicine
      8. Rheumatoid arthritis drug guide  WebMD
      9. Rheumatoid arthritis drug guide  WebMD
      10. Rheumatoid arthritis (RA) medications  RxList
      11. Miles EA et al, 2012, Influence of marine n-3 polyunsaturated fatty acids on immune function and a systematic review of their effects on clinical outcomes in rheumatoid arthritis  PubMed
      12. Rheumatoid arthritis: in depth  National Center for Complementary and Integrative Health
      13. Pattison DJ et al, 2004, The role of diet in susceptibility to rheumatoid arthritis: a systematic review PubMed
      14. Cameron M et al, 2011, Herbal therapy for rheumatoid arthritis  Cochrane
      15. Soeken KL et al 2003, Herbal medicines for the treatment of rheumatoid arthritis: a systematic review  PubMed
      16. Cameron M et al, 2009, Evidence of effectiveness of herbal medicinal products in the treatment of arthritis. Part 2: Rheumatoid arthritis  PubMed
      17. Evening primrose (Oenothera spp.)  Mayo Clinic
      18. Macfarlane GJ et al, 2011, Evidence for the efficacy of complementary and alternative medicines in the management of rheumatoid arthritis: a systematic review  PubMed
      19. Plendzki BC et al, 2011, Treatment of Rheumatoid Arthritis with Marine and Botanical Oils: Influence on Serum Lipids  Hindawi
      20. Omega-3 fatty acids, fish oil, alpha-linolenic acid, evidence  Mayo Clinic
      21. Complementary and Alternative Medicine for Patients with Rheumatoid Arthritis  John Hopkins Arthritis Center
      22. Diagnosis and differential diagnosis of rheumatoid arthritis  UpToDate

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