Family doctor

What is Rheumatoid Arthritis?

Rheumatoid arthritis (RA) has the following features. These may help distinguish it from other forms of arthritis:

• It is inflammatory, meaning that, as well as pain, there is swelling and stiffness in the joints. Symptoms are usually worse in the morning and improve with activity.
• It usually begins in the hands and feet. It is unusual for larger joints to be affected before the hands and feet are involved.
• It is usually fairly symmetrical, meaning that both right and left sides are affected, although not necessarily to the same extent.
• It tends to be a chronic disease which seldom goes into complete remission. The symptoms may wax and wane, but seldom disappear altogether.
• It has the potential to damage the joints, leading to deformity and loss of function. This feature varies greatly between individuals.
• Organs other than the joints may be involved. For example, dry eyes, dry mouth, skin ulcers and nodules, and lung involvement.

RA affects about 1% of people internationally. If you know 100 people, there is a good chance that you will know someone who has RA in one form or another.

Three out of every four people with RA are women. It is most likely to develop between the ages of 20 and 45, but can develop in childhood and in old age.

The basic disease process in RA is swelling of the lining of the joints caused by accumulation of white blood cells. These cells release substances which result in fluid accumulation, pain and damage to bone and cartilage.

The underlying cause of RA remains a mystery. Genetic factors play a role and we are beginning to understand how the inheritance of certain genes determines the risk of developing RA. You do not need to have a family history of RA to get it. If you do have a family history of RA the risk of getting it is increased but it is by no means certain that you will get it. It is possible that outside influences such as infection may be involved in triggering RA in susceptible individuals, but RA is not thought to be caused by infection.

How do I know if I have got it?

There is no definite test for RA. The diagnosis is made on the basis of the clinical features listed above. If you have joint problems which do not fit that pattern, then it is unlikely that you have RA, even if your blood tests suggest RA. Also, if your symptoms do fit the RA pattern, you could still have RA even if all the blood tests and x-rays are negative.

Seventy to 80% of patients with RA have rheumatoid factor which is an antibody detected in a blood test. Rheumatoid factor is sometimes found in other diseases, and occasionally in healthy individuals. This means that you can have RA and not have rheumatoid factor, and you can have rheumatoid factor and not have RA.

Most people with RA have raised levels of inflammatory markers detected in blood tests. ESR and CRP are commonly measured. These tend to be high when the inflammation is most active and come down when the inflammation is under control.

X-rays will usually be taken early on to look for damage in the joints. The finding of erosions is suggestive of RA but erosions can occur in other types of arthritis.

What can be done to treat RA?

The severity of RA differs greatly between individuals. The intensity of the treatment should be matched to the severity of the symptoms and the risk of joint damage later on. In a few cases, the disease if left untreated, may cause progressive destruction and loss of function. These cases need fairly intensive treatment to give the best chance of a good outcome. Other milder cases may just need symptomatic relief. A rheumatologist (arthritis specialist) is best qualified to determine the level of treatment needed.

Relief of symptoms may be obtained from analgesics (pain relievers) and nonsteroidal anti-inflammatory drugs (NSAIDs). These drugs relieve the symptoms of inflammation without having much effect on the inflammation itself. Paracetamol is the most common analgesic. This drug has few significant side effects if not taken in excess. NSAIDs (e.g. Voltaren, Brufen, Naprosyn, Oruvail, Indocid, Froben, Surgam, Tilcotil and others) are usually more effective than paracetamol in RA, but can cause irritation and even ulceration in the stomach. In patients with previous stomach ulcers, heart failure, kidney disease, and in those taking warfarin or prednisone, NSAIDs should be avoided or at least used with caution under medical supervision.

Corticosteroids (cortisone) are often used in short courses during flares of RA to bring the inflammation under control. This type of drug may be given in several ways. Systemic (whole body) treatment may take the form of tablets (e.g. prednisone), intramuscular injections or intravenous infusions. When injected directly into the joints, corticosteroids can provide rapid relief without exposing the rest of the body to side effects. Common side effects include weight gain, especially around the face and trunk, mood changes and facial flushing. If used in prolonged courses, corticosteroids can accelerate thinning of the bones and skin and the formation of cataracts. When used responsibly in RA, corticosteroids do far more good than harm.

Disease modifying anti-rheumatic drugs (DMARDs), sometimes referred to as slow acting anti-rheumatic drugs (SAARDs), work over a long period of time to reduce the amount of inflammation in the joints. They usually take between six weeks and three months to take effect, and must be used continuously rather than "as required" on a day to day basis. Examples include methotrexate, sulphasalazine (Salazopyrine), hydroxychloroquine (Plaquenil), azathioprine (Imuran), gold injections (Myocrisin), penicillamine and cyclosporine (Neoral).

• This type of drug can occasionally cause side effects such as nausea, rash and low blood counts.
• The decision to use DMARDs is based on a comparison of risk of side effects versus the risk of leaving the arthritis untreated.
• Many of these drugs reduce the risk of damage in the joints.
• Sometimes these drugs are used in combination with each other.
• They must be prescribed under the supervision of a rheumatologist.

How will this disease affect me in the long term?

The long term outcome of RA depends on a number of factors and varies greatly between individuals. Generally speaking, the outcome may be poorer if there is:

• A large number of joints involved
• High markers of inflammatory activity, i.e. ESR, CRP
• Involvement of tissues and organs outside the joints, e.g. eyes, lungs, nodules
• Positive rheumatoid factors
• Erosions seen in x-rays early on

Effective early use of DMARDs may improve the long term outcome. If the joints become badly damaged, surgery may help correct deformities, reduce pain and improve function.

The great majority of people with RA are able to lead normal lives. Most will continue to work full-time, often even in quite physical jobs. The ability to have a family is very seldom affected.

What else do I need to know?

All patients with established or suspected RA should see a rheumatologist as early as possible. It is not a good idea to delay matters by trying alternative unproven treatments, as the damage is often worst early in the course of the disease.

Rheumatologists are tolerant of people's desire to try alternative therapies in addition to proven medical treatments. Some alternative treatments have been shown to give a modest benefit to symptoms. Family doctors (GPs) and rheumatologists are the best sources of honest, objective information on alternative practices, as their income does not depend on your use of these remedies.

Dietary advice is widely available in the community, but most of it is unproven and unhelpful. There is no evidence that elimination of dairy foods, citrus fruits or so-called nightshade foods (e.g. tomatoes and potatoes) can help RA. Fish oils have been shown to have a modest benefit in RA, but these products are expensive and must be used in high doses to have effect. Dietary treatment alone will not prevent joint damage.

Where else can I get information about Rheumatoid Arthritis?

Your family doctor will be able to help.

The Arthritis Foundation of New Zealand is an excellent source of information and support for patients with arthritis and rheumatic diseases. Most countries have similar organisations. You will find the number for your local chapter in the phone directory.