Rheumatoid Arthritis

What is rheumatoid arthritis?

Arthritis means inflammation of joints. Rheumatoid arthritis (RA) is a common form of arthritis. About 1 in 100 people develop RA at some stage in their life. It can happen to anyone. It is not a hereditary disease. It can develop at any age, but most commonly starts between the ages of 40 and 60. It is three times more common in women than in men.

Understanding joints

What causes rheumatoid arthritis?

RA is thought to be an autoimmune disease. The immune system normally makes antibodies (small proteins) to attack bacteria, viruses, and other 'germs'. In people with autoimmune diseases, the immune system makes antibodies against tissues of the body. It is not clear why this happens. Some people have a tendency to develop autoimmune diseases. In such people, something might trigger the immune system to attack the body's own tissues. The 'trigger' is not known.

In people with RA, antibodies are formed against the synovium (the tissue that surrounds each joint). This causes inflammation in and around affected joints. Over time, the inflammation can damage the joint, the cartilage, and parts of the bone near to the joint.

Which joints are affected in rheumatoid arthritis?

The most commonly affected joints are the small joints of the fingers, thumbs, wrists, feet, and ankles. However, any joint may be affected. The knees are quite commonly affected. Less commonly the hips, shoulders, elbows, and neck are involved. It is often symmetrical. So, for example, if a joint is affected in a right arm, the same joint in the left arm is also often affected. In some people, just a few joints are affected. In others, many joints are involved.

What are the symptoms of rheumatoid arthritis?

Joint symptoms

The common main symptoms are pain and stiffness of affected joints. The stiffness is usually worse first thing in the morning, or after you have been resting. The inflammation causes swelling around the affected joints.

Other symptoms

These are known as 'extra-articular' symptoms of RA (meaning 'outside of the joints'). A variety of symptoms may occur. The cause of some of these is not fully understood.

• Small painless lumps or 'nodules' develop in about 1 in 4 cases. These commonly occur on the skin over the elbows and forearms, but usually do no harm.
• Inflammation around tendons may occur. This is because the tissue which covers tendons is similar to the synovium around the joints.
• Anaemia and tiredness are common.
• A fever, feeling unwell, weight loss, and muscle aches and pains sometimes occur.
• In a few cases, inflammation develops in other parts of the body such as the lungs, heart, blood vessels, or eyes. This is uncommon but if it occurs can cause various symptoms and problems which are sometimes serious.

How does rheumatoid arthritis develop and progress?

In most cases the symptoms develop gradually - over several weeks or so. Typically, you may first develop some stiffness in the hands, wrists, or soles of the feet in the morning which eases by mid-day. This may come and go for a while, but then becomes regular. You may then notice some pain and swelling in the same joints. More joints such as the knees may then become affected.

In a small number of cases, less common patterns are seen. For example:

• In some cases pain and swelling develops quickly in many joints - over a few days or so.
• Some people have bouts of symptoms which affect several joints. Each bout lasts a few days, and then goes away. Several bouts may occur before persistent symptoms develop.
• In some people, usually young women, the disease affects just one or two joints at first, often the knees.
• The non-joint symptoms such as muscle pains, anaemia, weight loss, and fever are sometimes more obvious at first before joint symptoms develop.

RA can vary greatly from person to person. It is usually a chronic relapsing condition. Chronic means that it is persistent. Relapsing means that at times the disease flares-up (relapses), and at other times it settles down. There is usually no apparent reason why the inflammation may flare-up for a while, and then settle down.

Most people with RA have this pattern of flare-ups followed by better spells. In some people, months or even years may go by between flare-ups. Some damage may be done to affected joints during each flare-up. The amount of disability which develops usually depends on how much damage is done over time to the affected joints.

In a minority of cases the disease is constantly progressive, and severe joint damage and disability can develop quite quickly.

Smoking seems to be a possible factor as, on average, the severity of RA tends to be worse in smokers than non-smokers.

Joint damage

Inflammation can damage the cartilage which may become eroded or worn. The bone underneath may become thinned. The joint capsule and nearby ligaments and tissues around the joint may also become damaged. Joint damage develops gradually. Over time, it may lead to deformities. It may become difficult to use the affected joints. For example, the fingers and wrists are commonly affected, so a good grip and other tasks using the hands may become difficult.

Most people with RA develop some damage to affected joints. The amount of damage can range from mild to severe. At the outset of the disease it is difficult to predict for an individual how badly the disease will progress. However, modern treatments can often limit the progression of the disease and limit the joint damage (see below).

How is rheumatoid arthritis diagnosed?

There is no single test which clearly diagnoses early RA. When you first develop joint pains, it may be difficult for a doctor to say that you definitely have RA. This is because there are many other causes of joint pains. Blood tests can detect inflammation, characteristic antibodies, and anaemia. These may suggest that you have RA, but do not prove that you definitely have it as these blood results can be caused by other conditions.

You may have a time of uncertainty when early symptoms 'could be' RA. In time, X-rays of joints may begin to show typical erosions (early damage) and other features of RA which makes the diagnosis more certain.

Some other associated diseases and possible complications

Associated conditions

The risk of developing certain other conditions is higher in people with RA. These include: heart disease, stroke, infections (joint infections and non-joint infections), gut problems, osteoporosis (thinning of the bones), and certain cancers.

It is not clear why these conditions develop more commonly in people with RA. One possible reason is that, on average, people with RA tend to have more 'risk factors' for developing some of these conditions. For example:

• Lack of exercise and high blood pressure are 'risk factors' for developing heart disease and stroke. People with RA may not be able to exercise very easily, and some of the drugs used to treat RA may increase blood pressure.
• Some of the drugs used to treat RA suppress the immune system. This may be a factor for the increased risk of developing infections and certain cancers.
• Poor mobility and steroid drugs increase the risk of developing osteoporosis.
• Some of the drugs that are used to treat RA can upset the lining of the gut. This sometimes causes gut and stomach problems.

Other complications

Other complications which may develop include:

• Carpal tunnel syndrome. This is relatively common. It causes pressure on the main nerve going into the hand. This can cause pain, tingling and numbness in parts of the hand. (See separate leaflet called 'Carpal Tunnel Syndrome' for details.)
• Tendon rupture sometimes occurs (particularly the tendons on the back of the fingers).
• Cervical myelopathy. This is an uncommon but serious complication of severe, long-standing RA. It is caused by a 'dislocation' of joints at the top of the spine. This can cause pressure on the spinal cord.

What are the treatments for rheumatoid arthritis?

There is no cure for RA. However, RA can be treated to reduce pain, stiffness, and damage to joints. The main aims of treatment are:

1. To reduce pain and stiffness in affected joints as much as possible.
2. To prevent joint damage as much as possible.
3. To minimise any disability caused by pain, joint damage, or deformity.
4. To reduce the risk of developing associated conditions such as heart disease.

Treatment aim 1 - to reduce pain and stiffness

During a flare-up of inflammation, if you rest the affected joint(s) it helps to ease pain. Special wrist splints, footwear, gentle massage, or applying heat may also help. Medication is also helpful. Drugs which may be advised by your doctor to ease pain and stiffness include the following:

Non-steroidal anti-inflammatories

These are sometimes just called 'anti-inflammatories' and are good at easing pain and stiffness and also help to reduce inflammation. There are many types and brands. Each is slightly different to the others, and side-effects may vary between brands. To decide on the right brand to use, a doctor has to balance how powerful the effect is against possible side-effects and other factors. Usually one can be found to suit. However, it is not unusual to try two or more brands before finding one that suits you best.

The leaflet which comes with the tablets gives a full list of possible side-effects. The most common side-effect is stomach pain (dyspepsia). An uncommon but serious side-effect is bleeding from the stomach. Your doctor may prescribe another drug to 'protect the stomach' from these possible problems. If you develop abdominal (stomach) pains, pass blood or black stools, or vomit blood whilst taking anti-inflammatory painkillers, stop taking the tablets and see a doctor urgently.

Painkillers

Paracetamol often helps. This does not have any anti-inflammatory action, but is useful for pain relief in addition to, or instead of, an anti-inflammatory. Codeine is another painkiller that is sometimes used.

Steroids

Steroids are good at reducing inflammation. However, because of the problem of possible side-effects, steroids are not recommended for routine use. This is not to say that they are never used. The main side-effects from steroids occur when they are used for more than a few weeks. Therefore, a short course of steroid tablets such as prednisolone is sometimes used. This may be prescribed to treat a flare-up which has not been helped much by a non-steroidal anti-inflammatory. A short course of steroids may also be used whilst waiting for a disease modifying drug (see below) to take effect.

An injection of steroid directly into a joint is sometimes used to treat a bad flare-up in one particular joint.

The serious side-effects that may occur if you take steroids for more than a few weeks, or if you have injections frequently, include: thinning of the bones (osteoporosis), thinning of the skin, weight gain, muscle wasting and an increased risk of serious infection.

Note: non-steroidal anti-inflammatories, ordinary painkillers, and steroids ease the symptoms of RA. However, they do not alter the progression of the disease or prevent joint damage. You do not need to take them if symptoms settle between flare-ups.

Treatment aim 2 - to prevent joint damage as much as possible

Disease-modifying drugs

There are a number of drugs called disease-modifying antirheumatic drugs (DMARDs). These are drugs that ease symptoms but also reduce the damaging effect of the disease on the joints. They work by blocking the way inflammation develops in the joints (by blocking certain chemicals involved in the inflammation process). DMARDs include: sulfasalazine, methotrexate, gold injections, gold tablets, penicillamine, leflunomide and hydroxychloroquine. It is these drugs that have improved the outlook (prognosis) in recent years for many people with RA.

It is usual to start a DMARD as soon as possible after RA has been diagnosed. This is to try and limit the disease process as much as possible. In general, the earlier you start one, the more effective it is likely to be.

DMARDs have no immediate effect on pains or inflammation. It can take several weeks, and sometimes several months, before you notice any effect. Therefore, it is important to keep taking a DMARD as prescribed, even if it does not seem to be working at first. After starting a DMARD, many people continue to take an anti-inflammatory tablet for several weeks until the DMARD starts to work. Once a DMARD is found to help, the dose of the anti-inflammatory tablet can be reduced or even stopped. It is then usual to take a DMARD indefinitely.

Other DMARDs include azathioprine, cyclosporin, and cyclophosphamide. These are usually reserved for people who do not respond well to the more commonly used DMARDs, due to the risk of serious side-effects.

Each DMARD has different possible side-effects. If one does not suit, a different one may be fine. Some people try two or three DMARDs before one is found to suit. (Some side-effects can be serious. These are rare and include damage to the liver and blood producing cells. Therefore, it is usual to have regular tests - usually blood tests - whilst you take a DMARD. The tests look for some possible side-effects before they become serious.)

Newer disease modifying drugs

A new class of drugs which have recently been developed are drugs that modify the effect of TNF-alpha. The chemical TNF-alpha plays an important role in causing inflammation in joints. Blocking the effect of TNF-alpha has been shown to reduce damage to joints, and reduce symptoms. Drugs which modify or block the effect of TNF-alpha include: etanercept, infliximab, adalimumab, and anakinra. They show promise but their long-term benefits are still being evaluated.

One problem with these drugs is that they need to be given by injection. They are also expensive. Recent guidelines state that one may be tried if there has been little success when using standard DMARDs.

Treatment aim 3 - to minimise disability as much as possible

• As far as possible, try to keep active. The muscles around the joints will become weak if they are not used. Regular exercise may also help to reduce pain and improve joint function. Swimming is a good way to exercise many muscles without straining joints too much. A physiotherapist can advise on exercises to keep muscles around joints as mobile and strong as possible. They may also advise on splints to help rest a joint if needed.
• If such things as your grip or mobility become poor, an occupational therapist may advise on adaptations to the home to make daily tasks easier.
• If you develop a joint deformity then surgery to correct it may be an option. If severe damage occurs to a joint, operations such as knee or hip replacements are an option.

Treatment aim 4 - to reduce the risk of developing other diseases

As mentioned, if you have RA you have an increased risk of developing diseases such as heart disease, stroke, osteoporosis, and certain cancers. Therefore, you should consider doing what you can to reduce the risk of these conditions by other means.

For example, if possible:

• Eat a good healthy diet and exercise regularly.
• Lose weight if you are overweight.
• Do not smoke. (In addition to increasing the risk of cancer, heart disease and stroke, smoking may also make symptoms of RA worse.)
• If you have high blood pressure, diabetes, or a high cholesterol level, they should be well controlled on treatment.

See leaflets called 'Preventing Heart Disease and Stroke' and 'Osteoporosis' for more details.

Immunisations

To prevent certain infections, you should have:

• An annual 'flu jab if you are over the age of 65 years, or are taking immunosuppressive drugs, or are taking steroids equivalent to 20 mg or more of prednisolone each day for more than a month.
• A 'one-off' pneumococcal immunisation if you are over the age of 65 years, or are taking immunosuppressive drugs, or are taking steroids equivalent to 20 mg or more of prednisolone each day for more than a month.

Other treatments

Some people try complementary therapies such as special diets, bracelets, acupuncture, etc. There is little research evidence to say how effective such treatments are for RA. In particular, beware of paying a lot of money to people who make extravagant claims of success. For advice on the value of any treatment it is best to consult a doctor, or contact one of the groups below.

What is the outlook (prognosis)?

The outlook regarding joint damage is perhaps better than many people imagine.

• About 2 in 10 people with RA have a relatively mild form of the disease, and can continue to do most normal activities for many years after the condition first starts.
• About 1 in 10 people with RA become severely disabled.
• About 7 in 10 fall somewhere in between with varying degrees of difficulties and disability. Most will have to modify their lifestyle to some extent, but can expect to lead a full life.

However, these figures are probably becoming out of date as treatment has improved in recent years. Symptoms can often be well controlled with medication. Because of the newer and better drugs, in particular the newer disease modifying drugs, the outlook for a person who is diagnosed with rheumatoid arthritis these days is likely to be much better than it was a few years ago. Follow up studies of people being treated with the newer drugs should give a clearer idea of prognosis over the next few years.

Another factor to bear in mind is that because of the increased risk of developing 'associated diseases' such as heart disease (see above), the average life expectancy of people with RA is a little reduced compared to the general population. This is why it is important to tackle any factors that you can modify such as smoking, diet, weight, etc.

In summary

• Rheumatoid arthritis can range from relatively mild to severe.
• The outlook cannot be predicted for an individual when the disease starts.
• RA can be treated to reduce pain, stiffness, and damage to joints. Treatment usually includes:
  • A disease-modifying drug which reduces joint damage. The earlier one is started, the less damage is likely to occur in the joints. You should take this all the time. It may take several weeks to begin working.
  • An anti-inflammatory to ease pain and reduce inflammation. This helps to ease symptoms but does not affect the progress of the disease. You do not need to take this if symptoms settle.
• A painkiller such as paracetamol or codeine may be added for extra pain relief.
• Other treatments such as physiotherapy, occupational therapy, and surgery may also be advised, depending on the severity of the disease and other factors.
• If possible, leading a healthy lifestyle such as not smoking, eating healthily, taking regular exercise, etc, can help to reduce the chance of developing associated diseases such as heart disease, stroke, osteoporosis, and certain cancers.

Further help and advice

Arthritis Research Campaign - ARC

Copeman House, St Marys Court, St Marys Gate, Chesterfield, Derbyshire, S41 7TD.
Tel: 0870 850 5000 Web: www.arc.org.uk

Arthritis Care

18 Stephenson Way, London, NW1 2HD
Helpline: 0808 800 4050 Web: www.arthritiscare.org.uk

National Rheumatoid Arthritis Society (NRAS)

Unit B4 Westacott Business Centre, Westacott Way, Littlewick Green, Maidenhead, Berks, SL6 3RT
Helpline: 0800 298 7650 Web: www.rheumatoid.org.uk