Rheumatoid arthritis

Rheumatoid arthritis is an inflammatory form of arthritis that causes joint pain and damage. Rheumatoid arthritis attacks the lining of your joints (synovium) causing swelling that can result in aching and throbbing and eventually deformity. Rheumatoid arthritis is two to three times more common in women than in men and generally occurs between the ages of 40 and 60. But rheumatoid arthritis can also affect young children and older adults.

Signs and symptoms of rheumatoid arthritis may include:

  • Joint pain
  • Joint swelling
  • Joints that are tender to the touch
  • Red and puffy hands
  • Firm bumps of tissue under the skin on your arms (rheumatoid nodules)
  • Fatigue
  • Morning stiffness that lasts at least 30 minutes
  • Fever
  • Weight loss

Rheumatoid arthritis usually causes problems in several joints at the same time. Early rheumatoid arthritis tends to affect your smaller joints first — the joints in your wrists, hands, ankles and feet. As the disease progresses, your shoulders, elbows, knees, hips, jaw and neck can also become involved. Rheumatoid arthritis signs and symptoms may vary in severity and may even come and go. Periods of increased disease activity — called flare-ups or flares — alternate with periods of relative remission, during which the swelling, pain, difficulty sleeping, and weakness fade or disappear.

Rheumatoid arthritis occurs when white blood cells — whose usual job is to attack unwanted invaders, such as bacteria and viruses — move from your bloodstream into the membranes that surround your joints (synovium). The blood cells appear to play a role in causing the synovium to become inflamed. The inflammation causes the release of proteins that, over months or years, cause the synovium to thicken. The proteins can also damage the cartilage, bone, tendons and ligaments near your joint. Gradually, the joint loses its shape and alignment. Eventually, it may be destroyed. It’s likely that rheumatoid arthritis occurs as a result of a complex combination of factors, including your genes, your lifestyle choices, such as smoking, and things in your environment, such as viruses.

Factors that may increase your risk of rheumatoid arthritis include:

Sex. Women are more likely to develop rheumatoid arthritis than men are.
Age. Rheumatoid arthritis occurs most commonly between the ages of 40 and 60. However, it can also occur in older adults and in children (juvenile rheumatoid arthritis).
Family history. If a member of your family has rheumatoid arthritis, you may have an increased risk of the disease. Doctors don’t believe you can directly inherit rheumatoid arthritis. Instead, it’s believed that you can inherit a predisposition to rheumatoid arthritis.
Smoking. Smoking cigarettes increases your risk of rheumatoid arthritis. Quitting can reduce your risk.

Diagnosing rheumatoid arthritis usually begins with a physical exam. Your doctor will ask you about your signs and symptoms and examine your affected joints.

In addition:

Blood tests. People with rheumatoid arthritis tend to have an elevated erythrocyte sedimentation rate (ESR, or sed rate), which indicates the presence of an inflammatory process in the body. Other common blood tests look for antibodies called rheumatoid factor and anti-cyclic citrullinated peptide (anti-CCP) antibodies in the blood. While commonly found in the blood of people with rheumatoid arthritis, rheumatoid factor and anti-CCP antibodies aren’t present in all cases. In early rheumatoid arthritis, the presence of rheumatoid factor and anti-CCP antibodies in the blood may be associated with an increased risk of joint damage. Rheumatoid factor and anti-CCP antibodies can be present in people who have chronic infections, such as active tuberculosis, and other autoimmune rheumatic diseases, such as lupus and Sjogren’s syndrome.

Joint fluid analysis. Your doctor may draw fluid from your joint using a needle. The fluid can be tested to help rule out other diseases and conditions.
X-rays. Your doctor may recommend X-rays to help track the progression of rheumatoid arthritis in your joint over time.

Treatment for rheumatoid arthritis aims to reduce inflammation in your joints in order to relieve pain and prevent or slow joint damage. Early and aggressive rheumatoid arthritis treatments may slow joint damage and help reduce the risk of disability. Treatment typically involves medications, though surgery may be necessary in cases of severe joint damage.

Rheumatoid arthritis medications can relieve pain and slow or halt the progression of joint damage. Medications used to treat rheumatoid arthritis include:

NSAIDs. Nonsteroidal anti-inflammatory drugs (NSAIDs) can relieve pain and reduce inflammation. Over-the-counter NSAIDs include ibuprofen (Advil, Motrin, others) and naproxen sodium (Aleve). Stronger versions of these NSAIDs and others are available by prescription. NSAIDs have risks of side effects that increase when used at high dosages for long-term treatment. Side effects may include ringing in your ears, gastric ulcers, heart problems, stomach bleeding, and liver and kidney damage. Consuming alcohol or taking corticosteroids while using NSAIDs also increases your risk of gastrointestinal bleeding.
Steroids. Corticosteroid medications, such as prednisone and methylprednisolone (Medrol), reduce inflammation and pain, and slow joint damage. In the short term, corticosteroids can make you feel dramatically better. But when used for many months or years, they may become less effective and cause serious side effects. Side effects may include easy bruising, thinning of bones, cataracts, weight gain, a round face 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). Doctors prescribe DMARDs to limit the amount of joint damage that occurs in rheumatoid arthritis. These drugs are typically used in the early stages of rheumatoid arthritis in an effort to slow the disease and save the joints and other tissues from permanent damage. You may need to take DMARDs for weeks or months before you notice any benefit. For that reason, they may be combined with other medications that give you more immediate relief from signs and symptoms, such as NSAIDs or corticosteroids. Common DMARDs include hydroxychloroquine (Plaquenil), the gold compound auranofin (Ridaura), sulfasalazine (Azulfidine), minocycline (Dynacin, Minocin) and methotrexate (Rheumatrex).
Immunosuppressants. These medications act to tame your immune system, which is out of control in rheumatoid arthritis. In addition, some of these drugs attack and eliminate cells that are associated with the disease. Some of the commonly used immunosuppressants include leflunomide (Arava), azathioprine (Imuran), cyclosporine (Neoral, Sandimmune) and cyclophosphamide (Cytoxan). These medications can have potentially serious side effects such as increased susceptibility to infection.

TNF-alpha inhibitors. TNF-alpha is a cytokine, or cell protein, that acts as an inflammatory agent in rheumatoid arthritis. TNF inhibitors target or block this cytokine and can help reduce pain, morning stiffness, and tender or swollen joints — usually within one or two weeks after treatment begins. There is evidence that TNF inhibitors may stop progression of disease. These medications often are taken with methotrexate. TNF inhibitors approved for treatment of rheumatoid arthritis are etanercept (Enbrel), infliximab (Remicade) and adalimumab (Humira). Potential side effects include injection site irritation (adalimumab and etanercept), worsening congestive heart failure (infliximab), blood disorders, lymphoma, demyelinating diseases, and increased risk of infection. If you have an active infection, don’t take these medications.
Anakinra (Kineret). Anakinra is similar to a naturally occurring chemical in your body — interleukin-1 receptor antagonist (IL-1Ra) — that stops a certain chemical signal from causing inflammation. You might consider anakinra if you have moderate to severe rheumatoid arthritis and haven’t been helped by conventional DMARD therapy. Anakinra is given as a daily self-administered injection under the skin, and is sometimes combined with methotrexate. Potential side effects include injection site reactions, decreased white blood cell counts, headache and an increase in upper respiratory infections. There may be a slightly higher rate of respiratory infections in people who have asthma or chronic obstructive pulmonary disease. If you have an active infection, don’t use anakinra.
Abatacept (Orencia). Abatacept reduces the inflammation and joint damage caused by rheumatoid arthritis by inactivating T cells — a type of white blood cell. People who haven’t been helped by TNF-alpha inhibitors might consider abatacept, which is administered monthly through a vein in your arm (intravenously). Side effects may include headache, nausea and mild infections, such as upper respiratory tract infections. Serious infections, such as pneumonia, can occur.
Rituximab (Rituxan). Rituximab reduces the number of B cells in your body. B cells are involved in inflammation. People who haven’t found relief using TNF inhibitors might consider using rituximab, which is usually given along with methotrexate. Rituximab is administered as an infusion into a vein in your arm. Side effects include flu-like signs and symptoms, such as fever, chills and nausea. Some people experience extreme reactions to the infusion, such as difficulty breathing and heart problems.

What medications you can consider will depend on the severity of your rheumatoid arthritis, the length of time that you’ve been experiencing signs and symptoms, results from blood tests and X-rays, your overall physical function, and other medical problems you have. Doctors use these factors to determine the duration of your disease, its severity and your prognosis, which help to develop a treatment plan.

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:

Total joint replacement (arthroplasty). During joint replacement surgery, your surgeon removes the damaged parts of your joint and inserts a metal and plastic prosthesis.
Tendon repair. Inflammation and joint damage may cause tendons around your joint to loosen or tighten. Your surgeon may be able to repair the tendons around your joint.
Removal of the joint lining (synovectomy). If the lining around your joint (synovium) is inflamed and causing pain, your surgeon may recommend removing the lining of the joint.

Surgery carries a risk of bleeding, infection and pain. Discuss the benefits and risks with your doctor.

You can take steps to care for your body if you have rheumatoid arthritis. Consider trying to:

Exercise regularly. Gentle exercise can help strengthen the muscles around your joints, and it can help fight fatigue you might feel. Check with your doctor before you start exercising. If you’re just getting started, begin by taking a walk. Try swimming or gentle water aerobics. Public pools and health clubs in your area may offer classes. Avoid exercising tender, injured or severely inflamed joints. If you feel new joint pain, stop. New pain that lasts more than two hours after you exercise probably means you’ve overdone it. If pain persists for more than a few days, call your doctor.
Eat a healthy diet. A healthy diet emphasizing fruit, vegetables and whole grains can help you control your weight and maintain your overall health. However, there’s no special diet that can be used to treat rheumatoid arthritis. It hasn’t been proved that eating any particular food will make your joint pain or inflammation better or worse.
Protect your joints. Find different ways to approach everyday tasks in order to take stress off your painful joints. For instance, if your fingers are sore, pick up an object using your forearms. Lean into a glass door to force it open, rather than pushing on the door with sore arms.
Use assistive devices. Assistive devices can make it easier to go about your day without stressing your painful joints. For instance, using specially designed gripping and grabbing tools may make it easier to work in the kitchen if you have pain in your fingers. Try a cane to help you get around. Your doctor or occupational therapist may have ideas about what sorts of assistive devices may be helpful to you. Catalogs and medical supply stores may also be places to look for ideas.
Apply heat. Heat can help ease your pain and relax tense, painful muscles. One of the easiest and most effective ways to apply heat is to take a hot shower or bath for 15 minutes. Other options include using a hot pack or an electric heat pad set on its lowest setting. If your skin has poor sensation or if you have poor circulation, don’t use heat treatments.
Apply cold. Cold may dull the sensation of pain. Cold also has a numbing effect and decreases muscle spasms. Don’t use cold treatments if you have poor circulation or numbness. Techniques may include using cold packs, soaking the affected joints in cold water and ice massage.
Relax. Find ways to cope with pain by reducing stress in your life. Techniques such as hypnosis, guided imagery, deep breathing and muscle relaxation can all be used to control pain.

If you’re interested in trying complementary and alternative medicine therapies for your rheumatoid arthritis pain, discuss these treatments with your doctor first. Some common complementary and alternative treatments that have shown promise for rheumatoid arthritis include:

Plant oils that contain gamma-linolenic acid (GLA). GLA is a type of omega-6 fatty acid that comes from plant oils, such as evening primrose, borage and black currant. Some studies indicate GLA may help with rheumatoid arthritis pain and morning stiffness, though more research is needed. 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.
Fish oil that contains eicosapentaenoic acid (EPA) or docosahexaenoic acid (DHA). EPA and DHA are omegea-3 fatty acids commonly found in fish oil. Some preliminary studies have found that fish oil may reduce rheumatoid arthritis pain and stiffness, but more study is needed. Side effects can include nausea, belching and a fishy taste in the mouth. More serious side effects can include bleeding and mercury poisoning. Fish oil can 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 tai chi may reduce rheumatoid arthritis pain, though more study is needed. Talk to your doctor if you’d like to give tai chi a try. When led by a knowledgeable instructor, tai chi is safe. But don’t do any moves that cause pain.

Be careful when considering alternative therapies. Many are expensive and some may be harmful. Before taking any complementary medications or dietary supplements, talk with your doctor to learn about potential dangers, particularly if you’re taking other medications.