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RA is a systemic rheumatic disease characterized by arthritis of many joints,usually in a symmetric pattern. Typically,RA
causes stiffness, pain, warmth,and swelling of the joints. With time,the affected joint may become misshapen,misaligned
and damaged. Synovial tissue surrounding the smooth,shiny cartilage that lines the joint becomes thickened and may erode
the surrounding ligaments and bones as it spreads. All patients do not have the erosive type of disease
RA primarily affects the synovial joints of the body. The most disabling form of arthritis,RA generally affects more
then one joint at a time,the elbows,shoulders hips,knees and neck. Ordinarily,it affects both hands or both feet. As a systemic
disease,areas outside the joints may be affected Examples include inflammation in the membranes surrounding internal
organs,such as the heart and lungs.
Stiffness,commonly called "morning stiffness," occurs in almost all inflamed joints after a period of rest or disuse.
This is particular common in RA. Morning stiffness can last from a few hours to all day long. To regain normal mobility inflamed
joints must be loosened up by applying heat or through exercise.
Rheumatoid arthritis may cause inflammation in the lining of the joints. This inflammation separates RA from other
more common forms of arthritis, such as osteoarthritis. RA may start gradually or with a sudden,severe attack with flu-like
symptoms. It's important to know that RA symptoms vary from person to person. In some people the disease will be mild
with periods of activity or joint inflammation (flare-ups) and inactivity (remissions). In other patients,the disease will
be continueously active and appear to get worse,or progress over time.
One important way to distinguish RA from other forms of arthritis is by the pattern of joint involvement. For example,RA
affects the wrist and many of the hand joints,but usually,not those joints closest to the fingernails.
Osteoarthritis,in contrast,affects those joints closest to the fingernails more often than other areas of the hand. In
RA,the joints tend to be involved in a symmetrical pattern,i.e.,if the knuckles on the right hand are inflamed,the knuckles
on the left hand are likely to be inflamed as well. A experienced and knowledgeable physician will recognize the differences.
Often joints commonly affected by RA include the elbows, shoulders, neck, jaw, feet, knees, and hips. Other than the
neck,the spine usually is not directly affected by RA. The lower back may be affected.
Along with painful,inflamed joints,RA can cause inflammation in other body tissues and organs. In 20% of cases,lumps,called
rheumatoid nodules develop under the skin,often over bony areas. These occur most often around the elbow but can be
found elsewhere n the body and even in internal organs.
Occasionally,people with RA develop inflammation of the memberanes that surround the heart and lungs or inflammation
of the lung itself. Inflammation of tear glands and salivary glands (called sicca syndrome) results in dry eyes
and dry mouth. Sometimes,RA causes inflammation of the blood vessels (vasculitis), which affects the skin,nerves and other
organs.
Establishing the correct diagnosis early is very important because the sooner appropriate treatment is started the better
chance of avoiding disability or deformity.
The doctor may be able to diagnose RA based on your medical history, and a physical examination. Usually he/she will
order certain tests to confirm the diagnosis,to determine how much joint damage exists,or to distinguish RA from other types
of arthritis. These tests may include blood tests (erythrocyte sedimentation rate,(sed test), rheumatoid factor etc.).
X-rays or joint fluid tests. If you are diagnosed with RA, speak to your doctor about a referral to a rheumatologist.
Although there is no cure or prevention of RA today,a lot can be done to manage the condition. A variety of treatment
exists to treat the symptoms resulting in less pain, stiffness,and easier movement. Four major treatment approaches are recognized
in the treatment of RA, medicine (pharmacological), physical (exercise),joint protection and lifestyle changes,and surgery.
Active involvement and understanding the "whys" in the prescribed treatment plan , and nature of the disease itself is
essential.
RA is a systemic rheumatic disease characterized by arthritis of many joints,usually in a symmetric pattern.
Typically,RA causes stiffness, pain, warmth,and swelling of the joints. With time,the affected joint may become
misshapen,misaligned and damaged. Synovial tissue surrounding the smooth,shiny cartilage that lines the joint becomes
thickened and may erode the surrounding ligaments and bones as it spreads. All patients do not have the erosive type of disease
RA primarily affects the synovial joints of the body. The most disabling form of arthritis,RA generally affects more
then one joint at a time,the elbows,shoulders hips,knees and neck. Ordinarily,it affects both hands or both feet. As a systemic
disease,areas outside the joints may be affected Examples include inflammation in the membranes surrounding internal
organs,such as the heart and lungs.
Stiffness,commonly called "morning stiffness," occurs in almost all inflamed joints after a period of rest or disuse.
This is particular common in RA. Morning stiffness can last from a few hours to all day long. To regain normal mobility inflamed
joints must be loosened up by applying heat or through exercise.
Rheumatoid arthritis may cause inflammation in the lining of the joints. This inflammation separates RA from other
more common forms of arthritis, such as osteoarthritis. RA may start gradually or with a sudden,severe attack with flu-like
symptoms. It's important to know that RA symptoms vary from person to person. In some people the disease will be mild
with periods of activity or joint inflammation (flare-ups) and inactivity (remissions). In other patients,the disease will
be continueously active and appear to get worse,or progress over time.
One important way to distinguish RA from other forms of arthritis is by the pattern of joint involvement. For example,RA
affects the wrist and many of the hand joints,but usually,not those joints closest to the fingernails.
Osteoarthritis,in contrast,affects those joints closest to the fingernails more often than other areas of the hand. In
RA,the joints tend to be involved in a symmetrical pattern,i.e.,if the knuckles on the right hand are inflamed,the knuckles
on the left hand are likely to be inflamed as well. A experienced and knowledgeable physician will recognize the differences.
Often joints commonly affected by RA include the elbows, shoulders, neck, jaw, feet, knees, and hips. Other than the
neck,the spine usually is not directly affected by RA. The lower back may be affected.
Along with painful,inflamed joints,RA can cause inflammation in other body tissues and organs. In 20% of cases,lumps,called
rheumatoid nodules develop under the skin,often over bony areas. These occur most often around the elbow but can be
found elsewhere n the body and even in internal organs.
Occasionally,people with RA develop inflammation of the memberanes that surround the heart and lungs or inflammation
of the lung itself. Inflammation of tear glands and salivary glands (called sicca syndrome) results in dry eyes and
dry mouth. Sometimes,RA causes inflammation of the blood vessels (vasculitis), which affects the skin,nerves and other organs.
Establishing the correct diagnosis early is very important because the sooner appropriate treatment is started the better
chance of avoiding disability or deformity.
The doctor may be able to diagnose RA based on your medical history, and a physical examination. Usually he/she will
order certain tests to confirm the diagnosis,to determine how much joint damage exists,or to distinguish RA from other types
of arthritis. These tests may include blood tests (erythrocyte sedimentation rate,(sed test), rheumatoid factor etc.).
X-rays or joint fluid tests. If you are diagnosed with RA, speak to your doctor about a referral to a rheumatologist.
Although there is no cure or prevention of RA today,a lot can be done to manage the condition. A variety of treatment
exists to treat the symptoms resulting in less pain, stiffness,and easier movement. Four major treatment approaches are recognized
in the treatment of RA, medicine (pharmacological), physical (exercise),joint protection and lifestyle changes,and surgery.
Active involvement and understanding the "whys" in the prescribed treatment plan , and nature of the disease itself is
essential.
A genetric component to rheumatoid arthritis was first implicated on the basis of a clustering of RA in families.
The incidence of RA is between 0.5 and one per cent in Caucasian population Young women have three times the risk of RA as
men,but after menopause this gender difference disappears. Although the precise means of inheritance is unknown,virtually
all genetric studies show an association of RA with the genes HLA DR4 and HLA DR1. However,this varies among different ethnic
populations studied. In identical twins in up to 15 per cent in fraternal twins.
A recent study of RA inheritance in Iceland shed some light on the risk for relatives of affected individuals.
The study indicated a life-time risk in the general population of one per cent. The lifetime risk in children who have a parent
with RA was estimated at between two to three times that of the general population,or two to three per cent over a life time.
The greatest risk was found in parents who have a child with RA;the risk was almost four times that of the general population.
Of note,there was no increased risk in the spouses of RA patients,supporting the current thesis that environment alone is
not an important risk factor. Prior to conception,it's important to ask the rheumatoligist which medications are safe to take
during pregnancy.
The typical patient with rheumatoid arthritis has inflammation in the wrist and MCP or metatarsophalangeal
(MTP) joints,or both,that persists beyond 6 weeks. Morning stiffness and inactivity stiffness are almost always present,and
swelling of affected joints is clear with careful examination.
Symmetric joint swelling,although not invariable,is characteristic of RA. Careful palpation of the joints
can help to distinguish the swelling of joint inflammation from the bony enlargement of osteoarthritis. In contrast to gout
or septic arthritis,redness of affected joint is not a prominent feature of RA. Pain on passive motion is the most sensitive
test for joint inflammation. occasionally inflamed joints will feel warm to the touch. Inflammation,structural deformity,or
both may limit range of motion of the joint. To institute proper therapy,it is important to determine which of these processess
is the major limiting joint function.
The condition may be episodic at the onset,but within weeks to months the symptoms become persistent and more
disabeling. A positive rheumatoid factor test supports the diagnosis,however,many as 30% of those affected have negative test
results. Specificity increases with consistent results on more than 1 test, and with high titre. The presence of antinuclear
antibodies at a low titre may be associated with more severe seropositive RA.
If the patient has had active polyarthritis for more than 1 year,joint erosion may be seen on radiographs
of the hand or foot. The importance of diagnosing RA cannot be overemphasized--early intervention with DMARDs has shown to
improve long-term outcomes,and once joint damage has occurred erosion and joint stability are irreversible.
If RA is mild and in its early stages many rheumatologists favor using hydroxchloroquine because it is safe
and convient. If control is suboptimal after 6 months,additional DMARDs are often prescribed.
If a patient has moderate or severe RA,especially if the rheumatoid factor is positive,injectable gold or
methotrexate may be the preferred DMARD. Gold treatment has the important advantage of offering potential disease remission,
but methotrexate is more convient and better tolerated. Sulfasalazine is safe as a second-line agent and can be used in combination
with methotrexate and other DMARDs. Many new DMARDs have become available.
There is frequently a delay betwen the presentation of polyarthritis and the confirmed diagnosis,and there
is always a delay before a prescribed DMARD has the expected benefit. When optimal DMARD therapy or a combination of DMARDs
does not control synovitis,low-dose predisone can provide symptom relief,acceptable low toxicity and joint protection.
Bisphosphonate,either cyclical tidronate or daily alendronate,reduces the risk of steriod-induced osteoporosis
and should be prescribed when the daily dose of predisone is 7.5 mg or more. Patients with active RA should be assessed by
a rheumatoligist on a regular basis,and clinical and laboratory evaluations should be repeated to measure the efficacy and
toxicity of treatment.
The aim of therapy is to minimize pain,stiffness, and joint swelling, retard joint damage,and reduce
future disability.Patients with inflammatory polyarthritis (i.e. inflammation in more than 4 joints) are a diagnostic
and management challenge.
The initial evaluation of the patient with RA should document symptoms of active disease (joint pain,morning
stiffness, fatigue), functional status,objective evidence of active disease activity (synovitis, ESR or CRP level),mechanical
joint problems,the presence of extraarticular diseases and comorbid conditions,and the presence of of radiographic damage
in selected involved joints. Later comparison with this baseline information facilitates assessment of disease progression
and assessment.
Careful history-taking, a complete review of systems,and a thorough physical examination (both general and
musculoskeletal) are necessary. The severity and duration of morning stiffness and constitutional symptoms of fatigue
should be recorded.Patient's and physicians's global assessment,tender and swollen joint counts,a quantitive assessment of
pain by a visual analogue scale or other mechanism,and functional evaluation are useful parameters to follow during the course
of the disease.
Often the patient first notices stiffness in one or more joints,usually accompanied by pain or movement,and
by tenderness in a joint. RA is an additive polyarthritis with the sequential addition of involved joints,in contrast to the
migratory or evanescent arthritis of systemic lupus erythematosus or the episodic arthritis of gout.
Early in the course of the disease inflammation of the synovium may occur leading to joint pain,stiffness,and
limitation of motion. Signs of osteoporosis in the ends of bones forming the joint may also be present early in the disease
process. With more advanced disease patients may exibit EAF's.
The joints involved most often are the proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joints
of the hands,the wrists (particularly at the ulnar-styloid articulation),shoulders,elbows,knees,ankles,and (MTP)metatarsophalangeal joints.
The distal interphalangeal (DIP) joints are generally spared. The spine,except the atlanto-axial articulation in late disease
is usually,never affected.
The number of joints involved is highly variable,but almost always the process is eventually polyarticular
involving more than five or more joints (often as many as 30-40 different joints).
Morning stiffness persisting for more than one hour but often lasting for several hours may be a feature of
any inflammatory arthritis but is especially charachteristic of RA. It's duration is often used as a useful gage of inflammation
present.
Rheumatoid arthritis may be better classified into four different types: spontaneous remitting disease,remitting,remitting
progressive,and progressive.
Spontaneous remission means that without treatment or just with NSAIDs,the symptoms of the disease dissapear. They may
return later,and you may need to start taking NSAIDs again,but for a while you have complete relief or almost. In rare cases,about
5 to 10 % of people with RA,the symptoms never return.
Remitting disease means that the person has a series of flare-ups with a return to normal in between. This can
be difficult to deal with,because it is not known when a remission is going to occur and when the symptoms will return. DMARDs
may be needed to prevent joint damage during the flare-ups
People suffering from remitting progressive disease experience flare-ups but never quite return to normal in between.
There is a good chance that the joints with this type of disease will be damaged without DMARD therapy.
The person with progressive disease never experiences remission or flare-ups,just a gradual increase in the pain,swelling,and
joint damage over time. Usually the progression is slow,but in some cases one can become disabled rather quickly.
New ACR guidelines recommended DMARD therapy to all RA patients upon diagnosis.
Approximately 15 % of cases of RA will "explode" over a matter of a few days. Although not all the joints that will eventually
cause trouble will be involved in the first attack,there will be quite a number-24 is typical. They will include both large
and small joints,and especially the MCPs and MTPs. Similar joints on both right and left sides will be involved. Morning stiffness
and fatigue will dominate.
About 75 % of the time,the picture is less spectacular. A wrist becomes swollen and for some time it's the only problem.
Or a patient develops marked tenderness under the balls of both feet (the MTP joints),particularily when first getting up
in the morning. Gradually,over several week to several months,more and more joints join the picture. Fatigue and morning stiffness
appear. It may take a year before a clear diagnosis is made.
In 10 % of cases,RA starts off much like gout. A single joint,such as a knee, wrist or shoulder,suddenly becomes very
painful,swollen and warm. Often the pain is so severe the joint is not useable. Two or three days later,its back to normal.
After a month or so,another attack strikes,usually in another joint. As time goes by,the attack becomes more frequent. Gradually
they are less and less severe but more and more frequent,and instead of clearing up,the swelling and pain start to persist.
One day,perhaps after a year or more,it becomes obvious that it is RA. This pattern is called palindromic rheumatism,and while
it doesn't always turn out to be RA,it more often does.
Very rarely,RA first appears in an ""extra-articular" (non-joint) site,with joint symptoms appearing months later. When
it does,it usually takes the form of chest complications,and the patient is usually male.
Factors that correlate with prognosis: More favorable factors; Onset at a younger age,absence of rheumatoid nodules (small
bumps over pressure points),absence of,or few,manifestations outside of joints,absence of rheumatoid factor in the blood and
perhaps male gender.
Less favourable prognosis : Rapid onset at a older age,high levels of rheumatoid factor,early in the disease,early involvement
of large joints,female,presence of rheumatoid nodules,early appearance of erosions in the joints,vasculitis (blood disorder
).manifestations outside of the joints,and scleritis. It was once though that the marker HLA-DR4 in the blood was a indicator
of severe disease,but some recent research suggests it may not be related to severe disease.It remains a debateable subject.
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