DEFINITIONS:

inflammation – redness, swelling, and fever in any part of the body, often with pain

arthritis – inflammation of a joint, usually accompanied by pain, swelling, and stiffness

chronic – lasting for prolong period of time

immune system –  complex network of cells, cell products, and tissues that protects the body from infections, destroys infected and malignant cells, and removes damaged or dead cells

anti-CCP antibodies – new test that if positive confirms the diagnosis of rheumatoid arthritis

ANA – antinuclear antibodies

ENA– extractable nuclear antibodies (include anti-SSA, -SSB, -Sm, -Scl-70, -Jo-1, -RNP)

ds-DNA – double-stranded DNA antibodies

erosive – damaged

 RHEUMATOID ARTHRITIS:

Rheumatoid arthritis (RA) is a condition that presents with the pain and swelling of the joints. In more complex words it involves the painful swelling of the inside lining of the joints, called synovium. Left untreated it can cause damage and destruction of the joint. It affects 0.5-1% of the population.

CAUSES:

There are different factors that can cause rheuamtoid arthritis. The important factors are genetic predisposition (presence of a combination of genes), gender and some environmental triggers.

For first degree relatives of patients with rheumatoid arthritis, the risk is increased by a factor 2 to 5.

It is more common in women. The disease is 2 to 3 times as common among women as it is among men. The effect of the estrogen on immune function probably play a part in the  female predominance.

Smoking can cause local inflammation in the lungs. It can trigger the production of the antibodies that activate the immune system and initiate inflammation in the joints.

Several infectious agents proposed as contributing agents such as viruses, oral or gut species. Although the single infectious agent that accounts for all patients is unlikely to be causal.

Additional factors that marginally increase the risk of rheumatoid arthrirtis  including obesity, low vitamin D and use of oral contraceptives.

Factors that decrease the risk of rheumatoid arthritis include a Mediterranean diet, n-3 fatty acid intake, and fish oil supplementation.

PRESENTATION:

In most people, rheumatoid arthritis begins gradually, and weeks or months can pass before  person seeks medical care. Early symptoms may include fatigue, muscle pain, low-grade fever, weight loss, and tingling in the hands. Joint symptoms include pain, stiffness (usually in the  morning or after prolong rest), redness, warmth, and swelling.

Rheumatoid arthritis can affect any joints but typically affects small joints, especially the joints at the base of the fingers (MCPs), the joints in the middle of the fingers (PIPs), and the joints at the base of the toes (MTPs). It may also begin in a single, large joint or it may come and go and move from one joint to another.

Joints commonly affected by RA:

• MCP 90-95%
• wrists 80-90%
• PIP 65-90%
• knee 60-80%
• MTP 50-90%
• ankle 50-80%
• cervical spine 40-50%
• hip 40-50%
• elbow 40-50%
• TMJ 20-30%

Some people with rheumatoid arthritis develop carpal tunnel syndrome because swelling compresses a nerve that runs through the wrist; this syndrome is characterized by weakness, tingling, and numbness of the hand.

The pictures on this page show typical rheumatoid deformities but they are less common now with the initiation of early treatment.

Characteristic deformities of  long-standing RA:

• ulnar deviation of fingers
• Swan-neck deformity
• Boutonniere deformity
• piano key deformity

Rheumatoid nodules are painless lumps that appear beneath the skin. They most often occur on the forearm and on the elbow, but they can also occur on other pressure points, including the back of the head, the Achilles tendon, and the tendons of the hand.

Rheumatoid arthritis can produce other symptoms but they are not common now with the current approach of early initiation of treatment as soon as a diagnosed is established. Outside of the joints it can present as:

• fever, fatigue, weight loss
• rheumatoid nodules
• inflammation of the eyes with visual changes, or pain and redness
• shortness of breath, cough with lung inflammation
• tingling and numbness with nerve involvement
• dryness in the eyes

RA is diagnosed based on the presentation, blood tests and changes on the XRs and ultrasound of the joints.

Blood work abnormalities are helpful to make a diagnosis. Some of the tests (low hemoglobin or high markers of inflammation, so called ESR and CRP) point to the presence and severity of the disease.

There are two blood tests, so called rheumatoid factor RF and anti-CCP antibodies, that can help to confirm the diagnosis of rheumatoid arthritis. Anti-CCP test is the new test and  if positive can be seen almost only in rheumatoid arthritis. Anti-CCP test is positive in approximately 70% of patients with rheumatoid arthritis.

Patient with rheumaoid arthritis can have negative RF and anti-CCP test. This type of rheumatoid arthritis is called seronegative rheumatoid arthritis as spposed to seropositive rheumatoid arthritis when both or one of RF or anti-CCP tests are positive.

Rheumatoid factor can be positive while tested in other conditions or with age.

Sometimes, patients with rheumatoid arthritis are positive for tests of other connective tissue diseases such as ANA, anti-dsDNA or ENA. If rheumatoid arthritis patients have dryness in the mouth and in the eyes they can have  positivity to anti-SSA and anti-SSB antibodies.

Your rheumatologist would perform radiograms or joint ultrasound to make sure that you have not developed a damage to your joints. Often radiographs have to be repeated every 1 or 2 years to make sure that the treatment is adequate.

Some factors may indicate less favourable prognosis:

• presence and higher levels of antibodies (RF and anti-CCP antibodies)
• higher levels of markers of inflammation (ESR, CRP)
• many swollen joints
• presence of erosions on the XRs in the early stage
• both smoking and positivity to the  anti-CCP test

COURSE AND TREATMENT:

Rheumatoid arthritis has a variable course: it can presents with very rare flare ups, fluctuate, or worsen steadily. In most people with rheumatoid arthritis, the severity of symptoms fluctuates for weeks or months. It is impossible to predict how arthritis will behave. It is noticed although that patients who have positive anti-CCP test might be prone to more severe disease. The presence of those antibodies and smoking is considered as a negative factor as well.

Treatment with drugs, especially when started early, is effective in reducing symptoms, preventing damage, and improving the quality of life. In a minority, the disease may remit completely, although remission is rare without continuing taking medications. In some people, rheumatoid arthritis may be resistant to the treatment.  The increasing number of drugs available makes it possible to control it.

Remission in pregnancy is common, although more than 90% of women have a flare of arthritis symptoms within 3-4 months after childbirth.

Rheumatoid arthritis is treated with so called DMARDs, disease modifying anti-rheumatic drugs (look under “Medications”).  Most commonly used drugs are methotrexate, leflunomide, sulfasalazine and hydroxychloroquine (plaquenil). Often, those medications are used together. The are also so called biologic DMARDs and JAK inhibitors.  They  can be used when regular drugs are failed or contraindicated.

COMPLICATIONS:

Rheumatoid arthritis promote systemic inflammation that affects many organ systems and results in complications and coexisting conditions.

Altered lipid metabolism and some inflmmatory factors contribute to atherosclerosis, heart attack adn stroke. Occasionally lungs can be affected. Rheumaoid nodules and so called vasculitis are seen rarely with the current treatments.

Patient may developed depression and altered coping mechanisms. Some patients may have fatigue due to pain and sleep disturbance.

Chronic inflammation can increase a risk of fractures (osteoporosis).

These complications and coexisting conditions may result in functional deterioration over time. Susceptibility to infections is increased in poatient with rheuamtoid arthritis secondary to decreased defence mechanisms and use of medicaitons. Therefore it is very important to get vaccinated for flu and shingles. Regular exercises and being outside may train your immune system to resist infections.

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