Rheumatoid Arthritis (RA)

Inflammatory and Immune System

Rheumatoid arthritis (RA) is an inflammatory autoimmune disease that can cause irreversible damage to the joints andconnective tissue. For reasons unknown, the immune system of a person with rheumatoid arthritis begins to attack the cells that line the joints of the body resulting in tissue damage and deformity. The damage to the joint tissues causing painful swelling and can be quite debilitating. Rheumatoid arthritis often affects the hands, wrists, and feet. However, in severe cases, other tissues in the body may be attacked by the immune system and cause problems in other organs (i.e., eyes, heart, and lungs). Women are two-to-three times more likely to be diagnosed with RA and your risk of getting RA increases with age. If the disease is caught early, the progression of the disease can be slowed down to prevent joint deformity and help to reduce pain and disability.

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Symptoms

If you have rheumatoid arthritis, you will notice that there are times when your symptoms get worse and then better. The times when your symptoms get worse are called flares. A remission is when you notice your symptoms have improved. The most common symptoms of RA are marked swelling, pain, and stiffness in more than one joint in the body. The aching pain and swelling may occur symmetrically or on both sides of the body, like in your hands or knees. Other symptoms of RA include:

  • Fatigue
  • Fever (low-grade)
  • Feeling unwell or tired
  • Soreness around joints and muscles
  • Poor appetite
  • Weight loss
  • Lumpy growths under the skin (i.e., elbows, hands, or feet)
  • Reduced ability to move joints
  • Redness or warmth over joints
  • Joint stiffness in the morning

Types

Doctors need to identify the type of rheumatoid arthritis you have before moving forward with treatment. There are only two and they are classified using a blood test.

Seropositive. The most common type of RA. Blood test results show the presence of an antibody known as anti-cyclic citrullinated peptide (anti-CCP) or anti-citrullinated protein antibody (ACPA). Anti-CCPs are the immune proteins that attack the joints and connective tissue and cause the disease. They can be detected several years before the symptoms appear.

Seronegative. Some people will have rheumatoid arthritis without the presence of Anti-CCPs. These cases are known as seronegative because they do not test positive for the anti-CCP and another antibody called rheumatoid factor. These patients need a diagnosis using other methods such as x-rays and scans that reveal bone and cartilage deterioration.

Risk Factors

  • Family history of rheumatoid arthritis
  • Smoking cigarettes
  • Sex – women 2-3 times more likely
  • Hormones (i.e., pregnancy hormones or oral contraceptives)
  • Age – risk increase with age
  • Childhood exposure to cigarette smoke

Diagnosis

Your healthcare provider willtake your medical history, including your family history, and give you a physical exam. Your doctor will closely examine your joints for signs of redness, swelling, and feel for tenderness. If your doctor is concerned you may have rheumatoid arthritis you may be referred to a rheumatologist (arthritis specialist) for further testing. Your rheumatologist will ask about your symptoms, especially the progression of pain and inflammation. Blood tests and diagnostic scans may follow and usually include:

Inflammatory marker tests. These blood testsdetect the presence ofinflammatory markers in the body and show the level of inflammation by looking for certain blood indicators. These include C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and tumor necrosis factor-alpha.

Rheumatoid factor test. This protein is present in 60-70% of people who have rheumatoid arthritis. It also occurs in people who have other chronic inflammatory diseases, like lupus.  Rheumatoid factor, or RF, found present in a blood test indicates that the RA is an aggressive type.

Anti-cyclic citrullinated peptide antibodies (ACPA) test. This test looks for the presence of antibodies that attack joints and connective tissues.

Imaging scans (x-rays, ultrasounds, magnetic resonance imaging). Detect erosion of cartilage and inflammation of joint tissues. Early stages of RA will not show damage and must be determined using blood tests.

Treatments

After a diagnosis of rheumatoid arthritis, you will work with your healthcare team to develop a treatment plan to manage your symptoms and slow the progression of the disease. There is no cure for RA. However, do not worry! There are several treatment methods that rheumatologists use to stop the damage to your joints. The earlier that the diagnosis is made the more effective the treatment and the less tissue damage occurs. In some cases, closely adhering to your treatment regimen will result in remission of symptoms. The following is a list of treatments available to you after diagnosis:

Pain-relieving medications. Non-steroidal anti-inflammatory drugs (NSAIDs) help to reduce pain and inflammation. If you are prescribed a strong NSAID, you will have reduced pain but may experience side effects, including upset stomach and gastrointestinal disturbances.

Corticosteroids. These slow the progression of the disease and stop the immune system from attacking joint tissues. Corticosteroids are given orally as pills or liquid or as an injection. Side effects of corticosteroids include weight gain, increased blood pressure, mood swings, and leg swelling. Long-term use of corticosteroids may cause serious and permanent side effects like diabetes, increased risk of infection, and calcium deficiency. For these reasons, corticosteroids are usually prescribed short-term.

Disease-modifying antirheumatic drugs (DMARDs). These are long-term medications that can slow or alter the progression of RA by inhibiting the ability of the immune system to attack tissues. They work to reduce pain and protect your joints from permanent damage. Serious side effects of DMARDs are liver damage and increased susceptibility to infections.

Biologic response modifiers. A type of DMARD medication. These drugs inhibit the T cells of the immune system that are responsible for attacking joint tissues and causing inflammation. Biologic response modifiers prevent joint damage, reduce the risk of further damage, and prevent infection.

Physical therapy. This type of therapy encourages you to incorporate low-impact exercises with the assistance of a physical therapist. You may find you have increased flexibility in your joints and increased strength after a physical therapy appointment.

Surgery. Rarely required. No surgery can restore the joints after the disease has progressed. However, in cases of severe joint damage, some surgical interventions may help to improve the quality of life of patients with RA. These include joint fusion, joint fusion, and tendon repair surgeries.

Alternative Treatments and Home Remedies

Many people suffering from rheumatoid arthritis will look to complementary and alternative medicine (CAM) to help them deal with the side effects of drug therapy and ease the pain and suffering. Make an appointment with your doctor to discuss these options if you are considering taking any herbal or vitamin supplement or trying an alternative treatment. Many supplements interact with medications and may be unsafe for you to take. Alternative treatments for RA include:

Omega-3 supplements. Has been shown in studies to have a beneficial effect on pain, stiffness in the morning, and tenderness in joints. Omega-3 polyunsaturated fatty acids (PUFAs) can be taken in fish oil supplements and is found in cold-water fish like salmon, mackerel, oysters, and chia seeds.

Turmeric, valerian, and ginger. These herbs have anti-inflammatory properties. Turmeric contains an active ingredient called curcumin that has been shown to reduce inflammation, swelling, and morning stiffness associated with rheumatoid arthritis. Valerian is a sleep aid that may help you relax and sleep better if you are having trouble sleeping. Ginger also has been shown to provide pain relief and improve discomfort in people with RA.

Acupuncture. May improve symptoms for those with rheumatoid arthritis. Acupuncture therapy is a painless procedure that uses very thin needles inserted into points on the body. Be sure to find a licensed practitioner.

Magnets. Using magnets for pain, this type of therapy has been shown to help patients with knee pain related to rheumatic arthritis.

Hydrotherapy. This form of therapy involves submersion in baths that usually contain mineral salts and herbal concentrations. Studies have shown that hydrotherapy helped improve grip strength and morning stiffness and may improve symptoms.

Essential oils. Lavender essential oil helps with relaxation. Eucalyptus and peppermint may provide pain relief. Diffuse in a vaporizer with a few drops or use a few drops in a carrier oil. Be sure to check for allergic reactions and make sure your product is from a safe and valid source.

Herbal tea. Drink herbal tea throughout the day to help relax you and provide hydration. Tea can be very soothing. Green tea, ginger tea, and turmeric blends all contain anti-inflammatory properties while providing comfort and warmth.

Biofeedback and meditation. Guided meditation and biofeedback can help move your thoughts away from focusing on the pain and relax your body.

Lifestyle Changes

  • Eat a healthy, well-balanced diet
  • Regular physical activity (walking, yoga, dancing, etc.)
  • Healthy stress management practices (i.e., breathing technique)
  • Actively play a role in your disease management
  • Participate in social support therapies
  • Be open with your healthcare providers

References

Aletaha, D. & Smolen, J. S. (2018, October 02). Diagnosis and management of rheumatoid arthritis: A review. JAMA, 320(13), 1360-1372. Retrieved from PubMed: https://pubmed.ncbi.nlm.nih.gov/30285183/

Boynes-Shuck, A. (2020, January 16). Top 10 alternative RA remedies: The natural ways I manage rheumatoid arthritis symptoms. Retrieved from Healthline: https://www.healthline.com/health/rheumatoid-arthritis/natural-ways-manage-ra

Centers for Disease Control and Prevention. (2020, July 27). Rheumatoid arthritis (RA). Retrieved from Centers for Disease Control and Prevention: https://www.cdc.gov/arthritis/basics/rheumatoid-arthritis.html#what-is

Duckworth, H. (2018, October 27). RA types: What distinguishes types of rheumatoid arthritis? Retrieved from RheumatoidArthritis: https://www.rheumatoidarthritis.org/ra/types/

Ezerioha, M. (2018, November 02). Treatment: What is the safest treatment for rheumatoid arthritis? Retrieved from RheumatoidArthritis: https://www.rheumatoidarthritis.org/treatment/

Gene-Siew, N. (2010, September). Rheumatoid arthritis. Australian Family Physician, 39(9), 626-628. Retrieved from Royal Australian College of General Practitioners: https://www.racgp.org.au/download/documents/AFP/2010/September/201009ngian.pdf

Haaz, S. (2008, December 19). Complementary and alternative medicine for patients with rheumatoid arthritis. Retrieved from Johns Hopkins Arthritis Center: https://www.hopkinsarthritis.org/patient-corner/disease-management/ra-complementary-alternative-medicine/

Wasserman, Amy M. (2011, December 1)). Diagnosis and management of rheumatoid arthritis. American Family Physician, 84(11), 1245-1252. Retrieved from American Academy of Family Physicians: https://www.aafp.org/afp/2011/1201/afp20111201p1245.pdf

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