Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.

Rheumatoid Arthritis

(RA; Arthritis, Rheumatoid)
by Editorial Staff and Contributors
Definition

Rheumatoid arthritis (RA) is an autoimmune disease. It causes pain, swelling, stiffness, and loss of function in the joints. RA usually affects the same joint on both sides of the body. It occurs mostly in the:

  • Elbows
  • Fingers
  • Hips
  • Jaw
  • Knees
  • Shoulders
  • Toes
  • Wrists
Causes

RA is caused by a combination of genetic and environmental factors that trigger an abnormal immune response. Possible causes:

  • Defects in the immune system can cause ongoing inflammation.
  • Environmental factors—Certain infectious agents, such as some viruses or bacteria, may increase susceptibility to RA.
  • Genetic factors—Certain genes that play a role in the immune system are associated with RA development.
  • Other factors—Some evidence suggests that hormonal factors may promote RA development in combination with genetic factors and environmental exposure.
Risk Factors

These factors increase your chance of developing RA. Tell your doctor if you have any of these risk factors:

  • Heavy or long-term smoking
  • Ethnic background: Pima Indians
  • Family members with RA
  • Sex: female
Symptoms

When RA begins, symptoms may include:

  • Joint pain and stiffness that is:
    • Lasts for at least half an hour
    • Most prominent in the morning
    • Symmetrical
  • Joint deformity
  • Loss of appetite
  • Mild fever, tiredness
  • Red, warm, or swollen joints
  • Small lumps or nodules under the skin

As RA progresses, it may cause complications with the:

  • Blood
  • Blood vessels
  • Eyes
  • Heart
  • Kidneys
  • Liver
  • Lungs
  • Nervous system
  • Skin

It is also linked to early cardiovascular disease and death.

Diagnosis

There is no single test for RA. The doctor will ask about your symptoms and medical history. She will examine your joints, skin, reflexes, and muscle strength.

Tests:

  • C-reactive protein (CRP) —an indicator of active inflammation in the blood
  • Erythrocyte sedimentation rate (ESR) of the blood—to measure inflammation in the body
  • Rheumatoid factor (RF) level in the blood
  • White blood cell count
  • X-rays of affected joints (especially dual energy x-ray absorptiometry )—a test that uses radiation to take a picture of structures inside the body, especially bones
Treatment

There is no cure for RA. The goals of treatment are to:

  • Improve functional ability
  • Reduce inflammation
  • Relieve pain
  • Slow down joint damage
Medications

There are a variety of medicines to treat the pain and inflammation of RA. In some cases, medicines may be used in combination.

  • Biologic response modifiers—drugs that interfere with the autoimmune response; includes TNF-inhibitors, such as:
    • Adalimumab (eg, Humira)
    • Certolizumab (eg, Cimzia)
    • Etanercept (eg, Enbrel)
    • Golimumab (eg, Simponi)
    • Infliximab (eg, Remicade)
  • Disease-modifying anti-rheumatic drugs (DMARDS)—to slow the course of the disease; used early in the course of the disease to prevent long-term damage:
    • Cyclosporine (eg, Neoral)
    • Gold (eg, Ridaura)
    • Hydroxychloroquine (eg, Plaquenil)
    • Leflunomide (eg, Arava)
    • Methotrexate (eg, Rheumatrex)
    • Minocycline (eg, Minocin)
    • Penicillamine (eg, Cuprimine)
    • Sulfasalazine (eg, Azulfidine)
  • Immunosuppressive drugs (only used when other DMARDS are ineffective):
    • Azathioprine (eg, Imuran)
    • Chlorambucil (eg, Leukeran)—rarely used
    • Cyclophosphamide (eg, Cytoxan)—rarely used
  • Over-the-counter medicines:
    • Nonsteroidal anti-inflammatory drugs (NSAIDs) including ibuprofen and naproxen
    • Acetaminophen (eg, Tylenol)
Steroids

Low-dose corticosteroids (eg, prednisone ) are often used first. They may be tapered when other drugs start working. Avoid long-term steroid use. Corticosteroid injections to inflamed joints may also be used.

Rest and Exercise

Rest reduces active joint inflammation and pain and fights fatigue. Exercise is important for maintaining muscle strength and flexibility. It also preserves joint mobility.

Joint Care

Splints applied to painful joints may reduce pain and swelling. Devices that help with daily activities can also reduce stress on joints. Devices include:

  • Long-handled shoehorns
  • Specially designed kitchen tools
  • Zipper extenders
Stress Reduction

Stress reduction can ease the difficulties of living with a chronic, painful disease. Participating in an exercise program or joining a support group are two strategies you can use to reduce stress. Cognitive behavioral therapy , a form of talk therapy, and meditation may also offer benefits in reducing your pain and improving your ability to cope with RA.

Surgery

Joint replacement and tendon reconstruction help relieve severe joint damage.

Lifestyle Measures

These may relieve stiffness and weakness and reduce inflammation:

  • If you smoke, quit .
  • Attempt mild strength training.
  • Avoid heavy impact exercise.
  • Control weight.
  • Maintain a balance between rest and exercise.
  • Participate in a physical therapy program.
  • Participate in aerobic exercise (eg, walking, swimming, dancing).
Prevention

There are no guidelines for preventing RA.

Last reviewed: October 2009 by Jill D. Landis, MD.

RESOURCES:
CANADIAN RESOURCES:
References:
  • Rheumatoid arthritis. National Institute of Arthritis and Musculoskeletal and Skin Disorders website. Available at: http://www.niams.nih.gov/Health_Info/Rheumatic_Disease/default.asp . Published January 1998. Updated May 2004. Accessed June 18, 2008.
  • Tanaka E, Saito A, Kamitsuji S, et al. Impact of shoulder, elbow, and knee joint involvement on assessment of rheumatoid arthritis using the American College of Rheumatology Core Data Set. Arthritis Rheum . 2005;53:864-871.
  • Verstappen SM, Bijlsma JW, Verkleij H, et al. Overview of work disability in rheumatoid arthritis patients as observed in cross-sectional and longitudinal surveys. Arthritis Rheum . 2004;51:488-497.
  • 4/16/2009 DynaMed's Systematic Literature Surveillance http://www.ebscohost.com/dynamed/what.php : Zautra AJ, Davis MC, Reich JW, et al. Comparison of cognitive behavioral and mindfulness meditation interventions on adaptation to rheumatoid arthritis for patients with and without history of recurrent depression. J Consult Clin Psychol. 2008;76:408-421.
  • 11/4/2009 DynaMed Systematic Literature Surveillance DynaMed's Systematic Literature Surveillance : Tumor necrosis factor (TNF) blockers (marketed as Remicade, Enbrel, Humira, Cimzia, and Simponi). US Food and Drug Administration website. Available at: http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm175843.htm . Updated August 31, 2009. Accessed November 4, 2009.
  • 12/31/2009 DynaMed's Systematic Literature Surveillance http://www.ebscohost.com/dynamed/what.php: Anis A, Zhang W, Emery P, et al. The effect of etanercept on work productivity in patients with early active rheumatoid arthritis: results from the COMET study. Rheumatology (Oxford). 2009;48:1283-1289.