Rheumatoid arthritis
Introduction
Rheumatoid arthritis is a condition which causes pain and swelling in the joints. Hands, feet and wrists are commonly affected, but it can also damage other parts of the body. Rheumatoid arthritis can make your joints feel stiff and can leave you feeling generally unwell and tired.
Who is affected?
Rheumatoid arthritis affects approximately 580,000 people in England and Wales and is more common in women than men. It is most common after the age of 40 and 70, but can affect people of any age.
Why does it happen?
Rheumatoid arthritis is an autoimmune disease. Your immune system, which usually fights infection, attacks the cells in the lining of your joints, causing them to become swollen, stiff and painful. Over time this can damage the joint itself, the cartilage and nearby bone.
The symptoms of rheumatoid arthritis usually vary over time. Sometimes, symptoms only cause mild discomfort, but at other times they can be very painful making it difficult to move around and get everyday tasks done. When symptoms become worse, this is usually known as a 'flare-up'. A flare-up is impossible to predict, making rheumatoid arthritis difficult to live with.
Outlook
At present, there is no known cure for rheumatoid arthritis. However, with early diagnosis and treatment can control symptoms and help prevent disability.
Currently, rheumatoid arthritis cannot be prevented as the exact trigger of the condition is unknown. Although viruses and bacteria may be involved, research is not yet conclusive.
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Symptoms
The symptoms of rheumatoid arthritis tend to develop gradually, with the first symptoms often being in small joints, such as your fingers and toes although shoulders and knees can be affected early, and muscle stiffness can be a prominent early feature.
Flare-ups
The symptoms of rheumatoid arthritis vary from person to person, and you will experience what are known as 'flare ups'. This means that from time to time, your condition will worsen and your symptoms will be more intense and severe. You can experience a flare-up at any time of the day or night. However, it is likely that your symptoms will be more painful in the morning, when you first wake up. Usually, your symptoms will begin to ease as the day progresses, as you start using and flexing your joints.
Symptoms
The symptoms of rheumatoid arthritis are outlined below.
Pain
This is usually a throbbing and aching sort of pain. It is usually worse in the mornings and after you have been sitting still for a while. Pain is often felt while you are resting, not after activity.
Stiffness
Joints affected by rheumatoid arthritis can feel stiff, especially in the morning. Morning stiffness associated with a kind of arthritis called osteoarthritis usually wears off within 30 minutes of getting up in the morning. However, rheumatoid arthritis morning stiffness usually lasts longer than half an hour.
Warmth and redness
The lining of the affected joint becomes inflamed, causing the joints to swell, become hot, tender to touch and painful.
Rheumatoid arthritis can also cause inflammation around the joints, such as rheumatoid nodules, and in other parts of your body. The condition can also cause inflammation of your tear glands, salivary glands, the lining of your heart and lungs, and your blood vessels.
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Causes
The exact cause of rheumatoid arthritis is unknown. We know how the condition attacks the joints, but it is not yet known what triggers the initial attack. Some ideas and theories have suggested that an infection, or a virus may trigger rheumatoid arthritis, but none of these theories have been proven.
Autoimmune condition
Rheumatoid arthritis is an autoimmune condition. This type of condition causes the body to attack its own tissues. Normally your immune system makes antibodies which attack bacteria and viruses, helping to protect your body against infection. If you have rheumatoid arthritis, your immune system sends antibodies to the lining of your joints, where instead of attacking harmful bacteria, they attack the tissue surrounding the joint.
Synovium
There is a membrane (thin layer of cells) that covers each of your joints. This membrane is known as the synovium. When antibodies attack the synovium, they leave it sore and inflamed. This inflammation causes chemicals to be released, which, over a several months, will cause the synovium to thicken. These chemicals can also damage bones, cartilage (the stretchy connective tissue between bones), tendons (tissue that connects bone to muscle) and ligaments (tissue that connects bone and cartilage). The chemicals gradually cause the joint to lose its shape and alignment and can eventually destroy the joint completely.
Genetic susceptibility
There is some evidence that rheumatoid arthritis can run in families. Your genes may therefore be one factor in the cause of the condition. However, having a family member with rheumatoid arthritis does not necessarily mean that you will inherit the condition. Even an identical twin of someone with rheumatoid arthritis, who shares all the same genetic material, would only have a one in five chance of developing the condition.
Hormones
Rheumatoid arthritis is twice as common in women than in men. This may be due to the effects of oestrogen (a female hormone). Research has suggested that oestrogen may be involved in the development and progression of the condition. However, this has not been conclusively proven.
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Diagnosis
Rheumatoid arthritis can be difficult to diagnose because there are very many conditions that causes joint stiffness and inflammation. Your GP will conduct a physical examination, checking your joints to see if they are swollen and to find out how easily they move. Your GP will also ask you about your symptoms. It is very important that you tell your GP about all of your symptoms, not just the ones you think are important. This will help your GP to make the correct diagnosis.
If your GP thinks you have rheumatoid arthritis, they will refer you to a specialist (rheumatologist).
After conducting a physical examination, and consulting your medical history, your GP may refer you for a series of tests to help confirm the diagnosis. Tests that you may have are outlined below.
Blood Tests
There is no definitive blood test which can diagnose rheumatoid arthritis. However, there are a number of tests that can indicate to your GP that you may have developed the condition, but they will not necessarily prove, or completely confirm a diagnosis. If you have persistent joint inflammation, you will need to see a rheumatologist.
Erythrocyte sedimentation rate (ESR)
In an ESR test, a sample of your red blood cells are placed into a test tube of liquid. They are then timed to see how fast they fall to the bottom of the tube in millimetres per hour. If they are sinking faster than usual, this could mean that you have an inflammatory condition, such as rheumatoid arthritis.
C-reactive protein (CRP)
CRP is another type of test that can indicate if there is inflammation anywhere in the blood. It checks to see how much CRP is present in your blood. CRP is produced by the liver. If there is more CRP than usual, there is inflammation in your body.
Full blood count
The full blood count will measure your red cells to rule out anaemia. Anaemia is a condition where the blood is unable to carry enough oxygen due to a lack of blood cells. Eight out of ten people with rheumatoid arthritis have anaemia. However, anaemia can be the result of many factors, such as a lack of iron in your diet. Therefore, having anaemia does not necessarily prove that you have rheumatoid arthritis.
Rheumatoid factor
This blood test checks to see if a specific antibody, known as the rheumatoid factor, is present in your blood. This abnormal antibody is present in eight out of ten people with rheumatoid arthritis. However, this antibody cannot always be detected in the early stages of the condition. The antibody is also found in one out of twenty people without rheumatoid arthritis, so again this test cannot definitively confirm rheumatoid arthritis. If it is negative, another antibody test (for anti-CCP) may be done, which is more specific for the disease.
Joint imaging
X-rays of your joints can help your doctor differentiate between different types of arthritis. A series of X-rays can also help show how your condition is progressing. A chest X-ray may also be taken as both the disease and certain treatments (such as methotrexate) can affect the chest.
Musculoskeletal ultrasound may be used in the clinic to confirm the presence, distribution and severity of inflammation and joint damage.
Magnetic resonance imaging (MRI) scans can help show what damage has been done to a joint.
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Treatment
What is good rheumatoid arthritis care?
The aim of rheumatoid arthritis treatment is to reduce inflammation in the joints, relieve pain, prevent or slow joint damage, reduce disability and provide support to help you live as active a life as possible. There is good evidence that early treatment and support can reduce joint damage and limit the impact of rheumatoid arthritis. Lifestyle changes, drug and non-drug treatments and surgery can all help reduce the negative effects of rheumatoid arthritis.
ARMA recommends that if you have rheumatoid arthritis-type symptoms, you should see a rheumatology specialist within 12 weeks of referral from your GP to confirm a diagnosis of rheumatoid arthritis.
Also, the National Institute for Health and Clinical Excellence (NICE) has produced guidance for the management of rheumatoid arthritis.
Medication
Many different medicines are used to treat rheumatoid arthritis. Some aim to relieve symptoms and others help slow the progression of the condition. Everyone experiences rheumatoid arthritis differently, so it may take time to find the best combination of medicines for your needs. Some of the different medicines that you may be prescribed are outlined below.
Painkillers
Painkillers reduce pain rather than inflammation and are used to control the symptoms of rheumatoid arthritis. The most commonly prescribed painkiller is paracetamol. Codeine is another painkiller that is sometimes prescribed as a combined medicine with paracetamol (known as co-codamol).
Non-steroidal anti-inflammatory drugs (NSAIDs)
Your GP may prescribe a nonsteroidal anti-inflammatory drug (NSAID) to relieve pain and swelling in your joints. There are two types of NSAIDs and they work in slightly different ways. These are traditional NSAIDs, such as ibuprofen, naproxen or diclofenac, and COX-2 inhibitors (often called coxibs), such as celecoxib or etoricoxib. NSAIDs help relieve pain and stiffness while also reducing inflammation. However, they will not slow down the progression of rheumatoid arthritis.
Your doctor will discuss with you what type of NSAID you should take and the benefits and risks associated with each of them. NSAID tablets may not be suitable if you have asthma, a peptic ulcer, angina or if you have had a heart attack or stroke. If you are taking low-dose aspirin, discuss with your GP whether you should use an NSAID.
Taking an NSAID tablet can increase the risk of serious stomach problems, such as bleeding internally. Taking an NSAID can break down the lining that protects against damage from acids in the stomach. While the risk is serious, it is not common. According to research, if between 2,000 and 3,000 people take NSAIDs, one person is likely to have a stomach bleed. The COX-2 agents have a lower risk of serious stomach problems, but carry a risk of heart attacks and strokes.
If you are prescribed an NSAID tablet, you will almost certainly have to take another medicine, such as a proton pump inhibitor (PPI), as well. Taking a PPI reduces the amount of acid in your stomach, which greatly reduces the risk of damage to your stomach lining caused by the NSAID.
Corticosteroids
Corticosteroids help reduce pain, stiffness and swelling. They can be used as a tablet (for example, prednisolone) or an injection into the muscle (to help lots of joints). They are usually used when NSAIDs fail to provide relief. If you have a single inflamed or swollen joint, your doctor may inject the steroid into the joint. Relief is rapid and the effect can last from a few weeks to several months, depending on the severity of your condition.
Corticosteroids are usually only used on a short-term basis, as long-term use of corticosteroids can have serious side effects. These can include weight gain, osteoporosis (thinning of the bones), easy bruising, muscle weakness and thinning of the skin. They can also make diabetes and glaucoma, an eye disease, worse.
Disease-modifying anti-rheumatic drugs (DMARDs)
DMARDs help to ease symptoms and slow down the progression of rheumatoid arthritis. When antibodies attack the tissue in the joints, they produce chemicals that can cause further damage to the bones, tendons, ligaments and cartilage. DMARDs work by blocking the effects of these chemicals. The earlier you start taking a DMARD, the more effective it will be.
There are many different conventional DMARDs including methotrexate, gold, leflunomide, hydroxychloroquine and sulfasalazine.
Methotrexate is often the first drug given for rheumatoid arthritis. You may take it in combination with another DMARD. The most common side effects of methotrexate are sickness, diarrhoea, mouth ulcers, hair loss or hair thinning, and rashes on the skin. Sometimes, methotrexate can have an effect on your blood count and your liver, and you will have regular blood tests to monitor this. Less commonly, it can affect the lungs, so you will usually have a chest X-ray and possibly breathing tests when you start taking methotrexate, to provide a comparison if you develop shortness of breath or a persistent dry cough while taking it. However, most people tolerate methotrexate well and around half those who start it will still be taking it five years later.
Methotrexate may also be combined with biological treatments (see below).
It can take four to six months to notice a DMARD working. Therefore, it is important to keep taking the medication, even if you do not notice it working at first. You may have to try two or three types of DMARD before you find the one that is most suitable for you. Once you and your doctor work out the most suitable DMARD, you will usually have to take the medicine in the long term.
Biological treatments
Biological treatments are a newer form of treatment for rheumatoid arthritis. They include TNF-alpha inhibitors (etanercept, infliximab, adalimumab and certolizumab), rituximab and tocilizumab.
They are usually taken in combination with methotrexate or sometimes with another DMARD. They work by stopping particular chemicals in the blood from activating your immune system to attack the lining of your joints.
Biological treatments are not suitable for use by everyone.
TNF-alpha inhibitors are usually only available on the NHS if you have already tried methotrexate and another DMARD at standard doses and your rheumatoid arthritis is still quite active.
Rituximab and tocilizumab are recommended by NICE, in combination with methotrexate, for severe rheumatoid arthritis only if you've tried DMARDs and one of the TNF inhibitors and still have quite active rheumatoid arthritis.
Side effects from biological treatments are usually mild and include skin reactions at the site of injection, infections, nausea, fever and headaches. Some people may be at risk of getting more serious problems, including people who have had tuberculosis (TB), septicaemia and hepatitis B in the past. There is a slight risk that biological treatments can reactivate these conditions and, in rare cases, trigger new autoimmune problems.
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Complications
Having rheumatoid arthritis can put you at a higher risk of developing other conditions, such as those outlined below.
- Carpel tunnel syndrome - this is a common condition in people with rheumatoid arthritis. Carpel tunnel syndrome is when there is too much pressure on the nerve in the wrist. It can cause aching, numbness and tingling in your thumb, fingers and, sometimes, part of the hand.
- Inflammation - because rheumatoid arthritis is an inflammatory condition, it can sometimes cause inflammation to develop in other parts of your body, such as your lungs, heart, blood vessels, or eyes.
- Tendon rupture - tendons are pieces of flexible tissue that attach muscle to bone. Rheumatoid arthritis can cause your tendons to be become inflamed which, in severe cases, can cause them to rupture. This most commonly affects the tendons on the backs of the fingers.
- Cervical myelopathy - if you have had rheumatoid arthritis for some time, you are at increased risk of developing cervical myelopathy. This condition is caused by dislocation of joints at the top of the spine which put pressure on the spinal cord. Although relatively uncommon, it is a serious condition which can greatly affect your mobility.
- Vasculitis - this is a condition that causes inflammation of the blood vessels. It can lead to the thickening, weakening, narrowing and scarring of blood vessel walls. In serious cases, it can affect blood flow to your body's organs and tissues. People with rheumatoid arthritis are more at risk of getting infections, such as colds, flu and pneumonia, particularly if they are taking powerful anti-rheumatic medicines that suppress the immune system.
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Living with
Rheumatoid arthritis can be life changing. You may need long-term treatment to control your symptoms and reduce joint damage. Depending on how much pain and stiffness you feel and how much joint damage you have, you may have to adapt the way you do simple daily tasks. They can become difficult or take a little longer to complete.
Self care
Self care is an integral part of daily life. It involves taking responsibility for your own health and wellbeing with support from the people involved in your care. Self care includes the things you do each day to stay fit, maintain good physical and mental health, prevent illness or accidents, and effectively deal with minor ailments and long-term conditions. People living with long-term conditions can benefit enormously if they receive support for self care. They can live longer, have less pain, anxiety, depression and fatigue, have a better quality of life and are more active and independent.
Take your medication
It is important to take your medication as prescribed, even if you start to feel better. Continuous medication can help prevent flare-ups. If you have any questions or concerns about the medication you are taking or side effects, talk to your healthcare team.
It may also be useful to read the information leaflet that comes with the medication about possible interactions with other drugs or supplements. Check with your healthcare team before taking any over-the-counter remedies, such as painkillers, or any nutritional supplements. These can sometimes interfere with your medication.
Regular reviews
Because rheumatoid arthritis is a long-term condition, you will be in contact with your healthcare team regularly. The more the team knows, the more they can help you, so discuss your symptoms or any concerns with them.
Keeping well
Everyone with a long-term condition, such as rheumatoid arthritis, is encouraged to get a yearly flu jab each autumn to protect against flu. They are also recommended to get an anti-pneumoccocal vaccination. This is a one-off injection that protects against a serious chest infection called pneumococcal pneumonia.
Get plenty of rest during a flare-up as this is when your joints can be particularly painful and inflamed. Putting further strain on very swollen and painful joints can often make pain and inflammation worse.
Healthy eating and exercise
Regular exercise and a healthy diet are recommended for everyone, not just people with rheumatoid arthritis. They can help prevent many conditions, including heart disease and many forms of cancer.
Exercising regularly can help relieve stress and reduce fatigue. A gentle form of exercise that does not put too much strain on your joints is best. Swimming, for example, helps exercise your muscles but puts very little strain on your joints because the water supports your weight.
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