Diseases & Conditions

Rheumatoid arthritis

Rheumatoid arthritis is an inflammatory form of arthritis that causes joint pain and damage. Rheumatoid arthritis attacks the lining of your joints (synovium) causing swelling that can result in aching and throbbing and eventually deformity. Sometimes rheumatoid arthritis symptoms make even the simplest activities — such as opening a jar or taking a walk — difficult to manage.

Rheumatoid arthritis is two to three times more common in women than in men and generally occurs between the ages of 40 and 60. But rheumatoid arthritis can also affect young children and older adults.

There's no cure for rheumatoid arthritis. With proper treatment, a strategy for joint protection and changes in lifestyle, you can live a long, productive life with rheumatoid arthritis.

Signs and symptoms of rheumatoid arthritis may include:

• Joint pain
• Joint swelling
• Joints that are tender to the touch
• Red and puffy hands
• Firm bumps of tissue under the skin on your arms (rheumatoid nodules)
• Fatigue
• Morning stiffness that lasts at least 30 minutes
• Fever
• Weight loss

Signs and symptoms appear in smaller joints first
Rheumatoid arthritis usually causes problems in several joints at the same time. Early rheumatoid arthritis tends to affect your smaller joints first — the joints in your wrists, hands, ankles and feet. As the disease progresses, your shoulders, elbows, knees, hips, jaw and neck can also become involved.

Signs and symptoms of a rheumatoid arthritis flare
Rheumatoid arthritis signs and symptoms may vary in severity and may even come and go. Periods of increased disease activity — called flare-ups or flares — alternate with periods of relative remission, during which the swelling, pain, difficulty sleeping, and weakness fade or disappear.

Rheumatoid arthritis occurs when white blood cells — whose usual job is to attack unwanted invaders, such as bacteria and viruses — move from your bloodstream into the membranes that surround your joints (synovium). The blood cells appear to play a role in causing the synovium to become inflamed. The inflammation causes the release of proteins that, over months or years, cause the synovium to thicken. The proteins can also damage the cartilage, bone, tendons and ligaments near your joint. Gradually, the joint loses its shape and alignment. Eventually, it may be destroyed.

Doctors don't know what causes this process that leads to rheumatoid arthritis. It's likely that rheumatoid arthritis occurs as a result of a complex combination of factors, including your genes, your lifestyle choices, such as smoking, and things in your environment, such as viruses.

Make an appointment with your doctor if you have persistent discomfort and swelling in multiple joints on both sides of your body.

If you've already been diagnosed with rheumatoid arthritis, contact your doctor if you experience side effects from your rheumatoid arthritis medications. Side effects may include nausea, abdominal discomfort, black or tarry stools, changes in bowel habits, constipation, and drowsiness.

Rheumatoid arthritis causes joint damage that can be both debilitating and disfiguring. Damage to your joints may make it difficult or impossible to go about your daily activities. You may find at first that tasks take more energy to accomplish. With time you may find you are no longer able to do them at all. Newer treatments may stop joint damage or prevent it so you can continue the activities you enjoy.

There is no cure for rheumatoid arthritis. Treatment for rheumatoid arthritis aims to reduce inflammation in your joints in order to relieve pain and prevent or slow joint damage. Early and aggressive rheumatoid arthritis treatments may slow joint damage and help reduce the risk of disability. Treatment typically involves medications, though surgery may be necessary in cases of severe joint damage.

Medications
Rheumatoid arthritis medications can relieve pain and slow or halt the progression of joint damage. Medications used to treat rheumatoid arthritis include:

• NSAIDs. Nonsteroidal anti-inflammatory drugs (NSAIDs) can relieve pain and reduce inflammation. Over-the-counter NSAIDs include ibuprofen (Advil, Motrin, others) and naproxen sodium (Aleve). Stronger versions of these NSAIDs and others are available by prescription. NSAIDs have risks of side effects that increase when used at high dosages for long-term treatment. Side effects may include ringing in your ears, gastric ulcers, heart problems, stomach bleeding, and liver and kidney damage. Consuming alcohol or taking corticosteroids while using NSAIDs also increases your risk of gastrointestinal bleeding.
• Steroids. Corticosteroid medications, such as prednisone and methylprednisolone (Medrol), reduce inflammation and pain, and slow joint damage. In the short term, corticosteroids can make you feel dramatically better. But when used for many months or years, they may become less effective and cause serious side effects. Side effects may include easy bruising, thinning of bones, cataracts, weight gain, a round face and diabetes. Doctors often prescribe a corticosteroid to relieve acute symptoms, with the goal of gradually tapering off the medication.
• Disease-modifying antirheumatic drugs (DMARDs). Doctors prescribe DMARDs to limit the amount of joint damage that occurs in rheumatoid arthritis. These drugs are typically used in the early stages of rheumatoid arthritis in an effort to slow the disease and save the joints and other tissues from permanent damage. You may need to take DMARDs for weeks or months before you notice any benefit. For that reason, they may be combined with other medications that give you more immediate relief from signs and symptoms, such as NSAIDs or corticosteroids. Common DMARDs include hydroxychloroquine (Plaquenil), the gold compound auranofin (Ridaura), sulfasalazine (Azulfidine), minocycline (Dynacin, Minocin) and methotrexate (Rheumatrex).
• Immunosuppressants. These medications act to tame your immune system, which is out of control in rheumatoid arthritis. In addition, some of these drugs attack and eliminate cells that are associated with the disease. Some of the commonly used immunosuppressants include leflunomide (Arava), azathioprine (Imuran), cyclosporine (Neoral, Sandimmune) and cyclophosphamide (Cytoxan). These medications can have potentially serious side effects such as increased susceptibility to infection.
• TNF-alpha inhibitors. TNF-alpha is a cytokine, or cell protein, that acts as an inflammatory agent in rheumatoid arthritis. TNF inhibitors target or block this cytokine and can help reduce pain, morning stiffness, and tender or swollen joints — usually within one or two weeks after treatment begins. There is evidence that TNF inhibitors may stop progression of disease. These medications often are taken with methotrexate. TNF inhibitors approved for treatment of rheumatoid arthritis are etanercept (Enbrel), infliximab (Remicade) and adalimumab (Humira). Potential side effects include injection site irritation (adalimumab and etanercept), worsening congestive heart failure (infliximab), blood disorders, lymphoma, demyelinating diseases, and increased risk of infection, including serious infection leading to death if treatment is delayed. Infections due to tuberculosis and certain types of invasive fungi, such as histoplasmosis, coccidioidomycosis and blastomycosis, have been associated with the use of TNF-alpha inhibitors. If you have an active infection, don't take these medications.
• Anakinra (Kineret). Anakinra is similar to a naturally occurring chemical in your body — interleukin-1 receptor antagonist (IL-1Ra) — that stops a certain chemical signal from causing inflammation. You might consider anakinra if you have moderate to severe rheumatoid arthritis and haven't been helped by conventional DMARD therapy. Anakinra is given as a daily self-administered injection under the skin, and is sometimes combined with methotrexate. Potential side effects include injection site reactions, decreased white blood cell counts, headache and an increase in upper respiratory infections. There may be a slightly higher rate of respiratory infections in people who have asthma or chronic obstructive pulmonary disease. If you have an active infection, don't use anakinra.
• Abatacept (Orencia). Abatacept reduces the inflammation and joint damage caused by rheumatoid arthritis by inactivating T cells — a type of white blood cell. People who haven't been helped by TNF-alpha inhibitors might consider abatacept, which is administered monthly through a vein in your arm (intravenously). Side effects may include headache, nausea and mild infections, such as upper respiratory tract infections. Serious infections, such as pneumonia, can occur.
• Rituximab (Rituxan). Rituximab reduces the number of B cells in your body. B cells are involved in inflammation. People who haven't found relief using TNF inhibitors might consider using rituximab, which is usually given along with methotrexate. Rituximab is administered as an infusion into a vein in your arm. Side effects include flu-like signs and symptoms, such as fever, chills and nausea. Some people experience extreme reactions to the infusion, such as difficulty breathing and heart problems. Ritixumab has been linked to a fatal brain infection in one person with rheumatoid arthritis.

What medications you can consider will depend on the severity of your rheumatoid arthritis, the length of time that you've been experiencing signs and symptoms, results from blood tests and X-rays, your overall physical function, and other medical problems you have. Doctors use these factors to determine the duration of your disease, its severity and your prognosis, which help to develop a treatment plan.

In 2008, the American College of Rheumatology (ACR) updated its recommendations for selecting certain rheumatoid arthritis medications. The ACR recommends hydroxychloroquine or minocycline for people with mild rheumatoid arthritis that has been present for less than two years, sulfasalazine for all levels of disease severity in people without a poor prognosis, and methotrexate or leflunomide for all levels of disease severity with or without a poor prognosis. For people with more severe rheumatoid arthritis, the ACR recommends combinations of DMARDs or a TNF-alpha inhibitor.

Surgery
If medications fail to prevent or slow joint damage, you and your doctor may consider surgery to repair damaged joints. Surgery may help restore your ability to use your joint. It can also reduce pain and correct deformities. Rheumatoid arthritis surgery may involve one or more of the following procedures:

• Total joint replacement (arthroplasty). During joint replacement surgery, your surgeon removes the damaged parts of your joint and inserts a metal and plastic prosthesis.
• Tendon repair. Inflammation and joint damage may cause tendons around your joint to loosen or tighten. Your surgeon may be able to repair the tendons around your joint.
• Removal of the joint lining (synovectomy). If the lining around your joint (synovium) is inflamed and causing pain, your surgeon may recommend removing the lining of the joint.

Surgery carries a risk of bleeding, infection and pain. Discuss the benefits and risks with your doctor.