Rheumatoid Arthritis

What is rheumatoid arthritis?

Rheumatoid arthritis is an autoimmune disease in which the immune system attacks the joints. 

During an RA flare-up, the tissue lining the joint becomes inflamed. This inflammation causes swelling, pain, redness, and stiffness. The pain may be worse after resting and can increase after vigorous exercise. Mirror joints—the same joint on both sides of the body—are often affected, including joints in the hands, wrists, feet, ankles, knees, shoulders, and elbows. Early symptoms of RA tend to begin in the smaller joints, such as those in the hands, feet, fingers, and toes.

Inflammation can damage joints over time. Early treatment can slow the progression and lessen long-term damage. Effective management of RA includes early diagnosis and treatment.

RA is different from osteoarthritis (OA), a form of arthritis caused by joint wear and tear. OA usually begins in a single joint and develops gradually over the years. In comparison, RA can develop over weeks or months and usually appears in several joints simultaneously

What are rheumatoid arthritis symptoms?

Early signs of rheumatoid arthritis include fatigue, weakness, and joint pain.

Common RA symptoms include:

• Tenderness and pain in the joints
• Pain in mirror joints or near symmetrical sides of the body
• Swelling around affected joints
• Redness or warmth in multiple joints
• Difficulty with the functioning of joints because of inflammation
• Morning stiffness that lasts an hour or more

Not everyone has the same manifestations of RA. However, most people experience symptoms in their wrists, knuckles, and finger and thumb joints.

While RA primarily causes joint pain, inflammation can also affect other parts of the body. For example, it can also affect:

• Skin. People can have nodules (growths or lumps under the skin) that appear on different body parts. They can be asymptomatic or painful and inflamed and they can sometimes limit movement. A medical professional can surgically remove them if needed.
• Eyes. The eyes can become inflamed, causing redness, pain, itching, dryness, and light sensitivity. Some people find that over-the-counter eye drops and lubricants work. Others find relief with prescription products.
• Nerves. Inflamed joints can press on nearby nerves, causing numbness and tingling. Because inflammation is common in the wrists, people with RA are at a higher risk of developing carpal tunnel syndrome.
• Ligaments and tendons. The ligaments and tendons holding bones in place can become damaged from inflammation, causing them to become misaligned. This can result in pain and deformity, most commonly in the hands and feet.
• Lungs. RA can cause inflammation or scarring of the lungs or lung lining. This can result in chest pain or shortness of breath.
• Bones. RA increases the risk of osteoporosis. Inflammation could contribute to bone thinning, and people with joint pain might be less likely to participate in weight-bearing exercises that help keep bones strong.

Individuals with RA are also twice as likely to develop heart disease as people without it. Scientists believe inflammation may be to blame, although the mechanism is not fully understood. Atherosclerosis (hardening of the arteries) occurs most frequently, but other cardiovascular risk factors may contribute, including high blood pressure, high cholesterol, and diabetes.

Rheumatoid arthritis treatments

There is no cure for rheumatoid arthritis (RA). However, in the past decades, scientists have created medications that can relieve inflammation and stop or slow the progression of the disease. These drugs work best when started within the first few months after initial symptoms appear. 

Disease-modifying antirheumatic drugs (DMARDs)

DMARDs alter the function of the immune system, slowing the progression of rheumatoid arthritis. Because these medications can reduce or prevent joint damage and preserve joint function, they have become the first line treatment for most people with rheumatoid arthritis.

Nonbiologic DMARDs

These medicines slow the progression of RA and also help reduce pain, stiffness, and swelling. Methotrexate (Trexall, others) is the most prescribed DMARD. Other DMARDs include hydroxychloroquine (Plaquenil), leflunomide (Arava), and sulfasalazine (Azulfidine.) 

Typically, people start with a low dose and gradually increase the dose over time. This can be a long process because DMARDs are slow-acting, and it can take three or more months to feel the full effects. 

Side effects of these medications include nausea, dizziness, hair loss, and decreased appetite. Some of them can also cause liver damage, so regular blood work to measure liver function is essential. Methotrexate can block the effects of folic acid in the body, so your doctor might recommend a folic acid supplement.

Biologic DMARDs and biosimilar drugs

Biologic DMARDs also modify the body’s response to inflammation. However, they are more narrowly targeted at specific components of the immune system than nonbiologic DMARDs. They target the underlying cause of the disease by blocking specific cells or chemical messengers in the immune system that trigger inflammation. These drugs are given if nonbiologic DMARDs have not worked and the two are typically taken in combination.

Biologic DMARDs work quicker than the nonbiological DMARDs. They are only available via injection. 

Biologic DMARDs fall into a few categories.

Anti-TNF agents block tumor necrosis factor (TNF), a molecule that is involved in joint inflammation. Anti-TNF agents for rheumatoid arthritis include:

• adalimumab (Humira)
• certolizumab (Cimzia)
• etanercept (Enbrel)
• golimumab (Simponi)
• infliximab (Remicade)

Non-TNF biologic agents target different parts of the immune system to dampen inflammation. Examples of non-TNF biologic agents include:

abatacept (Orencia)

• rituximab (Rituxan)
• tocilizumab (Actemra)
• sarilumab (Kevzara)
• anakinra (Kineret)

Scientists have also created biosimilar drugs that mimic, but not exactly replicate, biologic DMARDs. They have the same therapeutic effect and safety of biologic DMARDs but cost significantly less. 

One important risk of biological DMARDs and biosimilar drugs is that they suppress immune activity. This increases the risk of infections and, possibly, some cancers. These medicines are associated with tuberculosis and fungal lung infections. 

Janus kinase inhibitors 

A newer class of DMARDs for RA treatment is Janus kinase inhibitors, also known as JAK inhibitors. These medications target the inflammatory mechanism inside cells. Unlike many other biologic and biosimilar DMARDS that are injected, these are taken orally. 

Physicians might prescribe a JAK inhibitor if a person does not experience adequate symptom relief from other RA drug treatments. 

Some Janus kinase inhibitors are:

• Baricitinib (Olumiant)
• Tofacitinib (Xeljanz)
• Upadacitinib (Rinvoq) 

Possible side effects of these medications include upper respiratory infection, nausea, diarrhea, and headache. JAK inhibitors can also increase the risk of experiencing a cardiovascular event, cancer, blood clots, and death. 

Surgery

For some people, surgery can help reduce pain and increase joint function. However, surgery in one joint does not stop the condition from progressing in other joints. It also does not reduce the need for drug therapy. Surgery may be helpful when drug treatment alone is no longer helping to ease symptoms. Surgery may help increase function or correct a deformity caused by RA.

• Joint fusion. Bones are permanently fused; they cannot move but are stable to prevent pain. This can help with joints in the ankles, wrists, fingers, thumbs, or spine.
• Ligament or tendon reconstruction. Doctors reconstruct or reposition the ligaments and tendons to restore function. This is done on damaged tendons and ligaments that limit movement and cause substantial pain.
• Joint replacement. Damaged bone is removed and replaced with metal, plastic, or ceramic joints to increase mobility and reduce pain. The most common areas are the knees and hips, but it can also be done on the elbow, knuckles, wrist, and ankle, although not with the high success rate seen in the larger joints.

Nondrug rheumatoid arthritis treatments

Medication is a significant part of treating rheumatoid arthritis (RA), but nondrug treatments are also important. They can decrease pain, improve functional skills, and increase overall health and well-being. Here are common nondrug therapies used for RA. 

Physical and occupational therapy. Physical therapy works to improve movement by increasing strength and flexibility and building muscle. Occupational therapy improves the ability to complete daily life skills, such as cooking, bathing, dressing, and eating, and increases one's ability to work outside the home.  

Heat and cold therapy. Warm baths or showers, a heating pad or compress, or a paraffin wax bath can relax muscles and reduce pain. Ice or gel-filled cold packs applied to joints for about 15 minutes each hour can reduce pain and inflammation.

 Immobilizing devices. Splints and braces immobilize sore or inflamed joints, giving them time to heal. When used correctly, they should reduce pain but allow functioning. Splints and braces exist for different body areas, such as hands, wrists, elbows, knees, and ankles. A physical or occupational therapist can help determine the best style and size. 

Assistive devices. Assistive devices like canes and walkers allow mobility while taking the stress off affected joints. Everyday items can be replaced or adapted to reduce stress on hand joints. Examples include electric toothbrushes and utensils with long and padded handles. Gadgets like reach extenders with grippers can help pick up items, and jar keys can make opening jars easier. 

Sleep. Guidelines recommend adults get between seven and nine hours of sleep per night. Symptoms of RA, especially pain, can make it difficult to fall and stay asleep, and too little sleep can make symptoms worse during the daytime. Adjusting medications, setting up a relaxing bedtime routine, and adopting healthy sleep habits can help.

Weight. Being overweight or obese puts extra strain on weight-bearing joints. Keeping weight within normal body mass index (BMI) levels may help reduce the pain caused by the additional pressure on the joints. 

Exercise. Many people with achy joints avoid exercising. However, exercise helps strengthen joints and increases range of motion. A doctor or physical therapist can set up an individualized exercise program based on your current health and can monitor for necessary changes. 

Stress relief. Stress can trigger inflammation and worsen RA symptoms. In addition to adopting regular exercise and getting proper sleep, activities such as meditation, yoga, and tai chi may lower stress levels. 

Quitting smoking. Smoking is a risk factor for developing RA, and it also increases the risk of infection and heart disease. Most people find it hard to quit on their own. Certain medications and nicotine replacement therapies can help people quit. Speak with your doctor about these or other options.