What is it and what are the causes?

Rheumatoid arthritis (RA, rheumatism, former name: chronically progressive rheumatism) is a chronic inflammatory disease affecting joints and various organs. Its most characteristic symptoms are pain, stiffness, and swelling in the joints of the hands and feet, but other joints may also be inflamed. If untreated, the disease most often leads to joint damage and severe disability, as well as damage to many organs and premature death. Early application of effective treatment slows the progression of the disease, prevents its complications, and allows normal functioning.

Dig. 1. Localization of articular changes in RA

The causes of RA

The essence of the disease is the inflammatory process that begins inside the joint. An unknown factor stimulates the synovial membrane that lines the joint to an inflammatory response. It enlarges and destroys adjacent structures (cartilage, bones, ligaments, tendons). This is manifested initially by pain andswelling, followed by irreversible damage and loss of mobility in the joint. Inflammation of the cartilage and other structures of the joint favors the formation of secondary degenerative changes.

The causes of RA are not fully understood. Most likely, many factors must coexist for the development of the disease. The most important of them are:

• hereditary burden– there is a predisposition to RA in closely related people, but the genetic factor itself does not cause the disease – so the presence of RA in a parent does not mean that children will develop the disease, but the risk of developing it is 2-5 times higher
• immune system defect– leads to misidentification of one’s own tissues as an “enemy” and the production of autoantibodies to destroy them; several genes responsible for this process have been identified (including the HLA DRB1 histocompatibility genes)
• gender– women get sick about 3 times more often than men
• infection– some bacteria and viruses are suspected to play a role in initiating an inflammatory response
• smoking– increases the risk of falling ill and makes it more severe
• stress– in some patients the disease begins after experiencing severe stress.

How common is rheumatoid arthritis?

In developed countries, about 1 in 100 people suffer from rheumatoid arthritis, three times more women than men. The disease usually appears between the ages of 30 and 50 in women (although it can occur earlier or later), while in men its incidence increases with age.

How is rheumatoid arthritis manifested?

Most people with RA develop insidiously. It may take several weeks or even months for symptoms to become so bothersome that they are prompted to seek medical attention. Less often, we deal with a sudden development of the disease within a few or several days.At first, “general” flu– like symptoms such as feeling weak, low-grade fever, muscle pain, loss of appetite and weight loss are common. They may precede or accompany “joint” symptoms. Symptoms of involvement of other organs may also occur in the course of the disease.

Characteristic symptoms of RA

Joints

Dig. 2.Early changes in RA (joint swelling)

Fig. 3.Advanced changes in RA (numerous rheumatoid nodules visible above the joints)Source: Internal diseases, ed. A. Szczeklik, Medycyna Praktyczna, Krakow 2011

The disease typically affects the same areas on both sides of the body. Initially, these are the small joints of the hands and feet, and as the disease progresses, many other joints. An atypical (but possible) onset of the disease is either inflammation of one large joint (e.g., knee or shoulder joint) or the spread of the disease over multiple joints. The symptoms of arthritis include:

• pain and stiffness– most troublesome after waking up or after a period of not moving the joint, when there is an accumulation of inflammatory fluid and tissue swelling; morning stiffness is characteristic, which in RA usually lasts over an hour,
• swelling– is the result of the growth of the synovial membrane forming the so-called pannus, may be accompanied by exudate due to overproduction of inflammatory synovial fluid,
• tenderness of the joint to pressure– a characteristic feature is, for example, a painful handshake when shaking hands with a patient with RA,
• restriction of mobility– the affected joint loses the ability to perform the full range of movements; and if joint structures are damaged as a result of inflammation and secondary degenerative changes, the joint dysfunction becomes irreversible,
• joint deformation– is a consequence of a long-lasting disease; (Fig. typical joint deformities in RA).

Extra-statutory changes

Rheumatoid arthritis is a systemic disease that affects not only the joints, but also many organs (especially the long-term, severe form). Apart from relatively common benign lesions, such as rheumatoid nodules or dryness syndrome, severe complications leading to premature death (e.g.strokeormyocardial infarction) can occur very rarely.

• Rheumatoid nodules– painless subcutaneous nodules, most often located around the elbows, hand joints and other places exposed to pressure; they can also arise in internal organs.
• Atherosclerosis– its accelerated development is the result of activation of inflammatory processes; complications ofatherosclerosisare the leading cause of premature death in people with RA; in these patients the risk of heart attack andheart failure, sudden cardiac death or stroke is 2-3 times higher than in healthy people (see also:What is atherosclerosis,Coronary artery disease,Myocardial infarction).
• Heart– apart from ischemic heart disease and myocardial infarction resulting from the development of atherosclerosis, the following may occur: pericarditis, cardiomyopathy, damage to the heart valves – symptoms of these diseases are:chest pain,shortnessof breath and reduced exercise tolerance.
• Vessels– Vasculitis is a rare but serious complication of RA, leading to ischemia of various internal organs; You may also get ulcers on the fingertips and skin.
• Lungs– RA favors e.g. pleurisy and interstitialpneumonia; these diseases cause a drycough, shortness of breath, and chest pain.
• Osteoporosis– both RA and the steroids used in its treatment significantly accelerate the development ofosteoporosis; it is important to start treatment early in order to reduce the risk of bonefractures.
• Eyes– a common symptom is the dryness syndrome caused by conjunctivitis, characterized by a feeling of sand or a foreign body under the eyelids; other eye structures and vision problems are less common.
• Nerves– the so-called carpal tunnel syndrome; a rare but serious complication is pressure on the spinal cord caused by subluxation of the vertebrae in the cervical spine – symptoms includeheadache, sensory disturbances (numbness, tingling, decreased pain sensation) and limb weakness or paresis. This is a medical condition that requires urgent medical attention.
• Kidneys– both the disease itself and the drugs used can damage the kidneys; regular check-ups of kidney function are important.
• Haematological disorders– in the course of long-term disease, moderate anemia (anemia) and abnormal white blood cell counts are common. An increase in the number of platelets is characteristic of disease exacerbations. Lymph nodes and spleen enlargement is more common. RA increases your susceptibility to infections and the risk of developing lymphomas.

What to do in the event of RA symptoms?

If pain and swelling in the joints occur, see a doctor immediately. People suspected of RA should be looked after by a rheumatologist. Rapid diagnosis determines the effectiveness of treatment, and if it is started early enough, there is even a chance of permanent withdrawal of the disease.

In the course of RA, complications may develop, requiring urgent medical intervention. Most often, they can be prevented and effectively treated. Know the symptoms that indicate complications of RA (see above).

Important

Contact your doctor urgently if you experience:

• exacerbation of the disease (increased pain, stiffness and swelling of the joints, low-grade fever, weakness, weight loss) – requires more intensive treatment to suppress the disease activity as soon as possible
• any symptoms of infection, e.g.fever, cough,sore throat, burning when urinating, weakness, feeling broken – RA patients have a reduced ability to fight infections (these require quick and effective treatment)
• you have had a recentjoint puncture, after which there was a significant increase in pain, swelling and increased joint warmth, or fever – these may be signs of a joint infection that requires prompt treatment;pain in the joint, which passes within a day after the puncture is performed, do not worry (during this time you should avoid overloading the joint)
• cough, shortness of breath, chest pain, decreased exercise tolerance – require urgent diagnosis for pulmonary and heart diseases coexisting with RA
• any neurological symptoms (e.g. abnormal sensation, weakness or weakness in limbs, severe headache, visual disturbances) – these may be symptoms of a stroke or pressure on nerve structures
• stomach pain, dark-colored stools (or with blood) – these may be symptoms of peptic ulcer and gastrointestinal bleeding, which are complications of treatment with non-steroidal anti-inflammatory drugs.

It is also extremely important to inform the doctor about the planned pregnancy (this applies to both women and men). Rheumatoid arthritis is not a contraindication to pregnancy (most women experience a transient remission of the disease during pregnancy), but it should be planned in order to modify the treatment early enough, as most drugs may harm the baby.

How is the diagnosis made by the doctor?

The doctor diagnoses rheumatoid arthritis on the basis of the coexistence of characteristic symptoms with the results of laboratory and imaging tests. The criteria used so far for RA date from 1987 and were met only in the developed disease (which means that a certain diagnosis could only be established after longer follow-up). In 2010, new criteria (ACR / EULAR) were developed that enable RA diagnosis at the initial stage of the disease and start treatment before irreversible joint destruction occurs.

Laboratory tests

Laboratory tests are used to diagnose RA, predict the severity of the disease and control its course.

• RF(rheumatoid factor) is found in 70–80% of patients (the so-called seropositive form of RA); However, RF is also detected in healthy people and in other rheumatic diseases.
• Anti-CCP(antibodies against cyclic citrullinated peptide) – their advantage is that they occur almost exclusively in RA; they may appear earlier than disease symptoms and in people with seronegative RA.
  High levels of RF and anti-CCP indicate a severe form of the disease, with rapid destruction of the joints and the occurrence of extra-articular changes.
• Increased inflammatory markers, e.g.ESR,CRP, and changes inblood counts– they serve, among others, to assess disease activity.

The doctor may also perform other blood, urine or joint fluid tests to rule out other joint diseases and to check the functioning of various internal organs (e.g. kidneys, liver).

Imaging studies

If RA is suspected, radiographs (X-rays) of the hands and feet, and possibly other affected joints, are performed. Radiographic changes typical of RA include swelling of the soft tissues and a decrease in bone density around the joint, the presence of bone defects, narrowing of joint spaces, and later deformation of the joints.

At the beginning of the disease, magnetic resonance imaging andultrasoundare useful , which may show inflammatory changes earlier than X-ray. In some cases (e.g. when assessing the cervical spine)computed tomographyis helpful .

What are the treatments for RA?

Treatment methods for RA have changed significantly in recent years with the advent of new effective drugs. The emphasis is now on applying the disease-modifying drug (DMARDs) as soon as possible. Increasingly, this allows you to achieve remission (that is, a state in which there are no symptoms of the disease or features of its activity in laboratory and imaging tests) or its low activity. Unfortunately,the onset of RA is often tricky, and it often takes several months until the appropriate treatment is implemented – so don’t delay going to a doctor if you develop symptoms of arthritis!

Successful treatment of RA means resolving the symptoms of the disease, good quality of life and maintaining fitness. In addition to the basic pharmacological treatment in this disease, it is important to start rehabilitation early and, in some cases, surgical treatment. The exact drugs to be used is decided by the rheumatologist taking into account the severity of the disease, its activity (most often using the DAS 28 index), prognostic indicators and contraindications to the use of certain drugs (e.g. liver, kidney diseases,tuberculosis). It is important to develop an effective treatment plan with your doctor – this involves regular visits and laboratory tests assessing the effectiveness and possible side effects of the drugs used.

Pharmacological treatment

Disease-modifying drugs (DMARDs)play a fundamental role in the treatment of RA, as they not only alleviate symptoms, but most of all inhibit joint damage, allowing you to stay fit and function normally in everyday life. They should be applied as soon as possible after diagnosis to prevent irreversible changes to the joints. However, these drugs do not provide a full cure – the disease usually recurs after their discontinuation. DMARDs are distinguished between “non-biological (synthetic)” and “biological”. Non-biological DMARDs include:

• methotrexate
• leflunomide
• sulfasalazine
• gold salts
• chloroquine.

The initial effect of these drugs appears after some time, usually after 1-2 months (full after 3-6 months). Methotrexate is the drug of first choice in RA, it is highly effective and generally well tolerated (many side effects are temporary).

For several years in the treatment of RA, the so-calledbiological drugsobtained by genetic engineering techniques that target factors involved in the inflammatory process. There are several types of biological drugs, depending on their target site of action (including TNF, Il-1, Il-6, T or B lymphocytes).

The most common treatments for RA are:

• adalimumab
• etanercept
• infliximab
• certolizumab
• golimumab
• abatacept
• tocilizumab
• rituximab.

The effect of these drugs is noticeable a little faster, usually within 2–6 weeks. They can be used alone or in combination with synthetic drugs (most often with methotrexate). Biological drugs are reserved for patients who fail to achieve adequate disease control despite the use of the maximum tolerated doses of synthetic drugs, less often as initial treatment of people with high disease activity and factors of poor prognosis.

Glucocorticosteroidsquickly reduce the symptoms of arthritis and inhibit the process of their destruction, so they are often used at the beginning of the disease (before the basal DMARDs take effect) and in their exacerbations. Due to many side effects, the aim should be to reduce the dose of the steroid as quickly as possible and use it for the shortest possible time. Steroids can also be administered directly into the diseased joint (seePrednisolone,Methylprednisolone).

Non-steroidal anti-inflammatory drugs– reduce the symptoms of arthritis, but do not stop the progression of the disease, so they are used only as an adjunct to pain and stiffness in the joints. They show many side effects, such asgastrointestinal bleeding, kidney damage and an increased risk of heart disease. Never take more than one drug from this group and do not exceed the recommended doses.
See selected drugs from this group:Diclofenac,Ibuprofen,Ketoprofen,Naproxen,Nimesulide

Pain relieverssuch as paracetamol and opioids are used if pain persists despite complete basic treatment.

Non-pharmacological treatment

In all patients, in addition to the use of drugs, the following are very important:

• mental support– remember that illness, which is often associated with pain and disability, can also cause frustration, a sense of dependence on others, and evendepression, so do not hesitate to seek mental support from your relatives and specialist clinics; some methods (e.g. biofeedback and behavioral therapy) are very effective in controlling symptoms of the disease and improving self-esteem
• rest– fatigue is a common symptom of RA, especially in its active period; allow yourself to rest – short naps during the day will help you regain energy and relieve sick joints
• exercise– patients with RA often give up any physical activity, which leads to a reduction in joint mobility, contractures and muscle weakness; regular physical activity prevents and even reverses some adverse changes in the joints; it is advisable to use exercises that increase the range of motion and strengthen the muscles (they will help maintain the mobility and stability of the joints), as well as exercises that improve overall efficiency (e.g. walking, swimming, cycling); the exercise program should be developed by a physiotherapist and tailored individually to each patient, depending on the severity of the disease, the condition of the person and coexisting diseases
  ImportantExercise should be refrained from during acute exacerbation of the disease; Remember that the sooner you start targeted rehabilitation, the easier it will be to prevent joint deformity and disability.
• physical therapy– various techniques such as cryotherapy, ultrasound, massage and balneotherapy help reduce pain and inflammation in the joints and relax the muscular system; their use requires a careful health assessment and consideration of possible contraindications
• orthopedicequipment helps to relieve the diseased joints and deal with disability – it includes canes, crutches, walkers, wheelchairs that help in moving around, supports for arms, knees and ankles (so-called orthoses) to help maintain the correct position of the joints, orthopedic insoles for shoes improving the structure of the foot and relieving the load-bearing joints when walking
• adaptation of the environment to disabilities,e.g. specially adapted kitchen appliances, furniture, handles to help you get up, an adapted car – they will help you perform everyday activities
• proper diet– it is about maintaining a healthy body weight; avoid both overweight and obesity (which increase the load on the joints and accelerate the development of atherosclerosis) and malnutrition (which weakens the body and leads to muscle atrophy); it is also important to provide the bones with adequate amounts of calcium and vitamin D, as RA significantly accelerates the development of osteoporosis
• stopping smoking,which increases the risk of developing the disease and developing the disease severely.

Topical treatment

Topical treatment of rheumatoid arthritis is directly related to the affected joint.

Performs:

• puncture the joint to decompress it from the accumulated inflammatory fluid and administer anti-inflammatory drugs (steroids) inside
• treatments to remove the altered synovial membrane (so-called synovectomies) – there are various ways of performing them: surgical, chemical (by administering a substance that destroys the synovial membrane) or with the use of a radioisotope
• various types of corrective and reconstructive treatments aimed at improving the structure and functioning of deformed joints
• endoprosthesis, i.e. replacing a damaged joint with an artificial prosthesis
• arthrodesis, consisting in the total stiffening of the joint, thanks to which the pain is eliminated
• decompression of the carpal tunnel syndrome that often accompanies RA.

Is it possible to cure RA completely?

Currently, recovery of RA, i.e. the absence of disease without the need for medication, is very rare. Usually, the disease recurs after discontinuation of DMARDs. The available treatment methods more and more often allow the disease to remission and function normally. Unfortunately, in some patients (approx. 10-20%) the disease worsens despite treatment. Remission is common in pregnant women, but the disease is most often exacerbated within 3 months after delivery.

RA is still associated with frequent impairment of fitness – it is estimated that after 5 years, about half of patients lose their ability to work, and almost all after 10 years. Patients live a few years shorter than the general population, mainly due to complications of atherosclerosis. It is likely that these statistics will improve in the future thanks to earlier detection of RA and more effective treatment.

What should I do after completing my treatment?

RA is a chronic disease that requires constant rheumatological control. At the beginning of the disease and during its exacerbations, frequent visits to the doctor are necessary (on average every 1-3 months) in order to determine the appropriate doses of drugs and achieve remission of the disease. In a stable period, visits may be less frequent (usually every six months).

The disease activity and progression are assessed on the basis of the severity of clinical symptoms (number of joints involved, pain assessment, quality of life scales) and the results of laboratory tests (ESR, CRP,blood count) and imaging (X-ray of hands and feet). It is also important to detect side effects of drugs, including assessment of kidney, liver and bone marrow functions, and periodic tests for comorbidities (ultrasound of the abdominal cavity,chest X-ray, mammography, gynecological control). Due to the accelerated development of atherosclerosis, it is necessary to assess the cardiovascular risk and, if necessary, appropriate prophylaxis and treatment.

It is also important to remember about the early treatment of osteoporosis to reduce the risk of bone fractures. In addition to visits to the rheumatologist, the patient should participate in targeted rehabilitation activities and perform the prescribed exercises at home.

What to do to avoid getting rheumatoid arthritis?

Unfortunately, the onset of RA cannot be prevented at present, but timely detection and treatment of the disease allows for increasingly frequent long-term remission.