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Rheumatoid Arthritis

A chronic, systemic inflammatory disease, rheumatoid arthritis (RA) primarily attacks peripheral joints and surrounding muscles, tendons, ligaments, and blood vessels. Partial remissions and unpredictable exacerbations mark the course of this potentially crippling disease.

RA occurs worldwide, striking women three times more often than men. It it can occur at any age but 80% of patients develop RA between ages 35 and 50. RA affects more than 6.5 million people in the United States alone.

Causes

The exact cause of rheumatoid arthritis is not known. Rheumatoid arthritis is an autoimmune disorder, which means the body's immune system attacks its own healthy cells and tissues. The response of the body causes inflammation in and around the joints, which then may lead to a destruction of the skeletal system. Rheumatoid arthritis also may have devastating effects to other organs, such as the heart and lungs. Researchers believe certain factors, including heredity, may contribute to the onset of the disease.

Rheumatoid arthritis affects more women than men (75 percent of persons with rheumatoid arthritis are women). The disease most often occurs between the ages of 20 and 45.

Signs and symptoms

Some of the most common symptoms of rheumatoid arthritis are:

• Joint swelling. Especially in the small joints of the hands and feet.
• Bumps may be noted over the small joints
• Joint tenderness, stiffness, and pain. Especially in the morning.
• Decrease ability to grasp or pinch

Diagnosis

Typical clinical features suggest RA, with a firm diagnosis supported by laboratory and other test results:

• X-rays in early stages show bone demineralization and soft-tissue swelling;
  later, loss of cartilage and narrowing of joint spaces; and finally, cartilage and bone destruction and erosion, subluxations, and deformities.
• RF is positive in 75% to 80% of patients, as indicated by a titer of 1:160 or higher.
• Synovial fluid analysis shows increased volume and turbidity but decreased viscosity and elevated WBC counts (often greater than 10,000/µl).
• Serum protein electrophoresis may show elevated serum globulin levels.
• Erythrocyte sedimentation rate and C-reactive protein are elevated in 85% to 90% of patients (may be useful to monitor response to therapy because elevation frequently parallels disease activity) .
• Complete blood count usually shows moderate anemia, slight leukocytosis, and thrombocytosis.

Treatment

Salicylates, particularly aspirin, are the mainstay of RA therapy, because they decrease inflammation and relieve joint pain. Other useful medications include nonsteroidal anti-inflammatory agents (such as indomethacin, fenoprofen, and ibuprofen), antimalarials (hydroxychloroquine), sulfasalazine, gold salts, penicillamine, and corticosteroids (prednisone).

Immunosuppressants, such as methotrexate, cyclosporine, and azathioprine, are also therapeutic. They are being used more commonly in early disease.

Supportive measures include 8 to 10 hours of sleep every night, frequent rest periods between daily activities, and splinting to rest inflamed joints. A physical therapy program, including range­of-motion exercises and carefully individualized therapeutic exercises, forestalls loss of joint function.

Application of heat relaxes muscles and relieves pain. Moist heat usually works best for patients with chronic disease. Ice packs are effective during acute episodes.

Treatment in advanced disease

Advanced disease may require synovectomy, joint reconstruction, or total joint arthroplasty.

Useful surgical procedures in RA include metatarsal head and distal ulnar resectional arthroplasty, insertion of a Silastic prosthesis between MCP and PIP joints, and arthrodesis (joint fusion). Arthrodesis sacrifices joint mobility for stability and relief of pain.

Synovectomy (removal of destructive, proliferating synovium, usually in the wrists, knees, and fingers) may halt or delay the course of this disease. Osteotomy (the cutting of bone or excision of a wedge of bone) can realign joint surfaces and redistribute stresses.

Tendons may rupture spontaneously, requiring surgical repair. Tendon transfers may prevent deformities or relieve contractures.

Prevention

Although there is no known way to prevent the development of rheumatoid arthritis, you can reduce the pain of flare-ups and prevent joint deformity by following your doctor's treatment recommendations.