Rheumatoid arthritis (RA) is a clinical condition that is characterized by pains in the joints in different parts of the body. It occurs in response to certain inflammatory triggers, and an autoimmune response ensues that result in joint inflammation and synovial overgrowth. It is classed as a chronic systemic inflammatory disorder.
In this article, we will cover the causes, clinical features and management of rheumatoid arthritis.
Rheumatoid arthritis does bear genetic predisposition, with the risk of contracting the illness about 2 to 3 times higher in first degree relatives. It is a fairly common condition and the American College of Rheumatology estimates that around 1.3 million people suffer from rheumatoid arthritis.
Rheumatoid arthritis can be multi-factorial in origin, though there are certain common etiological features amongst all those that develop the diseases. Below are listed some of the causes –
- HLA-DR4 – This genetic factor is carried by most patients who suffer from RA
- Auto-immune causes – This describes the presence of antibodies in the blood stream against one’s own tissues and cells (antigens). This interaction results in a cascade of events that ultimately leads to destruction of the structure of the joints and other organs.
- Infections – On rare occasions, infectious agents such as Epstein-Barr virus and Mycoplasma infection can result in development of RA.
The clinical features of RA typically involve the joints, but other organs may also be involved.
1. Joint pains (Arthritis)
The classic clinical feature is symmetric polyarthritis of the hands and the feet. This means that a number of joints will be affected, with similar joints affected on both sides of the body. As a result, over time the joints become deformed and assume certain characteristic appearances. Patients complain of early morning joint stiffness, which usually lasts for around 2 hours, though it can last the whole day as well.
The most common joints involved are those of the hand, including the metacarpophalangeal joint, wrist joint, proximal inter-phalangeal joint along with a number of other joints in the hands, feet, neck and hip. Typically, the joints are swollen, red, hot and tender, especially during an acute flare up. The chronic inflammation and recurrent episodes of acute flare ups results in progressive damage of the joints, resulting in a swan-neck deformities, ulnar deviation, boutonniere deformity and hammer toes.
Image shows Swan Neck Deformity of the right hand
Image shows Boutonniere Deformity in the right hand
Other joint involvements include inflammation of the tendon sheaths, carpal tunnel syndrome and osteoporosis.
2. Extra-articular involvement
In RA, it is not just the joints that are involved, and other organs may also be involved. While a detailed discussion on these features is out of the scope of this article, some of the features are listed below –
- Lungs – Inflammation of the lining of the lung (called pleura) can occur. In advanced cases, the lungs can become thickened resulting in a condition called lung fibrosis. Patients typically have shortness of breath.
- Heart – Inflammation of the lining of the heart (called the pericardium) can occur, along with accumulation of fluid accumulation around the heart. Patients may also suffer from heart attacks.
- Skin – Patients can develop thickened nodules on the surface of the skin at pressure points such as the elbow. These are called rheumatoid nodules.
- Other systems – Other organs are usually affected due to the treatments prescribed. These can include the stomach and the kidney.
This list is not exhaustive, but does indicate to some extent the level of involvement that can occur in RA.
Diagnosing rheumatoid arthritis is mostly based on symptoms that the patients experience, along with the findings on clinical examination. However, there are certain tests that can be carried out to confirm the diagnosis –
1. Blood tests – Patients may have low haemoglobin (i.e. anemia). A special blood test looking for rheumatoid factor will be positive. The erythrocyte sedimentation rate (ESR), which is a marker of inflammation may be elevated.
2. X-rays – This will show changes in the bones and joints which are consistent with arthritis.
X-ray appearance in RA (hands)
Accurately diagnosing rheumatoid arthritis involves all these to be taken into consideration.
Rheumatoid arthritis requires a variety of treatments which are not only aimed at improving the symptoms and reducing the inflammation, but also improving the quality of life of patients. However, there is still no cure. Research is constantly being conducted to discover new ways of treating RA, and there have been some significant advances.
1. Disease Modifying Anti –Rheumatoid Drugs (DMARDs)
This is mentioned first as these are probably the most important treatments offered these days. These drugs are commonly prescribed along with other pain killers. The primary benefits of these drugs are a reduction in inflammation and slow down the progression of the disease. Some of the drugs that are used include –
These drugs are called non-biological agents. In addition, DMARDs also include biological agents that act against mediators of inflammation such as Tumour necrosis factor – alpha (TNF-?) and Interleukin – 1 (IL-1). Drugs include –
There are a number of criteria that need to be considered before prescribing treatment for patients with RA. The duration of the disease, the severity of the illness and the response to treatments mean that treatment requires constant review. This may be the reason for constant change in medications if there has been no response to treatment. Concurrent illnesses also need to be taken into consideration before prescribing these.
2. Non Steroidal Anti-inflammatory Drugs
These are basically pain killers and include drugs like Ibuprofen and Diclofenac. These are strong painkillers that should be taken after food.
3. Physical therapy
Physical therapists provide invaluable assistance in helping patients manage their condition and perform day to day tasks. This is extremely important in maintaining the patient’s independence which they cherish.
RA is a chronic condition characterised by joint pains and a lot more. If left untreated, it can result in significant impairment on the quality of their lives. Treatment offers no cure but help reduce pain and inflammation, and can improve the quality of life of patients.
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