Rheumatoid arthritis

What is rheumatoid arthritis?

Rheumatoid arthritis is quite different from osteoarthritis. It is caused by an intense inflammation in the synovial joints and it can arise at any time from the teenage years onwards. It is more common in women and the peak age of onset is between 30 and 50.

Rheumatoid arthritis is the most common form of inflammatory arthritis and it affects one to two per cent of the population. Even so, it is much less common than osteoarthritis which affects almost all of us to some degree as we get older.

Rheumatoid arthritis should really be called ‘rheumatoid disease’ because not only the joints but other parts of the body may be affected – for example, the skin, lungs and eyes. As it is such a complex, widespread disease with many effects, rheumatoid arthritis is usually treated by hospital specialists – rheumatologists – and most sufferers attend hospital clinics.

What’s going on?

Rheumatoid arthritis is one of a group of conditions called ‘autoimmune connective tissue diseases’. The other conditions in this group are much rarer. In all of these conditions, the body’s immune system is overactive and appears to attack the body’s own tissues. Something must trigger this process – for example, a virus or a toxin – but at the moment we do not know what.

A great deal of research is directed at finding the trigger with the hope of then developing a cure. But, although we do not have a cure at the present time, we do have drug treatments that are very effective at suppressing the over-activity of the immune system and keeping the process under control.

We may not know the cause of rheumatoid arthritis but we do understand many of the changes that take place in the body tissues during the disease process. We know that the seat of the inflammation is the synovium, the slippery lining of joints, tendon sheaths and bursas. The synovium becomes swollen and thickened and may produce large amounts of synovial fluid. Cartilage and ligaments may be damaged and eventually the bone also may be damaged, forming cavities called ‘erosions’.

In rare cases, the joint may eventually be destroyed. In severe cases, the inflammation may affect other tissues outside the joints, such as the eyes, skin and lungs.

Symptoms

The symptoms of rheumatoid arthritis are varied and they may begin quite suddenly.

In severe cases, morning stiffness seems to affect every joint in the body. Many people say that this stiffness and difficulty in getting going is more disabling than the pain. The inflammation may affect parts of the body outside the joints. Your eye may become red and sore and if this happens you will need to see an ophthalmologist. Your lungs may be affected and you should always report any increase in breathlessness to your doctor. Small blood vessels can become inflamed (a condition known as ‘vasculitis’), causing rashes and sometimes ulcers.

Symptoms in rheumatoid arthritis

• Many joints are affected at the same time with swelling, warmth and tenderness.

• The hands and feet are the most common joints involved, followed by the wrists, ankles, knees and shoulders, and neck.

• When the inflammation is active, fever, loss of appetite and weight loss are common.

• Many people feel tired and lacking in energy because they are anaemic.

• Severe stiffness first thing in the morning which tends to ease as the day progresses but may last for many hours.

Rheumatoid nodules

Some people develop nodules under the skin at sites of friction, such as the feet, the backs of the heels, the backs of the hands and the elbows. The nodules are painless and, apart from being unsightly, do not usually cause trouble. Occasionally, they grow to a large size and interfere with the wearing of shoes. The nodules are easily removed by minor surgery but we try not to do this without good reason as they tend to recur.

Later symptoms

Very occasionally, the symptoms of rheumatoid arthritis improve on their own after the first few weeks or months, but most people need treatment. Rheumatoid arthritis usually follows a pattern of ‘remissions’, followed by ‘relapses’ or ‘flares’. Remissions are good periods when the symptoms are less troublesome and relapses are when the inflammation is more active.

The aim of treatment is to control the relapses and maintain, or prolong, the remissions. Often, remissions can last for many years.

Who’s who at the hospital clinic

• The consultant rheumatologist, who is in overall charge, selects and monitors the appropriate drugs, and coordinates the input of the other specialists. You may also sometimes see other members of the consultant’s team, such as a specialist registrar or a senior house officer.

• The rheumatology nurse specialist will see you while your condition is in a stable phase to monitor your drug therapy. He or she is also a valuable contact for extra advice and information.

• The physiotherapist plays a vital role in relieving symptoms and preserving muscle strength and movement of affected joints. He or she may recommend splints for affected joints from time to time to protect them and maintain their correct position, and will also advise on the right sort of exercises for you to do at home.

• The occupational therapist is concerned with keeping you functioning as normally as possible and can advise on how to perform everyday activities most efficiently without straining the joints. He or she can also advise on aids and appliances.

• A podiatrist (as chiropodists are now known) may be needed if you develop foot problems, such as toe deformities, calluses and ulcers.

• The consultant orthopaedic surgeon will become involved if surgery, such as joint replacement, is being considered.

• Social workers can advise on the wide range of help and allowances that are available through the social services department of your local authority.

Diagnosis

A detailed history, with a careful examination and some simple blood tests are usually all that are needed for an experienced doctor to make a diagnosis of rheumatoid arthritis. A full blood count will show whether you are anaemic (a reduced number of red blood cells, common in rheumatoid arthritis) and an erythrocyte sedimentation rate (ESR) will show whether inflammation is present.

A test for rheumatoid factor may help in the diagnosis. X-rays often appear normal in the early stages of the disease but they should be taken so that they can be used as a baseline against which to compare later X-rays. A chest X-ray and X-rays of the hands and feet are the most useful.

Treatment

The aims underlying treatment for rheumatoid arthritis are to:

• relieve symptoms

• preserve muscle strength and joint movement

• protect the joints from further damage

• help the individual to lead as normal a life as possible.

At the hospital clinic, you will meet a number of specialists, each of whom can help in a different way.

Drug treatments

There are several different types of drug used to treat rheumatoid arthritis. First and very important are non-steroidal anti-inflammatory drugs (NSAIDs) and analgesics (simple pain-killers). Briefly, anti-inflammatory drugs reduce pain, stiffness and swelling, whereas analgesics provide added pain relief if this is necessary. Although these drugs can help the symptoms of rheumatoid arthritis, they do not have any effect on the long-term progression of the disease.

This is the role of the second and equally important group of drugs that help to prevent joint damage. The drugs in this group are methotrexate, sulfasalazine, azathioprine, leflunomide (Arava), gold salts, penicillamine and hydroxychloroquine. Methotrexate and sulfasalazine appear to be the most effective and so these are the DMARDs that are most often used.

Each has been shown to improve the long-term outcome in people with rheumatoid arthritis and they are known collectively as ‘disease-modifying anti-rheumatoid drugs’ or ‘DMARDs’ (pronounced ‘deemards’). These drugs are chemically very different from each other – we do not yet know in detail how they work but they have some common features.

Several new DMARDs work directly on the immune system. Examples are etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira) and rituximab (MabThera). As a group, they are known as ‘biologics’ or ‘biological agents’. They are powerful drugs that are given by injection and need to be closely monitored. Long-term effects are not yet clear so they are reserved for people with severe arthritis who have not been helped by other DMARDs. But these drugs can have a dramatic effect in some people and they are being much more widely used. Two of the drugs, etanercept and adalimumab, can be given by injections under the skin. People taking these drugs (or their relative or carer) can be taught to give the injections at home, making the treatment much more convenient.

Steroids can be useful in treating rheumatoid arthritis because they have a powerful anti-inflammatory action. They may be given as a course of tablets or by injection into particularly troublesome joints from time to time.

About DMARDs

• All DMARDs take a long time to take effect – eight to twelve weeks – and they need to be taken long term for the effect to be maintained. In other words, you do not stop taking them as soon as you feel better!

• Not all DMARDs are effective in all individuals, so if the first one that you try does not help then your rheumatologist may suggest that you try a different one, or perhaps a combination of drugs.

• All DMARDs have side effects but, in general, these can be picked up very early by blood tests and urine tests, before any harm is done. So anyone taking these drugs will need to have regular tests to monitor for problems. You should be given a booklet by your rheumatologist or hospital pharmacist to record the results of these tests.

The outlook

If it is not treated, rheumatoid arthritis goes through relapses (flares) and remissions. Flares may be triggered by illness, such as influenza, or even by stress, such as bereavement. If the flares are frequent and severe, then damage to joints accumulates and they may be destroyed.

Severe disease affecting the joints and other body tissues is fortunately rare. When first told the diagnosis, many people are shocked and upset and a common question is ‘Will I be in a wheelchair, doctor?’. They fear that rheumatoid arthritis automatically means immobility, disability and dependency. This is no longer true.

Many sufferers have only mild arthritis and symptoms of pain and stiffness are kept at bay with tablets and exercise. Even those with more extensive problems can, with the right help, lead almost normal lives with jobs and families.

KEY POINTS

• Rheumatoid arthritis causes joints to become inflamed – it is very different to osteoarthritis

• A lot of help is available for people with rheumatoid arthritis, mostly from specialists at the hospital clinic