December 2008: Diagnosing and Caring for Rheumatoid Arthritis
01 Dec 2008
Dr. Siddharth Tambar is a board-certified rheumatologist at Weiss Memorial Hospital. His specialties include rheumatoid arthritis, lupus, scleroderma, vasculitis and osteoarthritis, among other musculoskeletal disorders.
Diagnosing and Caring for Rheumatoid Arthritis
Dr. Siddharth Tambar
Weiss Memorial Hospital
Rheumatoid arthritis (RA) is one of the most disabling types of arthritis. Significant improvements in treatment during the past decade have dramatically improved the prognoses of newly diagnosed patients. Recent advances in treatment and appropriate management with a rheumatologist have made it possible to stop or at least slow the progression of joint damage.
What is rheumatoid arthritis?
RA is a chronic disease that causes pain, stiffness, swelling and limitation in the motion and function of multiple joints. It is the most common type of arthritis triggered by the immune system. Though joints are the principal body parts affected by RA, inflammation can develop in other organs as well.
The stiffness seen in active RA is typically worst in the morning. This long period of morning stiffness is an important diagnostic clue, as not many other arthritic diseases behave this way. Pain with RA is typically worse with rest and improves with activity. While RA can affect any joint, the small joints in the hands and feet tend to be involved more frequently than others.
Other symptoms that can occur in RA include:
- loss of energy
- low-grade fevers
- loss of appetite
- dry eyes and mouth from an associated condition known as Sjogren’s syndrome
- firm lumps called rheumatoid nodules beneath the skin in areas such as the elbow and hands.
What causes rheumatoid arthritis?
RA is classified as an autoimmune disease, which develops because certain cells of the immune system malfunction and attack healthy joints causing inflammation. The primary focus of the inflammation is the lining tissue of the joint. New medications have been developed that specifically block certain signals in the body from the immune system that are important in causing RA symptoms and joint damage.
Who gets rheumatoid arthritis?
RA is the most common form of inflammatory arthritis. More than 2 million Americans suffer from RA. About 75 percent of those affected are women, and 1 to 3 percent of women develop rheumatoid arthritis in their lifetime. The disease most often begins between the fourth and sixth decade of life; however, RA can develop at any age.
How is rheumatoid arthritis diagnosed?
RA can be difficult to diagnose because it may begin gradually with subtle symptoms. Many diseases, especially early on, behave in a manner similar to RA. For this reason, patients suspected of having RA should be evaluated by a rheumatologist, a physician with the necessary skill and experience to reach a precise diagnosis and develop the most appropriate treatment plan.
The diagnosis of RA is based on the patient’s symptoms, physical examination findings, laboratory tests and imaging findings. Classic symptoms described by patients include warmth, swelling and pain in the joints. Pain typically is worse with rest and better with activity. Stiffness first thing in the morning is another classic complaint.
Certain laboratory abnormalities commonly found in RA can help to establish a diagnosis. Rheumatoid factor and anti-cyclic citrullinated peptide are antibodies that are found in RA, but up to 25 percent of patients with RA will not have either of these antibodies. Other lab abnormalities that can be present include anemia, elevated erythrocyte sedimentation rate (also known as sed rate) and elevated C-reactive protein.
X-rays can be very helpful to diagnose RA but may not show any abnormalities in the first three to siz months of arthritis. X-rays are useful to determine if the disease is progressing. MRI and ultrasound are also being used more frequently to help detect the severity of disease in RA patients. The latter two modalities are more sensitive to in detecting early damage in RA, and ultrasound is also useful in more precise guidance of injections if needed.
It is important to remember that for most patients with this disease (especially those who have had symptoms for less than six months), there is no single test that confirms a diagnosis. Rather, a diagnosis is established by skillfully evaluating the appropriate symptoms, physical examination findings, laboratory tests and imaging studies.
Treatment for rheumatoid arthritis
Therapy for patients with RA has improved dramatically during the past 25 years. Current treatments offer most patients good to excellent relief of symptoms and the ability to continue to function at or near normal levels. Since there is no cure for RA, the goal of treatment is to minimize the patient’s symptoms and disability before permanent joint damage. The importance of early diagnosis and early treatment is essential in this regard.
Exercise and physical therapy are important for all arthritis patients, including those with RA. In general, patients are better able to participate in physical therapy when their RA is better controlled. Range-of-motion, cardiovascular and strengthening exercises are all important for RA patients.
Successful management of RA requires early diagnosis and, at times, aggressive treatment. To quickly reduce joint inflammation and symptoms, non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Motrin and others), naproxen (Naprosyn, Aleve) and celecoxib (Celebrex), are used. In addition, corticosteroids such as prednisone may be given orally at low doses or via injection into the joints. However, these medications do not prevent the progressive damage that occurs in RA.
All RA patients are candidates for treatment with disease-modifying anti-rheumatic drugs (DMARDs) because these medications can stop the progression of the disease unlike other treatments. DMARDs have greatly improved the symptoms and function as well as the quality of life for the vast majority of patients with RA. DMARDs include methotrexate (Rheumatrex and Folex), leflunomide (Arava), hydroxychloroquine (Plaquenil), sulfasalazine (Azulfidine), gold given orally (Auranofin) or intramuscularly (Myochrisine), and azathiaprine (Imuran).
For patients with more aggressive disease, medications referred to as biologic-response modifiers or “biologic agents” can specifically target parts of the immune system that lead to inflammation as well as joint and tissue damage in RA. These medications are also DMARDs, because they slow the progression of the disease. Currently available biologics used in the treatment of RA include adalimumab (Humira), etanercept (Enbrel), infliximab (Remicade), abatacept (Orencia) and rituximab (Rituxan). These medications are used in combination with methotrexate and result in greater efficacy in reducing pain as well as preventing the progression of disease.
Your rheumatologist will need to see you regularly in order to follow the course of your disease and monitor for any side affects related to your medications. Regular blood tests and occasional imaging is necessary as well to properly manage your RA and medications.
Lastly, omega 3 fatty acid is a naturally occurring molecule found in many foods (fish oil, flax seed oil, some fruit, various nuts and eggs) and in many nutritional supplements that may benefit RA patients. There is evidence that omega 3 supplementation can help to reduce pain and swelling in the joints of RA patients. This supplement, however, does not prevent the progressive damage that can occur in RA and should not be the sole treatment for any RA patient.
The rheumatologist’s role in the treatment of rheumatoid arthritis
RA is a complex disease, but many advances in treatment have been made recently. Rheumatologists are specialists in musculoskeletal disorders and therefore are more likely to make a proper diagnosis. They also can advise patients about the best treatment options available.
- Newer treatments for rheumatoid arthritis are available. These treatments are able to significantly control joint pain and swelling, improve activity level and prevent the progression of disease.
- Rheumatology expertise is particularly needed to establish a diagnosis of RA early, to rule out diseases that mimic RA (thereby avoiding unnecessary testing, drug therapy and costs) and to design a treatment plan that is best suited and customized for the patient and that addresses the need for and the risks and benefits of DMARD therapy.
- Studies have shown that people who receive early treatment of RA feel better, are more likely to lead an active life and are less likely to experience the type of joint damage that leads to joint replacement.
For more information
If you would like more information about the diagnosis and care of rheumatoid arthritis or would like to schedule an appointment, call Dr. Tambar’s office at (773) 696-5855.