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Rheumatoid Arthritis (RA) |
Rheumatoid arthritis (RA) is a chronic, progressive disease in which various joints of the body are inflamed, leading to swelling, stiffness, pain, and possibly loss of function. In RA, an error in the immune system causes production proteins that cause destruction and inflammation of the synovium. The synovium is a sac around a joint that lubricates the joint and protects the cartilage between joints. When the protective synovium is damaged the cartilage is gradually destroyed, narrowing the joint space and eventually damaging bone. Eventually, a pannus (growth composed of thickened synovial tissue) is formed, which causes damage to the remaining cartilage and bones. The involved joints can lose their shape and alignment, leading to pain and loss of function.
Affected areas of RA include:
- hands
- wrists
- elbows
- shoulders
- neck
- hips
- knees
RA also can harm other parts of the body, including the eyes, heart, lungs, and kidneys.
Rheumatoid arthritis (RA) affects nearly 2.1 million Americans, almost three-fourths of whom are female. Every year, RA results in more than 9 million doctor visits and more than 250,000 hospitalizations.
The disease can occur at any age from childhood to old age, but usually starts in young adults and peaks in middle age.
The exact cause of rheumatoid arthritis (RA) is not known. Several factors have been examined that may lead to the discovery of a possible cause of the disease.
The Immune Response
- The body's natural immune system does not function normally, resulting in the immune system attacking healthy joint tissue and causing inflammation and resulting in joint damage.
Genetic Factors
- Heredity, or the genes you get from your parents, may be a factor. It is believed that specific genes are involved in the process of RA and that these genes are required to activate the disease. However, not all people who inherit these genes have RA.
Biologic Factors
- While no bacteria or viruses have been shown to cause RA, it is believed that they may trigger the disease in people who have an inherited tendency for the RA.
- People with RA appear to have a below-normal level of cortisol, a hormone that has anti-inflammatory properties.
Other risk factors may place susceptible people at an increased risk of developing rheumatoid arthritis (RA). Risk factors include:
- Heavy smoking, especially in patients without a family history for RA
- Women who have a shorter reproductive life (lower levels of reproductive hormones)
- History of blood transfusions
- Obesity
- In rare cases, use of interferon-alpha (used to treat hepatitis and other diseases)
Pain, stiffness, swelling, redness, and difficulty moving the joints with full range of motion are the most commonly reported symptoms of rheumatoid arthritis (RA). Stiffness seen in active RA is typically worst in the morning and can last from one hour to an entire day. This long period of morning stiffness is an important diagnostic clue, as not many other arthritic diseases behave this way. While RA can affect just about any joint, some joints — especially those of the hands and feet — tend to be involved more frequently. This produces a pattern of joint disease that rheumatologists regard as characteristic of RA. It is common for the same joint on both sides of the body (for example, the right and left wrists) to both have symptoms of RA. In addition to the above complaints, other symptoms that can occur in RA include:
- loss of energy
- low-grade fevers
- loss of appetite
- dry eyes and mouth producing a condition known as Sjogren’s (pronounced “show-grens”) Syndrome
- soft skin lumps in areas such as the elbow and hands, called rheumatoid nodules.
Rheumatoid arthritis (RA) can be difficult to diagnose because symptoms may occur gradually. Many diseases, especially early on, can behave similarly to RA. For this reason, patients suspected of suffering from 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.
A diagnosis of RA is based on the symptoms described by the patient and physical examination findings characterized by warmth, swelling, and pain in the joints. X-rays can be very helpful in diagnosing RA and can be used to determine if the disease is progressing. In addition, the following abnormal lab values are utilized by physicians as diagnostic aids:
- anemia (low red blood cell count)
- positive rheumatoid factor (antibody found in approximately 80 percent of RA patients)
- elevated erythrocyte sedimentation rate (ESR or "sed-rate"- a blood test that tends to correlate with the amount of inflammation in the joints
It is important to remember that for the majority of patients with this disease (especially those who have had symptoms for six months or less), there is no single test, whether a blood test or an X-ray, that can "confirm" a diagnosis of RA. Rather, the diagnosis is typically established when the physician combines the appropriate symptoms, physical examination findings, laboratory tests, and X-rays.
Daily life: Affected joints can become deformed and the performance of ordinary tasks may be very difficult or impossible.
Other parts of the body: In addition to joints, RA can affect other parts of the body. People with severe RA may be at higher risk for complications such as the following:
- Peripheral neuropathy: A condition that affects the nerves, most often nerves in the hands and feet. It can result in tingling, numbness, or burning.
- Anemia: A low red blood cell count. Red blood cells deliver oxygen to your body's tissues.
- Scleritis: An inflammation of the blood vessels in the eye that could result in corneal damage.
- Infections: RA patients have a higher risk for infections, which may be caused by immune-suppressing drugs used to treat RA.
- Gastrointestinal problems: Patients may experience stomach and intestinal distress.
- Osteoporosis: Disorder in which bone density decreases, is more common than average in postmenopausal women with rheumatoid arthritis. The hipbone is particularly affected. The risk for osteoporosis in men with RA over the age of 60 also appears to be higher than average.
- Lung disease: There may be an association between a history of smoking and increased risk for RA. Cigarette smoking, in any case, may also increase the severity of the disease.
- Heart disease: There is growing evidence that RA can increase the risk for heart disease, possibly because of the inflammatory response in RA, which may injure arteries and heart muscle tissue.
- Lymphoma and other cancers: Alterations in the immune system associated with RA and certain RA treatments may play a role in the higher risk for lymphoma observed in RA patients. Patients who have had total lymphoid irradiation, a RA therapy popular in the 1980s, may have a higher risk for lymphoma and blood cancers. People with RA may also have increased frequency of prostate and lung cancer. Aggressive treatments for RA that suppress the immune system may help prevent such cancers, but more research is needed to evaluate this possibility.
- Periodontal disease: People with RA may be twice as likely as non-arthritic individuals to have diseases of the teeth, gums, and mouth. Chronic inflammation and immune dysfunction play a role in both diseases.
Long-term effects: Rheumatoid arthritis (RA) is a progressive disease that can lead to permanent deformities and bone and ligament destruction. However, in some patients the disease becomes less aggressive and symptoms may improve over time. RA is not fatal, but complications of the disease may decrease survival by a few years in some individuals.
There is no known cure for rheumatoid arthritis (RA). The goal of treatment is to minimize symptoms and disability by introducing appropriate drug therapy early in the course of the disease, before permanent damage to the joints has occurred.
The primary goals of treatment are to:
- reduce inflammation
- prevent damage to the bones and ligaments of the joint
- preserve movement
- keep the patient free from side effects or minimize side effects over the long term.
Successful management of rheumatoid arthritis (RA) requires early diagnosis and, at times, aggressive treatment.
Nonsteroidal anti-inflammatory drugs (most commonly referred to as NSAIDs) such as Motrin®/Advil® (ibuprofen) or Naprosyn® (naproxen) are usually the initial drugs used to treat RA. These drugs reduce joint pain, reduce swelling, and improve joint function. NSAIDS do not alter the course of the disease or prevent joint destruction. They should not be used as the only treatment for RA. Patients receiving NSAIDs should also receive other medications for the treatment of RA.
It is also important to note that the Food and Drug Administration has issued black box warnings for the use of NSAIDs:
- NSAIDs, including Celebrex®, may increase the risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke, which can be fatal. This risk may increase with duration of use. Patients with cardiovascular disease or risk factors for cardiovascular disease may be at greater risk.
- NSAIDs increase the risk of serious gastrointestinal adverse events including bleeding, ulceration, and perforation of the stomach or intestines, which can be fatal. These events can occur at any time during use without warning symptoms. Elderly patients are at greater risk for serious gastrointestinal events.
Cyclooxygenase 2 inhibitors (commonly referred to as COX-2 inhibitors), such as Celebrex® (celecoxib) are prescription NSAIDs used to treat RA. Celebrex® (celecoxib) is currently the only COX-2 inhibitor available and shares the same black box warnings as other NSAIDs.
Disease-modifying antirheumatic drugs (commonly referred to as DMARDs) such as Rheumatrex® (methotrexate), Plaquenil® (hydroxychloroquine), or Azulfidine®/Azulfidine EN-tabs® (sulfasalazine), also are used to treat RA. These drugs have the potential to reduce or prevent joint damage, preserve joint integrity and function, and maintain productivity of the RA patient. The majority of patients with newly diagnosed RA are started on DMARD therapy within three months of diagnosis.
Corticosteroids, such as Deltasone® (prednisone) are highly effective in relieving symptoms in patients with active RA. Low-dose oral corticosteroids may be used in some patients who cannot take NSAIDs and have also been used in conjunction with DMARDs. Evidence suggests that low-dose corticosteroids slow the rate of joint damage. Corticosteroids may be injected directly into a joint for relief of RA flare-ups. In general, the same joint should not be injected more than once within three months.
A newer class of medications, referred to as biologic response modifiers or "biologic agents" can specifically target parts of the immune system (tumor necrosis factor-alpha [TNF-a] and interleukin-1 [IL-1]) that lead to joint and tissue damage in RA. FDA-approved treatments include Enbrel® (etanercept), Remicade® (infliximab), Humira® (adalimumab), and Kineret® (anakinra). Improvement is usually seen within the first two weeks of treatment. These drugs are administered by subcutaneous or intravenous injection and have a high cost. They should not be used in patients with significant chronic infections or active infections. Not all RA patients respond to these therapies, and disease flare-ups occur after therapy is discontinued.
Other drugs used in the treatment of RA include Ridaura® (auraofin), Myochrysine® (gold sodium thiomalate), Arava® (leflunomide), Neoral® (cyclosporine), Imuran® (azathioprine), and Cuprimine® (penicillamine).
No one treatment is effective for all patients and many patients will need to change therapies during the course of the disease.
- This technique filters the blood and removes certain antibodies that cause pain and inflammation in rheumatoid arthritis (RA). The procedure lasts for about 21/2 hours and is performed once a week for 12 weeks in an outpatient setting.
- Side effects may include anemia, fatigue, itching, fever, a drop in blood pressure, and nausea. Nearly all patients experience an immediate flare-up of joint pain that lasts a few days. Some patients may develop an infection from the catheter used to remove blood.
Joint Surgeries
- Arthroscopy is a surgical technique whereby a doctor inserts a tube-like instrument into a joint to inspect, diagnose, and repair tissues. It is performed to remove bone and cartilage fragments that cause pain and inflammation. Arthroscopy is usually performed on the knee, but also may be performed on the hip.
- Osteotomy refers to removal of part or all of a bone or cutting into or through bone. It is performed only if a certain section of the knee is damaged and deformed.
- Synovectomy refers to surgical removal of the joint lining. It is performed to remove a diseased joint lining (synovia). Synovectomy is used when more conservative measures fail, particularly in the wrist.
- Joint replacement surgery (arthroplasty) is performed when RA progresses to the point that normal functioning of a joint is not possible.
Since the cause of rheumatoid arthritis (RA) is still unknown, there currently is no way to prevent it. As research into RA continues, preventive measures may be found to decrease an individual's chances of developing this disease.
It is important to maintain a balance between rest (which will reduce inflammation) and exercise (which will relieve stiffness and weakness). Studies have suggested that even as little as three hours of physical therapy over six weeks will help people with rheumatoid arthritis (RA), and that these benefits are sustained. The goal of exercise and physical therapy is to:
- maintain a wide range of motion
- increase strength, endurance, and mobility
- improve general health
- promote well-being
The following approach may be helpful in reaching treatment goals, but discuss these with your physician before beginning a new exercise program.
- Start with the easiest exercises, stretching and tensing of the joints without movement.
- Next, attempt mild strength training.
- Aerobic exercises may then be tried, for example, walking, dancing, or swimming (particularly in heated pools). Avoid high-impact exercises such as running, downhill skiing, and jumping.
- T'ai chi, which uses slow sweeping movements, is an excellent method for combining stretching and range-of-motion exercises with relaxation techniques. Many elderly RA patients report significantly less pain after practicing this technique.
While traditional guidelines have restricted RA patients to only gentle exercise, recent research suggests that more intense exercise may not only be safe, but may actually produce greater muscle strength and overall functioning. Common sense is the best guide when exercising:
- If exercise is causing sharp pain, stop immediately
- If aches and pains continue for more than two hours after exercise, then a lighter exercise program should be tried for a while.
- Using large joints instead of small ones for ordinary tasks can help relieve pressure — for instance, closing a door with the hip or pushing buttons with the palm of the hand.
Reducing stress may help prevent some RA flare-ups. It is important to manage stress well by identifying triggers, removing negative stress in your life, and having coping mechanisms if stress occurs.
Gene therapy and stem cells are being proposed as therapeutic measures to treat rheumatoid arthritis (RA).
Gene transfer is being researched to provide a more efficient and sustained way to deliver agents that inhibit the inflammatory cytokines (immunoregulatory substances) of RA.
Stem cells are also being evaluated for tissue repair in arthritic disease, including bone and cartilage.
The Arthritis Foundation® can give you information about rheumatoid arthritis (RA) support groups in your area. These support groups can help you find other people who may share your interests or concerns about RA. Contact the Arthritis Foundation on the Internet at http://www.arthritis.org/communities/rahome.asp or by phone at 1-800-568-4045.
It is important to find a pharmacy that understands the complexities of injectable medications for rheumatoid arthritis (RA). Walgreens Specialty Pharmacy was created to help with some of the time-consuming tasks of medication management of RA patients. Specially trained Walgreens pharmacists join your treatment team, working hand in hand with your physician and other healthcare providers, to support their services and help ensure that you receive the best results from your (or your child or partner's) RA therapy.
To enroll in Walgreens Specialty Pharmacy program, call us toll free at 1-888-782-8443, or click here for an enrollment form.
Arthritis Foundation
www.arthritis.org
National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)
www.niams.nih.gov
MedLine Plus — Rheumatoid Arthritis
www.nlm.nih.gov/medlineplus/rheumatoidarthritis.html
Mayo Clinic
www.mayoclinic.com
- Enbrel [package insert]. Cambridge, MA: Immunex Corporation; July 2005
- Remicade [package insert]. Malvern, PA: Centocor; September 2005.
- Kineret [package insert]. Thousand Oaks, CA: Amgen, Inc.; February 2005.
- Humira [package insert]. North Chicago, IL: Abbott Laboratories; October 2005.
- Arava [package insert]. Kansas City, MO: Aventis Pharmaceuticals Inc.; March 2005.
- Reents S, Seymour J. Clinical Pharmacology, Version 5.05, Rheumatrex. Standard Multimedia Inc., producers, Tampa, FL; 2005.
- Reents S, Seymour J. Clinical Pharmacology, Version 5.05, Plaquenil. Standard Multimedia Inc., producers, Tampa, FL; 2005.
- Reents S, Seymour J. Clinical Pharmacology, Version 5.05, Azulfidine. Standard Multimedia Inc., producers, Tampa, FL; 2005.
- Arthritis Foundation. Accessed September 2005 at www.arthritis.org
- MedLine Plus - Rheumatoid Arthritis. Accessed September 2005 at http://www.nlm.nih.gov/medlineplus/rheumatoidarthritis.html
- Rheumatoid Arthritis Fact Sheet - American College of Rheumatology. Accessed September 2005 at http://www.rheumatology.org/public/factsheets/index.asp?aud=pat
- American College of Rheumatology subcommittee on Rheumatoid Arthritis Guidelines: Guidelines for the Management of Rheumatoid Arthritis. Arthritis & Rheumatism 2002; 46(2): 328-346
- National Institute of Arthritis and Musculoskeletal and Skin Diseases. Accessed September 2005 at http://www.niams.nih.gov
- Shanahan JC, Moreland LW, Carter RH. Upcoming biologic agents for the treatment of rheumatic diseases. Current Opinion in Rheumatology 2003;15:226-236
- Furst DE, Breedveld FC, Kalden JR, et al. Updated consensus statement on biological agents for the treatment of rheumatoid arthritis and other rheumatic diseases (May 2002). Ann Rheum Dis 2002;61(Suppl II):ii2-ii7.
- 16. Robbins PD, Evans CH, Chernajovsky Y. Gene therapy for arthritis. Gene Therapy 2003;10:902-911.
- Jorgensen C, Noel D, Apparailly F, Sany J. Stem cells for repair of cartilage and bone: the next challenge in osteoarthritis and rheumatoid arthritis. Ann Rheum Dis 2001;60:305-309
- Fleischmann R. Safety and efficacy of disease-modifying antirheumatic agents in rheumatoid arthritis and juvenile rheumatoid arthritis. Expert Opin Drug Saf. 2003;2(4):347-365.
- 19. Firestein GS. Evolving concepts of rheumatoid arthritis. Nature 2003;423:356-361
- Cannella AC, O'Dell JR. Is there still a role for traditional disease-modifying antirheumatic drugs (DMARDs) in rheumatoid arthritis. Current Opinion in Rheumatology 2003;15:185-192.
- Gendreau RM. Prosorba Clinical Trial Group. A randomized double-blind sham-controlled trial of the Porsorba column for treatment of refractory rheumatoid arthritis. Ther Apher 2001;5(2):79-83.
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