Rheumatoid arthritis (patient information)

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 * Jinhui Wu, MD Associate Editor-In-Chief: Ujjwal Rastogi, MBBS [mailto:urastogi@perfuse.org]

Overview
Rheumatoid is an autoimmune disease that typically affects the small joints in your hands and feet. The cause is not clear. When the disease is active,usual signs and symptoms include morning stiffness, joint pain and swelling, rheumatoid nodules, fatigue and weakness, low fever, and weight loss. Blood tests on rheumatoid factor, anti-cyclic citrullinated peptide (anti-CCP) and antinuclear antibody (ANA) can not only help diagnose but also help assess prognosis. Joint images such as x-ray and MRI may help track the progression of rheumatoid arthritis in the joints over time. Treatment opinion includes medications, physical therapy and surgery. The opinion depends on the diesease condition. Prognosis of rheumatoid arthritis varies from person to person. Some patients may get less aggressive over time, while others may lose their abilities of doing daily tasks.

Images courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology



What are the symptoms?
Affected joints of rheumatoid arthritis include the fingers, wrists, elbows, shoulders, hips, knees, ankles, toes, jaw, and neck. Signs and symptoms come and go, depending on the degree of tissue inflammation. When the disease is active, the following symptoms appear.
 * Morning stiffness in the joints
 * Joint pain
 * Joint swelling
 * Rheumatoid nodules: Firm bumps of tissue under the skin on the arms.
 * Fatigue and weakness
 * Low fever
 * Weight loss
 * When heart is affected, patient may show signs of chest pain, shortness of breath or edema of lower limbs.

Who is at highest risk?
As a autoimmune disease, the cause of rheumatoid arthritis is not clear.

When to seek urgent medical care?
Call your doctor if your symptoms of rheumatoid arthritis progress.

Diseases that can present with similar symptoms are
 * Gout
 * Osteoarthritis

Diagnosis
To come to a proper diagnosis, your doctor might run the following test
 * Blood tests: These tests can assist in making a diagnosis of rheumatic arthritis.
 * Rheumatoid factor and anti-cyclic citrullinated peptide (anti-CCP) and antinuclear antibody (ANA): These antibodies can be found in most of patients with rheumatoid arthritis.
 * Sedimentation rate (ESR): This test can measure how much inflammation is in the body. Patients with rheumatoid arthritis may show an increased ESR.
 * Complete blood count


 * Synovial fluid examination: When a patient demonstrate the signs of acute inflammatory arthritis, it is necessary to aspirate synovial fluid of the involved joint to rule out an infectious arthritis. During the procedure, the doctor may use a needle to draw fluid from your affected joint. Based on the discovery of urate crystals in the synovial fluid or soft tissues, the doctors can confirm the diagnosis.
 * Joint x-ray: This image can help track the progression of rheumatoid arthritis in the joints over time.
 * Magnetic resonance imaging (MRI): An MRI uses magnetic fields but it is a different type of image than what is produced by computed tomography (CT) and produces detailed images of the joint.

Images courtesy of RadsWiki

Treatment options
There is no cure for rheumatoid arthritis. Treatment opinion includes medications, physical therapy and surgery. The opinion depends on the diesease condition.
 * Medications: The goal of medications can reduce inflammation to relieve pain and prevent or slow joint damage.
 * Nonsteroidal anti-inflammatory drugs (NSAIDs): NSAIDs may be used to control inflammation and pain in patients with rheumatoid arthritis. Usual drugs include ibuprofen, naproxen and indomethacin. Usual side effects are [][pain]], bleeding and ulcers in upper gastrointestinal tract.
 * Corticosteroids: Corticosteroids are generally prescribed for patients who cannot take NSAIDs. These drugs can be used by oral or by injection into the joint to control inflammation and pain. Side effects of corticosteroids may include a decreased ability against infection, worse healing in the wound and osteoporosis.
 * Disease-modifying antirheumatic drugs (DMARDs): These drugs can slow the progression of rheumatoid arthritis and prevent the joints and other tissues from permanent damage. Usual medications of DMARDs include methotrexate, leflunomide, hydroxychloroquine, sulfasalazine and minocycline. Side effects include liver damage, bone marrow suppression and severe pulmonary infections.
 * Immunosuppressants: Because rheumatoid arthritis is a autoimmunedisease, immunosuppressants can be use to control your immune system. Common medications include azathioprine, cyclosporine and cyclophosphamide. Side effects may include a decreased ability against infection.
 * TNF-alpha inhibitors: TNF-alpha inhibitors, such as etanercept, infliximab and adalimumab, can also help relieve symptoms of rheumatoid arthritis. Side effects include injection site irritation, congestive heart failure, lymphoma and increased risk of infection.


 * Physical therapy: The aim of physical therapy is to teach you how to protect the joints. The therapist can treat you by hands or by assistive devices. Common therapies include:
 * Range-of-motion exercises
 * Joint protection techniques
 * Heat and cold treatments
 * Deep heat or electrical stimulation treatments


 * Surgery: If medications fail to prevent or slow joint damage, surgery may be recommended to repair damaged joints and restore your ability to use the joints. Surgeries on rheumatoid arthritis include:
 * Total joint replacement (arthroplasty)
 * Tendon repair
 * Removal of the joint lining (synovectomy)
 * Joint fusion (arthrodesis)

Where to find medical care for rheumatoid arthritis?
Directions to Hospitals Treating rheumatoid arthritis

Prevention of rheumatoid arthritis
For the cause is not clear, the prevention of rheumatoid arthritis is unknown.

What to expect (Outlook/Prognosis)?
Prognosis of rheumatoid arthritis varies from person to person. Disease may get less aggressive over time in some patients. In other group, patients may lose their abilities of doing daily tasks. Prognosis depends on:
 * Whether the patient shows rheumatoid nodules or not: Patients with subcutaneous nodules seem to have a more severe form of the disease.
 * Rheumatoid factor, anti-CCP antibody test: Patients with positive outcomes of rheumatoid factor, the anti-CCP antibody may have a worse outlook than those who have a negative outcomes.
 * Tha age of developing rheumatoid arthritis: If the patient develops rheumatoid arthritis at younger age, the prognosis seems poor.