Let's talk about Rheumatoid Arthritis

Rheumatoid Arthritis (RA), according to the Portuguese Society of Rheumatology (Sociedade Portuguesa de Reumatologia — SPR), is an inflammatory, chronic and autoimmune disease, characterized by the “inflammation of the joints and can lead to the destruction of joint and periarticular tissues.”

Patients often experience swelling, stiffness and pain in the joints on both sides of the body, with a greater incidence in the fingers, knees and ankles, which generally have an impact on their mobility and freedom of movement to carry out their daily tasks. It is, moreover, this symmetry of symptoms (affecting both sides of the body) that makes it possible to differentiate this disease from other forms of arthritis.

Joint inflammation, if not contained in a timely manner, can lead to bone deformities and other serious health problems. The eyes, nerves and lungs can be affected, and  the the arteries can even get clogged, which can trigger heart attacks and strokes.

Although it is a chronic disease, that is, without a cure, this does not mean that it cannot be effectively treated. If identified at an early stage, inflammation can be suppressed using drug therapies, which are constantly evolving and being improved, thus resulting in a substantial improvement in long-term vital and functional prognosis.

This autoimmune disease has a considerable prevalence in the global population. In Portugal, according to the Portuguese Institute of Rheumatology (Instituto Português de Reumatologia — IPR), it is estimated that RA affects around 50 to 60 thousand people (0.8 to 1.5% of the population). In the UK, an incidence of around 1% of the population is estimated, with around 400,000 adults over the age of 16 being affected. In France, around 250,000 adults suffer from the disease. In the US, approximately 1.3 million adults suffer from RA, about 0.6 to 1% of the population. We can thus say that the prevalence in industrialized countries varies between 0.5 and 1.5% of the population, which means that this is not a rare disease.

Of all those affected, women between the ages of 30 and 60 are the most afflicted. Globally, the occurrence of RA is two to four times higher in women than in men. Although the peak incidence in women is after menopause, this is a disease that can affect people of all ages and genders, including children and adolescents.

Main symptoms

Symptoms of Rheumatoid Arthritis (RA) vary from person to person. Generally, the disease starts with the presence of a symmetrical polyarthritis, that is, more than 4 joints are affected on both sides of the body. The most commonly affected joints tend to be the smaller ones in the hands and feet.

This inflammation of the joints (arthritis), a typical feature of this disease, is usually responsible for the swelling (edema), pain, redness and a feeling of heat in the joints. Patients tend to experience stiffness of joint motion in the mornings or after periods of prolonged inactivity.

According to the SPR, “As the disease progresses, more joints can become inflamed, including shoulders, elbows, hips, and knees”, since any joint with a synovial membrane (which is the membrane that lines some joints and tendons and produces a lubricating fluid that nourishes and facilitates joint movement) may be affected, such as the first cervical joint.

If left untreated, this inflammatory disease can result in the progressive destruction of joints, leading to loss of function. When the joints are destroyed, we witness progressive bone and joint deformities, the most characteristic being the deformities in the hands.

The symptoms of RA are not limited, however, to the joints. Difficulty in movement can lead to a loss of muscle mass through atrophy, to weight loss, fatigue, fever and loss of appetite.

Several organs can be affected by the disease, and it can manifest itself in other ways:

  • Dry eyes or eye inflammation
  • Skin lesions or leg ulcers
  • Emergence of rheumatoid nodules
  • Compression of peripheral nerves
  • Pleural inflammation (membrane that lines the lungs)
  • Inflammation of the pericardium (membrane that lines the heart)
  • Increase in liver size and production of liver enzymes
  • Other disorders such as thyroid, osteoporosis and depression
  • The risk of developing diabetes may also be increased

According to the IPR, although symptoms may be mild in some people, with short duration and possibility of reminiscence (asleep state), in certain people the symptoms can be moderate with occasional attacks, and there may even be some patients who suffer from severe illness and frequent seizures.

Main causes

The exact cause of Rheumatoid Arthritis (RA) is not yet known. What we do know is that, being an autoimmune disease, the immune system does not work properly and reacts against the patient’s own tissues. But, according to SPR, the « cause of the immune system deregulation in RA is unknown. »

Everyday, we are witnessing an increase in research in this area that allows us to identify certain risk factors and that it is the association of these risk factors with a genetic predisposition possibly causing the disease.

The known risk factors as of today are:

  • genetic predisposition
  • feminine gender
  • smoking
  • excessive weight
  • hormonal imbalances
  • possibly depression (still debatable)

Diagnosis

Since Rheumatoid Arthritis (RA) is a disease for which there is currently no known cure, it is essential that an early diagnosis is made (ideally within the first 3 months of the onset of the first symptoms) and that treatment begins as soon as possible. This way, the progress of the disease can be significantly influenced.

The medical specialty dedicated to this disease is Rheumatology, and the specialist physician being the Rheumatologist. The initial diagnosis, however, does not need to be carried out by a specialist doctor. The physician only has to be able respond to the challenge of recognizing the symptoms in a timely manner.

After the symptoms are recognized by the physician, he/she performs a physical examination of the patient, which is complemented by an assessment of his/her clinical history and by performing X-rays of the hands and feet. With this data, the doctor can usually diagnose whether the patient’s joint symptoms are due to RA.

As a way to rule out other possible diseases and confirm the diagnosis, the doctor may order other laboratory blood tests:

  • Sedimentation velocity and protein C
  • Blood count
  • Presence of antibody known as Rheumatoid Factor
  • Presence of antibody against citrullian peptides (anti-CCP)
  • Presence of antinuclear antibody (ANA)

Tests that rule out other autoimmune conditions, such as lupus or psoriatic arthritis, should also be ordered.

Treatment

In recent years, we have seen a substantial improvement in treatment strategies for Rheumatoid Arthritis (RA), making it possible to live with the disease in a functional way.

According to the SPR, “on the one hand, there was an improvement in treatment strategies with the effective use of existing disease-modifying drugs; on the other hand, new drugs have emerged”.

The treatment of RA does not rely, however, solely on drug-based treatments, but rather on a combination of lifestyle improvement measures, specific treatment for the disease, and strength and mobility improvement therapies:

LIFESTYLE IMPROVEMENT

  • healthy and regulated diet, with lower intake of inflammatory foods (sugar, alcohol, fried foods, etc.), ideally under the supervision of a nutritionist;
  • regular physical exercise, in order to reduce or prevent excess weight, as it wears out the joints and promotes other diseases such as hypertension and diabetes. With essential follow-up and medical guidance;
  • stop smoking, as it is recognized that tobacco smoke is associated with bone degeneration.

SPECIFIC TREATMENT

  • Classic DMARDs (Disease Modifying Anti-Rheumatic Drugs) — should be used alone or in combination once the diagnosis is confirmed. These control the symptoms and signs of RA, as well as decrease the risk of deformities. Methotrexate is the most widely used drug due to its good profile of efficacy and toxicity.
  • Biological DMARDs — are molecules that modulate cytokines (inflammation proteins) and have been shown to be effective in the treatment of RA, including Methotrexate-resistant patients. The introduction of these drugs is done in very specific situations and in accordance with the guidelines of the SPR.
  • anti-inflammatory drugs (NSAIDs) — relieve the symptoms of the disease (inflammation of the joints), but do not stop the progression of the disease. NSAIDs may interact with other medications or be contraindicated in your case. Therefore, taking it without a doctor’s prescription is not recommended.
  • pain relievers — should be considered as an aid to the patient who cannot bear joint pain.
  • Corticosteroids — in low doses they can be used in combination with DMARDs, helping to control symptoms in the short term and to minimize medium and short term joint damage. These may be prescribed in higher doses and for a short duration to rapidly reduce symptoms in recent RA patients or in an outbreak of the disease. There is an increased risk of potentially serious effects (diabetes, osteoporosis, cataracts), the doses recommended by your doctor must be respected. They can also be given intravenously when a specific joint causes more pain or relieves symptoms of more problematic joints.
  • Surgery — surgical intervention can be considered in very specific cases.

COMPLEMENTARY THERAPIES

  • Physiotherapy — a recovery plan for the affected joints and limbs must be prepared by a specialist, for muscle strengthening and training in activities of daily living.
  • Complementary therapies — therapies such as acupuncture, can be considered to help with pain and mobility.

Monitoring

Since Rheumatoid Arthritis (RA) is a chronic disease, it will accompany the patient throughout life, in a more or less severe way. Therefore, regular monitoring of the disease should be carried out, with regular visits to the doctor and frequent blood tests, in order to assess the prescribed therapy and its possible adverse effects.

Considering this disease can trigger the development of other diseases, those should be screened regularly as well.

Prevention

The specific cause of Rheumatoid Arthritis (RA) is not yet known, we know only that it arises through a combination of risk factors and multiple genetic, immunological and environmental factors. So, to prevent AR we must reduce the risk factors.

We can, indeed, reduce the possible complications and limitations that uncontrolled and advanced stages of the disease cause in people’s mobility, through early diagnosis and treatment.

Living with Rheumatoid Arthritis

Nowadays, Rheumatoid Arthritis (RA) cannot be considered a severely debilitating disease, especially if it is early diagnosed and treatment is started quickly and effectively.

Patients usually go through several periods of worsening and remissions, so patient adherence to prescribed therapy is essential for remissions to overlap the periods of worsening.

As a way to reduce the impacts on mobility and the difficulty of performing daily activities, patients should maintain a regular exercise plan. This way, they will strengthen the muscles around the joints and fight fatigue. The most recommended exercises for patients with RA are water aerobics and swimming.

When the patient feels pain in the joints, he/she should apply heat or cold to them, as heat relieves pain and promotes relaxation, and cold also relieves pain and reduces muscle spasms.

It is also essential that the patient is able to relax, learning and applying relaxation techniques such as meditation or yoga, in order to learn to control the pain.

In cases where the disease is already advanced and/or the treatment has been delayed, more severe orthopedic complications may occur, which sometimes have a strong impact on the lives of patients with RA. In these cases, the adaptation to the disease can be more complicated and cases of clinical depression are not rare and should be followed up by specialists.

The patient must also take into account the potential for infectious complications caused by the disease or the treatments.

In all cases, patients should not resort to self-medication and should always be accompanied by a doctor in their treatment.