Rheumatoid Arthritis does not refer to all forms of arthritis in general. Additionally, it is not a term used to describe any kind of severe arthritis. It is a particular kind of arthritis that starts in the synovium, the soft tissue that surrounds the joint (sin-O-vee um). 1% of Americans have RA, with women greatly outnumber men 2:1 to 4:1. RA can start at any age, although the peak time for onset is between the ages of 30 and 50. The disease worsens most quickly in the first two years after beginning, and people with RA have a death rate that is twice as high as individuals who are the same age inside the general public.
Inflammation of synovium, which causes swelling, discomfort, and morning stiffness and can result in irreparable joint injury and the loss of function, is the fundamental issue with RA. The wrists and tiny joints of the hands, often the first through second row of knuckles after the wrists, are the joints that are most frequently afflicted. The ankles, knees, shoulders, elbows, and joints in the balls of the foot are other joints that are frequently impacted. Although the neck is frequently involved, the lower back is usually unaffected. The same joint on both parts of the body are typically affected by arthritis in a symmetrical fashion.
In Rheumatoid Arthritis, afflicted joints don't just pain; they also sustain progressive deterioration. Without correct treatment, the inflammatory synovium may infect the cartilage and bones around the joint, causing irreparable harm and functional loss. In addition to pain, this may also cause stiffness, deformity, and difficulties using the affected joint. No of their age, color, or gender, people with RA seem to be at risk of problems from this procedure.
While RA's most obvious symptom is joint illness, other organs are frequently affected by the inflammation. Lung function problems can occur in up to 40% of RA patients, albeit they are frequently modest and may go undiagnosed. However, many patients may suffer from severe lung damage necessitating more intensive therapy. About one-fourth of patients will have secondary Sjögren's syndrome, which is characterized by dry mouth and eyes (see the section on secondary Sjögren's syndrome), as well as about 20% will have inflammatory that could irritate the eyes or, less frequently, result in vision loss. Low blood counts & repeated spleen enlargement are symptoms of Fealty’s syndrome, although skin ulcers, rheumatoid vacuities, and less frequently injury to the nerves or even other organs can arise from inflammation of such blood vessels. About 1% of people with RA experience any of these two diseases.
A detailed analysis of a patient's symptoms and a physical examination are the two main methods for diagnosing RA. Although laboratory tests can aid in evaluation, they cannot confirm or exclude a RA diagnosis. A novel antibody known as anti-CCP, indicators of inflammation, and the rheumatoid factor (RF) are all helpful studies and frequently used to estimate the severity of RA in specific patients. In particular, X-rays of the hands and feet are helpful diagnostic tools that can be used to track disease development by determining the extent of joint damage.
Reducing symptoms and averting joint deterioration and impairment are the two main objectives of RA therapy. Today, we have much more tools than ever before to treat RA, and studies have shown that early use of particular drugs has a long-term effect on the progression of the illness. Even while all treatments could have adverse effects, the implications of not treating RA are typically far worse. The ideal meds will be carefully chosen specifically for you as an individual by your doctor and you. In the treatment of RA, non-steroidal anti-inflammatory medications (NSAIDs) like ibuprofen (Motrin), basic analgesics like acetaminophen (Tylenol), or even narcotic-strength painkillers, may be used. However, these treatments are only effective in short-term symptom relief and have no impact on how the disease progresses over the long run. To relieve pain in inflamed joints, many of these drugs may be used in conjunction with other RA treatments.
Prednisone and other corticosteroids may be particularly efficient at quickly reducing inflammation and pain in swollen joints whether administered orally or intravenously. There is some evidence to support the idea that these drugs might potentially prevent joint deterioration. However, the use of corticosteroids in RA is constrained by long-term adverse effects. In general, to prevent these side effects, steroids should only be administered during disease flare-ups, for short periods of time or in low doses (see Medications section).
For the majority of RA patients, disease-modifying anti-rheumatic medications (DMARDs) should be the cornerstone of treatment. Generally speaking, they are more efficient at treating the disease the earlier they are started just after onset of symptoms. To achieve the best response, DMARDs should ideally be started within 3 months of the disease's inception. Since every patient is unique, your doctor will consult with you to choose the best DMARD based on the severity & stage of your illness. These agents are all included in the list below.
Anti-malarial drugs Although they are frequently used to treat milder RA, anti-malarial medications are typically among the healthiest of the DMARDs. It takes 3 to 6 months for hydroxychloroquine (HCQ), also known as Plaquenil, to start working. HCQ can be used alone or in cooperation with other DMARDs. The only potential issue that needs monitoring is injury to the retina, the layer at the rear of the eye that may affect color perception. Although this is concerning, it happens in only one out of every 1,000 people who take the medication and can be caught before major harm is done if your eyes are checked by your eye specialist every six to twelve months. Retinal injury is generally very rare at HCQ doses compared with fewer than 6.5 mg/kg/day.
Sulfasalazine (SSZ) was developed many decades ago to treat RA and is also commonly used to treat Crohn’s disease, an inflammatory intestinal disorder. SSZ takes effect in 1 to 3 months and seems to have a modest effect on slowing down joint damage in RA. This drug also seems to be more effective in patients who are “seronegative” (with a negative RF). The most common side effect of SSZ is stomach upset, which may be eliminated by using a coated preparation of the drug. Allergic reactions are also no unusual. Serious problems, such as a drop in the white blood cells or acute damage to the liver, are unusual and typically occur early in the course of therapy, if at all. Blood tests to monitor for these complications will generally pick up any problems before they become severe.
Methotrexate (MTX) is perhaps the most popular and most commonly prescribed DMARD among rheumatologists, and for good reason. MTX slows joint damage, improves symptoms and physical functioning in RA patients, and has an onset of action of 1 to 3 months after starting the medication. It is taken once weekly in the form of pills or injections, with injections being associated with better availability of the medication and often less side effects. Nausea, mouth sores, thinning of the hair, lowering of blood counts, susceptibility to infection, and liver damage are among the more common side effects and can be reduced by taking folic acid or folic acid (Leucovorin) supplementation. Rarely, acute lung injury may occur that can resemble pneumonia. Despite these potential side effects, problems with MTX can generally be detected with regular lab monitoring every 1 to 2 months. Most importantly, patients with RA taking MTX have a mortality rate that is only 40% of the mortality rate of RA patients not taking the drug. This finding seems to indicate that for most patients, the trade-off between benefit and side effects is very good.
Leflunomide (LEF), marketed under the trade name Arava, is a relatively new drug used to treat RA. It is taken orally once daily and begins to take effect in 1 to 3 months. The efficacy of LEF is similar to that of MTX, and it does seem to slow down the development of joint damage. LEF can result in nausea, diarrhea, hair loss, and liver damage, but the incidence of lowered blood counts and infection are lower than with MTX.
TNF antagonists are perhaps the most exciting class of medications to be recently introduced for the treatment of RA. Currently, there are 3 available medications in this class: etanercept (Enbrel), infliximab (Remicade), and adalimumab (Humira). Enbrel is given as a once weekly injection, Remicade is given as an intravenous infusion every 4-8 weeks, and Humira is administered as an injection every 2 weeks. Each of these medications inhibits a substance known as tumor necrosis factor (TNF) in one way or another. TNF is known to play a key role in inflammation in inflammation and joint damage in RA, and for this reason these medications are highly effective in controlling both the symptoms of the disease and the joint damage. In fact, some studies suggest that these medications actually halt joint damage in RA patients.
Each of the TNF antagonists may begin working within a few weeks of starting therapy. While individual patients may respond more favorably to one agent over another, all of these drugs seem to have similar efficacy. Disadvantages of these therapies include cost, inconvenience of injections or infusions, injection site or infusion reactions, and suppression of the
Immune system. Respiratory infections occur in increased frequency in patients treated with TNF antagonists, and those exposed to tuberculosis may experience reactivation of their disease. For this reason, a TB skin test is recommended prior to starting therapy. Patients with multiple sclerosis or severe congestive heart failure may experience worsening of their disease and therefore should not take these medications. Thus far, cancer rates have not been clearly shown to be increased in RA patients taking TNF antagonists versus other RA patients, but the data is somewhat confusing. Recently, the press has publicized an increased rate of a cancer known as lymphoma in patients taking these medications, but this was compared to the normal population. Because RA patients as a whole have an increased risk of lymphoma, it is not clear if the medications themselves or the disease accounts for this increased rate.
On the whole, we have found these medications to be well worth the cost and the potential side effects and have seen them virtually eliminate signs of active disease in patients resistant to many of our standard therapies. Currently, we are using TNF antagonists mostly in patients who have inadequately responded to MTX or other therapies. Most often, these drugs are added to MTX and may be more effective when used in this manner but may also be used alone. Use of TNF antagonists earlier in the course of the disease is being investigated and may be recommended for certain patients in the future.
Miscellaneous drugs that are less commonly used to treat RA but which may be useful in certain individuals include minocycline, azathioprine (Imuran), injectable gold, D-penicillamine, and anakinra (Kineret).
Minocycline is an antibiotic that is also used to treat acne and other skin diseases. Like HCQ, minocycline is usually used to treat milder RA, but one study showed that if started within one year of disease onset and continued for one year, up to 40% of patients went into remission. Other than nausea, dizziness, and sun sensitivity in some individuals, minocycline is usually very well tolerated.
Imuran is a medication that suppresses the immune system and may be effective at reducing the inflammation in the joints of RA patients as well as in other organ systems, such as the lungs. Increased infection rates, lowered blood counts, and liver damage are potential side effects.
Injectable gold is given once weekly in the doctor’s office and must be monitored closely, including blood and urine tests with each visit to screen for low blood counts and protein in the urine. Rashes, damage to the liver, and lung damage are also potential side effects. While effective in treating RA, the inconvenience, toxicity, and delayed onset of action (4 to 6 months) have made gold a less popular choice among rheumatologists and patients.
D-penicillamine, a drug also used to bind toxic levels of heavy metals in the body, has a therapeutic effect in RA. The toxicity of this agent, however (blood cells, kidneys, liver, secondary autoimmune diseases), has led to less frequent use in treating RA patients.
Kineret is a newly introduced injectable drug given once daily and inhibits a substance known as interleukin-1 (IL-1). While effective in a subset of RA patients, responses to therapy are generally less dramatic that those seen with TNF antagonists. A somewhat increased infection rate and injection site reactions are the most commonly observed side effects.
