Rheumatoid Arthritis (RA)
system is quieted down with the biologics or other DMARDs (Disease Modifying Anti-Rheumatic Drugs), like methotrexate.
For most patients with moderate to severe RA (>75%), methotrexate is insufficient in halting the bone damaging process, requiring the addition of the
biologic medications, that do a great job of stopping the disease in its tracks. The biologics not only decrease joint pain and swelling, they also preserve
joint structure and function, ultimately, preserving a patient’s quality of life too.
pain, swelling and destruction of the joint space and bones. RA typically involves the joints in your hands, wrists, feet and ankles, but can involve almost any
Although almost anyone can develop RA, it typically affects women in their 30’s to 40’s. Among individuals with RA, women are affected three times more
commonly than men. RA has been seen in all ethnic groups and in all parts of the world.
What causes RA?
The cause of RA is still unknown, although we know that the body’s immune system plays an important role in causing the joint inflammation and damage.
Your immune system normally helps your body to fight off infections and monitor for pre-cancerous cells. In RA, the cells of the body’s immune system start
to attack the joints and other organs it is normally supposed to protect.
Genes play an important role in the development of RA, however genes associated with the development of RA are found in many people who will never
develop RA. In other words, simply having the genes that predispose you to develop RA is not sufficient to cause RA by itself. In many auto-immune
diseases like RA, there needs to be a triggering event (stress, infection) in an individual who may have predisposing genes, which then leads to the
development of RA. Gene testing is not helpful in the diagnosis and care of patients with RA and thus not typically performed unless for research purposes.
What are the symptoms of RA?
The typical symptoms of RA include joint pain, warmth and swelling, which is associated with more than 30 minutes of morning stiffness. The joints that
are typically affected in RA are circled in the picture below. RA patients typically need “time to warm up” to loosen their stiff joints in the morning and may
find some relief from a warm shower or running warm water over their hands. You may also have low grade fevers, have less energy or may become
anemic (low blood count) due to the inflammation process which is also occurring in the blood. RA is also associated with another auto-immune process
known as Sjogren’s syndrome, which causes dry eye and dry mouth symptoms.
Persons with more aggressive RA can also develop rheumatoid nodules, which are lumps that form under the skin, over bony areas like the elbow. They
can also develop inflammation of the lining of the heart (pericarditis), lungs (pleuritis) or the eye (scleritis), which can cause chest pain, pain with taking a
breath or a red, painful eye respectively. In very severe cases, RA causes vasculitis (inflammation of blood vessels), which can affect the skin, nerves, brain
and kidneys. If you have been diagnosed with any of these “extra-articular manifestations,” (inflammation of other organs besides the joints) you may have
How is RA diagnosed?
In order to diagnose RA, your physician will need to perform a complete history and physical examination to differentiate among the over 100 forms of
arthritis. The pattern of affected joints along with blood tests and x-rays help to distinguish RA from other arthritis conditions. A positive “RF Test” by itself is
NOT sufficient to diagnose rheumatoid arthritis because it can be positive in other auto-immune diseases (like lupus or Sjogren’s syndrome) or in patients
Although x-rays are “normal” in early RA, most moderate to severe RA patients will develop EROSIONS (bone loss at the edge of the joint space) in the first
few years of disease. RA is much more responsive to treatment if diagnosed early and early treatment can prevent the development of erosions. Once
erosions have developed, there are no medications to repair the joint and the more erosions you have on x-rays, the more likely you are to become
disabled. With more than 100 forms of arthritis and since there are many safe and effective medications to treat RA, the diagnosis and management of RA
often requires the assistance of an “arthritis specialist,” also known as a rheumatologist.
How is RA treated?
Although there is no cure for RA, there are many safe and effective medications. The medications are not only used to help reduce pain, swelling and
inflammation, but they also prevent bone damage and long term disability. Medications used in the treatment of RA can be divided into two categories: 1)
symptomatic relief medications and 2) Disease Modifying Anti-Rheumatic DrugS (DMARDS). Although medications used for the symptomatic relief of RA
do help reduce pain, they do not prevent progressive bone damage (erosions), which over time lead to disability. DMARDS on the other hand take longer to
decrease pain, however, they do prevent bone damage and safely control inflammation for longer periods of time. Thus, medications from both categories
are often used together to treat patients with RA to provide quick pain relief and to also prevent long term bone damage and disability.
Medications used for symptomatic relief of RA include 1) aspirin and the Non Steroidal Anti-Inflammatory Drugs (NSAIDS) like ibuprofen or naproxen, 2)
analgesics including acetaminophen (Tylenol), tramadol (Ultram) or propoxyphene (Darvon) and 3) low dose corticosteroids (prednisone). For further
information on these medications, please look for upcoming medication reviews on our website.
The DMARD medications are used to prevent the development of erosive bone damage and are also useful to control the pain and inflammation of RA.
Some of the commonly used DMARD medications include hydroxychloroquine (Plaquenil), sulfasalazine (Azulfidine), methotrexate (Rheumatrex, Trexall)
and leflunomide (Arava). Your rheumatologist can help you to decide which of these medications are most appropriate for you and how to safely monitor
you if you take them. Most people with RA will need to continue their DMARDS as long as they are effective and cause no serious side effects. If the
DMARDS are stopped, the inflammation, pain, swelling and bone damage often return. For more specific information on the DMARDS listed above, please
see our drug-information webpage.
For people with moderate to severe RA, who have an inadequate response to the DMARD medications, your rheumatologist may discuss with you the pros
and cons about a new class of medications called the biologic response modifiers (BRMS). BMRS target specific chemicals (TNF & IL-1) involved in the
immune system problem that causes RA. Examples of BRMS include etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira) and anakinra
(Kineret). Because these medications alter your immune system, you should not begin or continue BRMS when you have an infection. Furthermore, you
should NOT receive live vaccinations, like oral polio, chicken pox, Measles-Mumps-Rubella (MMR) or FluMist, while on BRMS. Please inform your
rheumatologist if you have been exposed to or treated for tuberculosis (TB) in the past as the use of BRMS have been associated with re-activation of TB. If
you have certain medical conditions like uncontrolled congestive heart failure, multiple sclerosis or are prone to the development of infections, you may not
be a good candidate for a BRM.
Can diet help control RA?
Some people with RA suspect that certain foods may either aggravate or help their arthritis. Careful scientific studies so far have NOT proven that dietary
changes have affect on the symptoms of RA in most people with RA, however, it is very important to maintain a healthy diet. During RA flares, you may lose
your appetite due to the inflammatory process and lose weight. At these times it is very important to consume enough calories to maintain a healthy
weight. When your arthritis is less active or if you are taking corticosteroids (prednisone), it is important to avoid excess weight gain. Prednisone can cause
you to feel hungry and it is important for you to watch your meal size with portion control of your food intake.
Adequate amounts of calcium and vitamin D are also important to maintain strong bones and to prevent fractures. The inflammatory process in RA and
corticosteroids (prednisone) both contribute to thinning bones in people with RA. For specific calcium and vitamin D recommendations, please see our
osteoporosis informational page. If you are taking methotrexate, or have had elevated liver function tests, you should avoid all alcohol intake as most
medications used to treat RA are processed by the liver. If you liver is irritated by alcohol and or your medications, your doctor may have to stop your RA
medications which will causer your RA to flare.
Exercise & Rest
For many years it was thought that people with arthritis should rest their joints to protect them from further damage, however, this leads to weakening of the
muscles and thinning of the bones (osteoporosis). Your doctor and physical therapist can help you decide what types of exercise are best for you so that
you can exercise without hurting your joints. When your arthritis is active, simple passive range of motion exercises are preferable to help maintain the
range of motion of your joints. Range of motion exercises are generally performed without weights. You need to move your joints through their full range of
motion and pay special attention to the end of the motion where mobility may be lost first.
When your arthritis is under better control, you can gradually increase your physical activity to help improve your muscle and bone strength, increase your
flexibility and stamina and improve your overall sense of well being and decrease fatigue. Low-impact aerobic exercises like walking or riding a bike are
generally good options. The Arthritis Foundation also provides a list of exercise programs around the Bay area organized specifically for people with
arthritis. They have a warm water based exercise program, which is helpful for people with hip, knee and feet arthritis to exercise safely and the P.A.C.E
program, (People with Arthritis Can Exercise) which is a land based exercise program. To learn more about these exercise programs and other Arthritis
Foundation events, please visit them at their website at www.arthritis.org.
How do Physical & Occupational Therapists help?
Physical therapists work with your rheumatologist to develop a exercise program for your specific needs. The physical therapist will teach you how to
perform each exercise appropriately to improve your joint mobility, muscle strength and increase your aerobic fitness. Physical therapists may also use
special equipment to apply deep heat or electrical stimulation to reduce pain or improve joint mobility. The also are useful with post-operative rehabilitation,
splinting and the use of walking devices.
Occupational therapists teach you how to protect and use your joints without stressing them. Occupational therapists can teach you ways to use your
energy wisely and plan your daily activities in an efficient manner. They can also help you find assistive devices to help you perform your activities of daily
living more easily.
When is joint surgery the best option?
If you are experiencing severe pain and disability from your arthritis and you have failed to respond to medications, you may be a candidate for total joint
replacement surgery. Joint replacements are performed by orthopedic surgeons who replace your damaged joints with metal and plastic parts. The most
common joint replacement surgeries are performed for hip and knee arthritis and should be performed by a very experienced surgeon. You will need to
have a pre-op physical exam with your primary doctor to see if you are strong enough to tolerate the stress of the surgery and participate with physical
therapy both before and after the surgery. If you have many medical problems or are high risk of developing a heart attack or stroke as a result of the
surgery, you may decide not to have the joint replacement. You should weight the recommendation of your orthopedic surgeon, rheumatologist and primary
care physicians’ to help you to make your decision.