Rheumatoid arthritis (RA) is a chronic and potentially debilitating inflammatory disease that causes pain, swelling, stiffness and loss of function in the joints.

1. Rheumatoid Arthritis
Rheumatoid arthritis (RA) is a chronic and potentially debilitating inflammatory
disease that causes pain, swelling, stiffness and loss of function in the joints.
According to the Arthritis Foundation, RA affects about 1.3 million Americans,
mostly women; two to three times more women have RA than men, and the
number of women with the disease appears to be increasing. The age of onset
can vary, but it typically occurs between ages 30 and 60, with the risk increasing
as a person ages. The good news is that new advancements in treatment have
made it possible to slow or stop the progression of RA.
Unlike the more common osteoarthritis, which is mainly a disease of the cartilage
in joints, RA occurs when the body’s immune system attacks and damages the
joints and, sometimes, other organs. RA often occurs in a symmetrical pattern,
meaning that if one knee or hand is involved, the other one is, too.
The condition is considered an autoimmune disease. Such diseases are
characterized by an immune-system attack on the body’s healthy tissues. In RA,
white blood cells travel to the synovium (the membranes that line the inner
surface of the joint capsule) and cause inflammation, namely synovitis. The
ensuing warmth, redness, swelling and pain are typical symptoms of RA, which
usually affects the wrists, fingers, knees, feet and ankles.
The continuous inflammation associated with RA gradually destroys cartilage- the
specialized tissue that coats and cushions the bony ends in the joints. The loss of
cartilage leads to narrowing and loss of joint space and, eventually, damage to the
bone. The surrounding muscles, ligaments and tendons that support and stabilize
the joint also become weak and unable to work normally.
Systemic symptoms often include fatigue, general sense of malaise, low-grade
fever, morning joint stiffness and difficulty moving a joint or several joints. Pain
and signs of inflammation such as redness and warmth in or around a joint are
often severe.

2. RA varies from person to person, but most cases are chronic, meaning they never
go away. Some people have mild or moderate disease, with flares (periods of
worsening symptoms) and remissions. For others, the disease is active most of
the time. The resulting joint damage can be disabling.
The disease can affect more than just the joints, bones and surrounding muscle.
About one-quarter of those with RA develop rheumatoid nodules. These are
bumps under the skin that often form close to the joints. Many people with
rheumatoid arthritis develop anemia. Other effects, which occur less often,
include neck pain and dry eyes and mouth. Very rarely, RA results in inflammation
of the blood vessels, the lining of the lungs, or the sac enclosing the heart. If you
have RA, you may also be at increased risk for infections and gastrointestinal
ailments.
Although no one knows the causes of rheumatoid arthritis, it seems to develop as
a result of an interaction of several factors, including genetics, environment
andhormones.
Diagnosing and treating rheumatoid arthritis can sometimes be difficult. It may
require a team effort between you and several types of health care professionals,
including arheumatologist, a physician who specializes in arthritis and other
diseases of the joints, bones and muscles. Physical therapists, psychologists and
social workers can also play a role.
RA can be devastating, but current treatment strategies can help you cope and
possibly reduce the impact of the disease. These strategies can include pain
relievers and other medications, rest, appropriate exercise, education and
support programs. Involvement of the rheumatology health care professional is
essential in the care of RA.
The psychological element is important: Some studies indicate that if you are well
informed about your condition and participate in your own treatment plan, you
will probably have less pain and make fewer visits to your health care professional
than otherwise. You can find treatment support groups in many cities.

3. Diagnosis
Rheumatoid arthritis (RA) can be difficult to diagnose in its initial stages, but an
early diagnosis can be crucial to limiting its progress and severity. Some studies
indicate that rheumatoid arthritis causes the most joint damage in the first two
years.
There is no single test to determine if you have RA. The symptoms often are
similar to those of other types of arthritis and joint conditions. The types of
symptoms you experience—and the severity—may differ markedly from those of
another person with RA. To make matters more confusing, symptoms can vary in
the same person: Symptoms develop over time, and only a few may be present in
the early stages of RA.
Often, RA is diagnosed by recognizing the type and pattern of joint involvement; it
is a hallmark of RA, for example, if the same areas are affected symmetrically on
both sides of the body.
The typical symptoms of RA include:
 tender, warm and swollen joints
 symmetrical pattern
 joint inflammation often affecting the wrists, fingers, knees, feet and ankles
 fatigue
 occasional fever
 a general sense of malaise
 pain and stiffness lasting for more than 30 minutes in the morning or after
a long rest
 rheumatoid nodules (bumps under the skin—often formed close to the
joints—that affect about a quarter of those with RA)
Less common symptoms can include neck pain and dry eyes and mouth. Very
rarely, RA may cause inflammation of the blood vessels, the lining of the lungs or
the sac enclosing the heart.

4. If you have any of these symptoms, you should visit a health care professional. He
or she will take several factors into consideration before rendering a diagnosis:
Medical history. Your description of the symptoms—including their duration and
intensity—can help with the diagnosis.
Physical examination. Your health care professional will do a physical exam and
pay particular attention to your joints, skin, reflexes and muscle strength.
Laboratory tests. Some lab tests can help establish the presence of RA. Your
health careprofessionalwill probably order a test to detect rheumatoid factor (an
antibody eventually present in the blood of most people with rheumatoid
arthritis). It’s inconclusive, however, since not all people with RA test positive for
rheumatoid factor, especially in the early stages. Some people with other types of
rheumatic disease and a small number of healthy individuals also have a positive
rheumatoid factor test, so you could test positive and never develop the disease.
A test called anti-cyclic citrullinated peptide, or anti-CCP, is now available and is
more specific than rheumatoid factor tests. Specificity is even higher when both
of the tests are positive. Other common tests include one that indicates the
presence of inflammation in the body (the erythrocyte sedimentation rate, or
ESR, and the C-reactive protein, or CRP), a test for antinuclear antibodies
(antibodies that appear in about 30 percent to 40 percent of people with RA), a
white blood cell count and a blood test for anemia.
X-rays. Thesecan help determine the extent of joint destruction. If you identify RA
in its early stages, X-rays may not be helpful in diagnosis. However, they can be
used to monitor the disease’s progress. Other imaging techniques, such as MRI
and particularly joint ultrasound, have been shown to be very useful in
assessment of the extent of inflammation and joint damage in RA.
Treatment
The main goals of rheumatoid arthritis (RA) treatment are to relieve symptoms of
inflammation and to significantly slow the progression of joint damage. Although
there is no cure, you and your health care professional can develop strategies for
keeping the disease under good control. You may need to try several approaches

5. and different types of medication before you can satisfactorily relieve pain,
reduce inflammation, slow joint damage and improve your ability to function.
In addition to the guidance of your primary health care professional, you may
need care froma physicaltherapist, a rheumatologist (a physician who specializes
in diagnosing and treating disorders that affect the joints, muscles, tendons,
ligaments and bones) or an orthopedist.
When symptoms occur, you can take steps to lessen their severity. Protecting
your joints fromundue stress can help. Your health care professionalcan help you
obtain a properly fitting splint. You may want to talk to him or her about self-help
devices that can reduce stress on the joints while you participate in everyday
activities. Zipper pullers, long-handled shoehorns and products that help you get
on and off chairs, toilet seats and beds can all ease the strain on your joints.
Most likely, your treatment plan will include medications to relieve pain and/or
reduce inflammation. Although there is no cure, disease-modifying antirheumatic
drugs (DMARDs) may slow or stop the course of the disease. In the past, health
care professionals often hesitated to prescribe these strong drugs until the
disease had become relatively advanced. However, this approach has changed,
especially for those who suffer from severe, rapidly progressing RA. Most
rheumatologists believe that early treatment with more powerful drugs and the
use of drug combinations is the best way to halt RA’s progression and to reduce
or prevent joint damage. It is therefore important to establish care of RA with a
rheumatologist as early as possible.
The following are commonly used rheumatoid arthritis medications:
Analgesics. Analgesics are drugs that provide pain relief, and they can be used
either orally or topically in people with RA. Analgesics include topical capsaicin
(Capsagel), oral acetaminophen (Tylenol), tramadol (Ultram) and the more potent
narcotics oxycodone (OxyContin) and hydrocodone (Vicodin). Narcotics are
usually discouraged in the treatment of rheumatoid arthritis, however, becauseof
the long-term nature of the condition and the danger of dependence.

6. Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs such as aspirin,
ibuprofen, ketoprofen and naproxen help diminish pain, swelling and
inflammation. However, each NSAID is a different chemical and can have different
effects in the body.NSAIDs may cause side effects including ringing in your ears,
bruising, heart problems, gastric ulcers, stomach irritation, and liver and kidney
damage. The longer you use NSAIDs, the more likely you are to have side effects,
and the more serious those effects can be. Many other drugs cannot be taken
with NSAIDs—in particular, the blood thinner warfarin (Coumadin). NSAIDS
should be used with caution in people over 65 and in those with any history of
ulcers or gastrointestinal bleeding, congestive heart failure, renal insufficiency
and hypertension. Even the nonprescription, over-the-counter forms of these
medications have the same risks. It’s important to ask your health care
professional for safety information associated with pain relievers with your
personal health history in mind.
A newer NSAID (called a COX-2 specific inhibitor) inhibits an enzyme (COX-2),
which triggers pain and inflammation, while sparing an enzyme called COX-1,
which helps maintain the normal stomach lining. The COX-2 inhibitor celecoxib
(Celebrex) is sometimes prescribed for RA, osteoarthritis and other pain-causing
conditions, such as acute pain and menstrual cramps. Celebrex is currently the
only COX-2 inhibitor on the market. Celebrex may increase the risk of heart attack
and stroke; discuss these risks with your health care professional. And if you are
currently taking Celebrex and think you are having an allergic reaction or have
other severe or unusual symptoms while taking any NSAID, call your health care
professional immediately. For more information on the risks associated with
Celebrex.
Disease-modifying antirheumatic drugs (DMARDs). Theseareslower-acting drugs,
which work by altering the natural course of the disease and therefore slow or
even prevent joint and cartilage destruction. They can produce significant results.
You may need to wait weeks—even months—before seeing any effect, and you
may use some or all of these, depending on the specifics of your condition. In
some cases, one DMARD is used by itself. In other cases, more than one DMARD
may be prescribed at the same time. You may have to try different medicines or

7. combinations to find one that works best with the fewest side effects.Common
DMARDs include: methotrexate (Rheumatrex, Trexall), sulfasalazine (Azulfidine),
hydroxychloroquine (Plaquenil), leflunomide (Arava), cyclosporine (Sandimmune,
Neoral), and azathioprine(Imuran, Azasan). People taking methotrexate and most
other DMARDs need periodic monitoring to make sure that toxicity to the liver or
bone marrow does not occur. Although there is clearly a potential for toxicity of a
powerful drug like methotrexate, it actually has a remarkable safety profile in RA
and can be taken continuously for many years. Side effects of DMARDS vary
greatly but may include nausea or vomiting, diarrhea, heartburn, high blood
pressure, sun sensitivity, rash, temporary hair loss, damage to the retina, liver or
kidney damage, lung infections and bone marrow suppression.
Pay attention to how your body responds to these drugs. Not only do you need to
make sure the medications are effective (since efficacy can occasionally diminish
over time), you also need to be alert to any problems arising from the drugs.
Corticosteroids. Also known as glucocorticoids, corticosteroids such as prednisone
and methylprednisolone (Medrol) reduce inflammation and pain and may slow
joint damage from RA. Because they can cause dramatic improvements in a very
shorttime, health care professionals often use them while waiting for DMARDs to
kick in, and then may gradually discontinue use. They may be an option if your RA
doesn’t respond to NSAIDs and DMARDs. These medications also have serious
side effects, especially at high doses, including increased bruising, thinning of
bones, increased appetite, weight gain, worsening of diabetes and cataracts.RA
can increase bone loss, leading to osteoporosis. This bone loss is more likely in
people who use corticosteroids for longer periods of time. To keep your bones as
strong as possible, use the lowest possibledoseof corticosteroids for the shortest
amount of time, consumeat least 1,000 to 1,200 milligrams of calcium and 400 to
1,000 IUs of vitamin D a day and talk to your doctor about medications called
bisphosphonates, such as alendronatesodium(Fosamax) and ibandronatesodium
(Boniva), that can help reduce bone loss.
Biologic response modifiers. These are protein drugs that must be administered
by subcutaneous injection or intravenous infusion. These drugs help to reduce

8. joint-damaging inflammation by interfering with the inflammation process. The
most commonly used short-acting drugs in this category are adalimumab
(Humira), etanercept (Enbrel) and infliximab (Remicade). The longer-acting drugs
in this category are certolizumab pegol (Cimzia) and golimumab (Simponi). They
all target and inactivate a protein called tumor necrosis factor, or TNF-alpha,
which is involved in the cascade of immune responses that cause inflammation in
people with RA. Other biologic response modifiers target different molecules
involved in the inflammation process. For instance, the drug anakinra (Kineret)
blocks a cytokine called interleukin-1 (IL-1). Abatacept (Orencia) blocks the
activation of T cells, and rituximab (Rituxan) blocks B lymphocytes. Tocilizumab
(Actemra) is a biologic response modifier that inhibits interleukin-6. The biologic
response modifiers are used as a second line drugs in individuals who do not
respond to one or several TNF-alpha blocking agents.There have been very rare
reports of serious nervous systemdisorders such as multiple sclerosis, seizures or
inflammation of the nerves of the eyes, and serious infections, including sepsis
and tuberculosis, with the TNF-inhibitors. The risk of tuberculosis has been greatly
decreased with pre-therapy screening of TB skin tests and/or chest X-rays and
treating with anti-TB drugs if these tests are positive.
Additionally, there is some evidence that people treated with TNF inhibitors might
have a somewhat higher risk of lymphomas. Although you need to be aware of
these risks, it is equally important to recognize that the benefits can be
substantial
Non-biological DMARD. Recently, the U.S. Food and Drug Administration
approved a new non-biological DMARD for RA treatment named tofacitinib
(Xeljanz). This medication is the firstin the new category of RA drugs that work by
inhibiting intracellular enzymes called kinases. Tofacitinib is a JAK (Janus kinase) 1
and 3 inhibitor. Kinases are involved in generation of inflammation in RA.
Tofacitinib has been approved as a second-line drug for RA patients who have
inadequate response or are intolerant to a first- line DMARD methotrexate.
Similarly to biologic response modifiers, Tofacitinib may increase risk for infection
and cause liver abnormalities. In addition, in clinical trials, it has been associated
with lipid and various blood cell count abnormalities in a small percentage of

9. people. Your health professional will be able to tell if and when this new drug
would be appropriate for treatment of your RA.
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