Rheumatoid Arthritis – Causes, Symptoms, Treatments

What is Rheumatoid Arthritis?

Rheumatoid Arthritis (RA) is an autoimmune disease that causes chronic inflammation in your joints [Mayo Clinic, rheumatoid arthritis – Symptoms and causes]. In other words, your immune system, which normally fights off germs, mistakenly attacks the healthy tissue lining your joints.

Here’s a breakdown of what happens inside the body:

1. Immune System Attack: The immune system attacks the synovium, the soft tissue that lines your joints. This triggers inflammation.
2. Inflammation: The inflamed synovium thickens and produces fluid, causing swelling, pain, and stiffness in the joints.
3. Joint Damage: Over time, the inflammation can damage the cartilage and bone within the joint, leading to deformity and limited mobility.

RA primarily affects the hands, wrists, and knees, but it can also impact other joints throughout the body. In severe cases, RA can even affect other organs like the lungs, heart, and eyes.

Chronic inflammation in Rheumatoid Arthritis (RA) attacks the synovial membrane, the soft tissue lining your joints. The synovium produces a lubricating fluid, this fluid keeps the joint surfaces gliding smoothly against each other during movement.

The synovium also acts as a nourishing membrane, delivering nutrients to the cartilage (the tough, elastic tissue cushioning your joints) and whisking away waste products. It also plays a minor role as a protective barrier, helping to prevent infections from reaching the space between joints.

How Does Inflammation Affect the Synovium

1. Inflammation and Thickening: The immune system goes awry, causing inflammation in the synovium. This inflammation makes the synovium thicken, restricting joint movement and causing pain.
   
2. Fluid Buildup and Erosion: As inflammation persists, fluid builds up within the joint, leading to swelling. Over time, the relentless inflammatory response can erode cartilage and even bone, causing deformity and limiting mobility.
   
3. Autoimmunity Run Amok: RA being an autoimmune disease means the misguided immune system doesn’t stop at the joints. The inflammatory signals and immune cells can travel throughout the body, potentially affecting other organs and systems.

Impacts Beyond the Joints:

This systemic inflammation can have far-reaching consequences:

• Skin: Rheumatoid nodules, firm lumps, can appear under the skin near affected joints.
• Eyes: Dryness, inflammation, and even vision problems can occur.
• Lungs: Inflammation in the lung tissue (pleuritis) can lead to shortness of breath.
• Heart: Increased risk of heart disease due to inflammation affecting blood vessels.
• Blood Cells: RA can cause anemia, a decrease in red blood cells.

Prevalence and Statistics of Rheumatoid Arthritis

Rheumatoid Arthritis (RA) is a relatively common autoimmune disease. Estimates suggest RA affects around 0.5% to 1% of the global population. This translates to roughly 18 million people worldwide living with RA according to the World Health Organization (WHO). In the US, approximately 1.3 million adults suffer from RA, representing 0.6% to 1% of the adult population.

While RA can strike at any age, it generally develops in adults between 40 and 70 years old. Interestingly, more than half of all new cases are diagnosed within this age range.

Women are two to three times more likely to develop RA compared to men. The reasons behind this gender disparity are still being explored, but some possible explanations include:

• Hormonal Influences: Sex hormones like estrogen might play a role. Estrogen levels fluctuate throughout a woman’s life, and some theories suggest these fluctuations could influence the immune system, making women more prone to autoimmune conditions like RA.
• Immune System Differences: Women tend to have a more robust immune response compared to men. While this can be beneficial in fighting infections, it can also lead to an overactive immune system that attacks healthy tissues in autoimmune diseases like RA.
• Genetic Predisposition: Genes likely play a role in RA susceptibility. Some genes associated with RA are located on the X chromosome, which women have two of compared to men’s single X and Y chromosome combination. This could potentially increase the risk for women.

The prevalence of RA might be higher in developed countries compared to low- and middle-income countries. This could be due to factors like better access to healthcare leading to more diagnoses and differences in environmental exposures.

Differences Between Rheumatoid Arthritis and Osteoarthritis

Rheumatoid arthritis (RA) and osteoarthritis (OA) can both cause significant joint pain, but the culprit behind the pain and the pattern of joints affected are quite different. RA is an autoimmune disease where the body’s immune system mistakenly attacks the synovial membrane lining the joints. This attack leads to inflammation, pain, and damage over time. In contrast, OA is a wear-and-tear condition where the cartilage cushioning the joints gradually breaks down due to overuse or age.

One key difference between RA and OA lies in the pattern of joint involvement. RA is known for its symmetrical nature. This means that multiple joints on both sides of the body tend to be affected in a mirrored fashion. For instance, you might experience pain and swelling in both hands, wrists, or knees at the same time. OA, on the other hand, often affects single joints or a few joints, typically on one side of the body more prominently. Joints that bear weight, like hips and knees, or those frequently used, like hands, are more commonly targeted in OA.

The specific joints affected by each condition also differ. RA has a preference for smaller joints, particularly those in the hands (especially the knuckles closest to the fingers and the middle joints), wrists, feet (especially the balls of the feet), and sometimes larger joints like elbows, shoulders, knees, and ankles. OA, on the other hand, tends to affect larger weight-bearing joints like hips, knees, and the lower back, along with joints in the hands (usually the base of the thumb and the end joints of the fingers).

The symmetrical nature of RA joint symptoms is a result of the underlying cause. Because RA is a systemic disease triggered by a malfunctioning immune system, it isn’t targeting specific joints. Instead, the immune system attacks the synovial membrane throughout the body. While there can be variations, this symmetrical pattern is a hallmark of RA, especially in the early stages of the disease.

Symptoms of Rheumatoid Arthritis

Rheumatoid Arthritis (RA) can bring a variety of symptoms, and their intensity can differ from person to person. These symptoms tend to worsen in episodes called flare-ups. 

These flare-ups can be triggered by various factors like stress, illness, hormonal changes, or even certain foods. During a flare-up, you might experience increased joint pain, stiffness, swelling, and fatigue. The intensity and duration of flare-ups can vary significantly from person to person.

Joint pain and tenderness are classic symptoms of RA. This pain typically affects multiple joints and often feels worse in the mornings or after periods of inactivity. Additionally, stiffness in the joints, especially upon waking up or staying still for extended periods, is another common complaint. Inflammation is another hallmark of RA. The inflamed joints may become swollen, red, and feel warm to the touch.

An interesting feature of RA is its symmetry. This means that the same joints on both sides of the body are often affected. For instance, you might have pain and swelling in both hands, wrists, or knees.

Beyond joint problems, RA can also cause fatigue. Many people with RA experience unexplained tiredness and lack of energy, even after getting enough sleep. In some cases, individuals with RA may also experience a low-grade fever and a reduced appetite.

Long Term Complications

Untreated Rheumatoid Arthritis (RA) can have devastating consequences for joint health, leading to a vicious cycle of inflammation and progressive damage. Here’s how:

The Inflammation Cascade:

• Persistent Inflammation: When RA goes untreated, the chronic inflammation in the joints persists. This ongoing inflammatory response attacks the synovial membrane, the lining of the joint, causing it to thicken and become inflamed.
  
• Cartilage Erosion: The relentless inflammatory attack doesn’t stop at the synovium. Over time, enzymes released due to inflammation begin to eat away at the cartilage, the smooth, protective cushioning between your bones.
  
• Bone Damage: As cartilage deteriorates, the inflamed synovium can start to invade and erode the underlying bones. This erosion can lead to deformities and misalignment of the joints.
  
• Loss of Function: With cartilage and bone damage, the smooth gliding motion of your joints gets disrupted. This leads to stiffness, pain, and a significant loss of mobility and function in the affected joints.

The Irreversible Impact:

The key point is that much of the damage caused by untreated Rheumatoid Arthritis is irreversible. Cartilage has limited regenerative capacity, and once it’s eroded, it’s difficult to regrow. Similarly, bone damage can be permanent.

Long-Term Consequences:

Left unchecked, RA can lead to:

• Joint Deformities: The combination of cartilage and bone erosion can cause the joints to become permanently bent or misaligned.
• Joint Fusions: In severe cases, the inflamed joint surfaces can fuse together, essentially immobilizing the joint.
• Increased Disability: The progressive loss of joint function can significantly limit a person’s ability to perform daily activities, leading to increased dependence on others.

Impact Beyond Joint Issues

While primarily known for its attack on joints, RA can wreak havoc beyond the bones and cartilage. Chronic inflammation, the hallmark of RA, can have far-reaching consequences, manifesting in various systemic complications. 

Chronic inflammation disrupts the health of blood vessels, increasing the risk of atherosclerosis, a buildup of plaque that can narrow arteries. This can lead to cardiovascular issues such as heart attack, stroke, and peripheral artery disease (PAD) that affects blood flow in the legs.

Inflammation can affect the lungs, causing complications like pleurisy (inflammation of the lung lining) or even pulmonary fibrosis (scarring of lung tissue) leading to shortness of breath and difficulty breathing.

Rheumatoid Arthritis can disrupt blood cell production, leading to anemia (low red blood cell count) causing fatigue and weakness. Additionally, RA may elevate platelet levels, increasing the risk of blood clots.

Sjogren’s Syndrome is an autoimmune condition, sometimes linked to RA, that can cause dry eyes and mouth, leading to discomfort and vision problems.

Chronic inflammation can weaken bones, increasing the risk of osteoporosis, a condition that makes bones brittle and prone to fractures.

Impact on Overall Health:

These systemic complications can significantly impact a person’s well-being:

• Increased Risk of Infections: RA can weaken the immune system, making individuals more susceptible to infections.
• Fatigue and Reduced Quality of Life: The combination of pain, inflammation, and complications like anemia can lead to fatigue and a decline in overall quality of life.
• Mental Health Concerns: Chronic illness like RA can take a toll on mental health, leading to anxiety and depression.

How is Rheumatoid Arthritis Diagnosed?

Diagnosing Rheumatoid Arthritis (RA) involves a multi-step approach since there isn’t a single definitive test. Doctors typically follow a process to gather as much information as possible to reach an accurate diagnosis.

The first step usually involves a consultation with your doctor. They will ask about your medical history in detail, focusing on your symptoms such as pain location, duration, stiffness, and any other relevant medical conditions. A physical examination will then be performed to assess your joints for swelling, tenderness, warmth, and limitations in movement.

Several tests come into play after the initial consultation. Blood tests are conducted to evaluate inflammation and identify potential markers of RA. These include the erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) to measure inflammation, and rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) antibodies, which can be elevated in RA but aren’t always conclusive. Doctors may also use imaging tests like X-rays to reveal joint damage, especially in later stages of RA. Ultrasound can be helpful in detecting early signs of inflammation and thickening of the synovial membrane. In some cases, more detailed MRI scans might be used.

It’s important to remember that no single test can definitively diagnose RA. Doctors consider all the information gathered, including your symptoms, physical exam findings, and blood test results, to arrive at a diagnosis. Often, a pattern of symptoms along with positive blood tests for inflammatory markers or specific antibodies helps establish a diagnosis of RA.

The American College of Rheumatology (ACR) has established classification criteria that consider factors like joint involvement, duration of symptoms, and serological tests (blood tests for antibodies). Fulfilling a certain number of these criteria increases the likelihood of an RA diagnosis.

How is Rheumatoid Arthritis Treated?

Rheumatoid Arthritis (RA) treatment focuses on managing chronic inflammation and preventing joint damage. There isn’t a single cure, but a combination of approaches can significantly improve a person’s quality of life. Here’s a breakdown of the typical treatment strategies:

Medications:

• Disease-modifying antirheumatic drugs (DMARDs): These medications are the cornerstone of RA treatment. They work by slowing disease progression and reducing inflammation. Methotrexate is often the first-line DMARD, sometimes combined with others like leflunomide, hydroxychloroquine, or sulfasalazine.
• Biologic agents: These powerful drugs target specific parts of the immune system involved in inflammation. Biologics are typically used when DMARDs alone aren’t sufficient. Examples include TNF-alpha inhibitors and interleukin-6 receptor inhibitors.
• Corticosteroids: These medications can provide quick relief from inflammation and pain during flare-ups. However, long-term use of corticosteroids is often avoided due to potential side effects.
• Pain relievers: Over-the-counter pain relievers like ibuprofen or acetaminophen can help manage everyday pain and stiffness.

Therapies:

• Physical therapy: A physical therapist can design an exercise program to improve joint flexibility, strength, and range of motion. This can help maintain function and reduce pain.
• Occupational therapy: An occupational therapist can help you adapt to daily activities despite joint limitations, recommending assistive devices or modifications to your home environment.

Lifestyle Modifications:

• Maintaining a healthy weight: Excess weight puts extra stress on joints, so weight management can be beneficial.
• Exercise: Regular physical activity, even low-impact exercises like walking or swimming, can improve joint health and overall well-being.
• Diet: While there’s no specific RA diet, a healthy eating plan rich in fruits, vegetables, and whole grains can promote overall health and potentially reduce inflammation. Some people find eliminating certain foods, like gluten or processed foods, helps manage their symptoms.
• Stress management: Stress can worsen RA symptoms. Techniques like yoga or meditation can help manage stress and improve overall well-being.

Surgery (in severe cases):

• In some advanced cases where joint damage is severe, surgery might be considered to repair or replace damaged joints.

What Medications are Most Often Prescribed for Rheumatoid Arthritis?

In Rheumatoid Arthritis (RA), medications play a central role in managing inflammation and preventing joint damage. While there’s no one-size-fits-all approach, two main categories of drugs are typically prescribed:

• Disease-modifying antirheumatic drugs (DMARDs): These medications are the workhorses of RA treatment. They work by slowing the progression of the disease and dampening the overactive immune response that fuels inflammation. Here are some commonly used DMARDs:
  
  • Methotrexate: Often the first-line DMARD, methotrexate helps suppress the immune system and reduce inflammation.
  • Leflunomide: This DMARD can be used alone or combined with methotrexate and offers a different mechanism of action to control inflammation.
  • Hydroxychloroquine: Primarily used for malaria prevention, hydroxychloroquine can also be helpful in managing RA symptoms, particularly in milder cases.
  • Sulfasalazine: This DMARD combines two medications – one that suppresses the immune system and another with anti-inflammatory properties.
• Biologic agents: These powerful drugs target specific aspects of the immune system involved in the inflammatory process. Biologics are typically used when DMARDs aren’t effective enough on their own. Here are some common examples:
  
  • TNF-alpha inhibitors: These drugs target a protein called tumor necrosis factor-alpha (TNF-alpha), a key player in inflammation. Examples include adalimumab, etanercept, and infliximab.
  • Interleukin-6 receptor inhibitors: These drugs target interleukin-6, another molecule involved in the inflammatory cascade. Examples include tocilizumab and sarilumab.

Additional Medications:

• Corticosteroids: Medications like prednisone can provide quick relief from inflammation and pain during flare-ups. However, due to potential side effects, long-term use is often discouraged.
• Pain relievers: Over-the-counter pain relievers like ibuprofen or acetaminophen can help manage everyday pain and stiffness associated with RA.