Rheumatoid Arthritis

Rheumatoid arthritis is a chronic inflammatory condition of the joints, usually in the wrists and knee. It affects all ethnic groups. 

Rheumatoid arthritis is characterized by an inflammatory reaction and the release of several mediators of inflammation which are responsible for symptoms such a fatigue, loss of appetite, increased perspiration, fever, loss of body weight and insomnia. Joint problems appear only later in the course of disease.

Approximately 1% of the people are affected. It appears in all age groups, but most often between the ages of 30 and 50.

This disease has a characteristic family linkage; it more commonly appears among close relatives. A genetic disease factor is at work here, connected with the presence of specific HLA antigens. HLA stands for human leukocyte antigen, which is a protein found on the outer cell membrane and is person-specific. The immune system uses the HLA system to differentiate between the self and the foreign cells; in the case of autoimmune diseases such as rheumatoid arthritis this system goes awry meaning that an individual's immune system attacks the body's own organs and tissues. In the case of rheumatoid arthritis, the immune system turns against the joint capsule components resulting in an inflammatory reaction and the release of several inflammatory mediators (mainly various interleukins, interferon gamma, TNF alpha). The inflammatory reaction causes joint capsule lesions which manifest in the disease symptoms.

Disease development

The initial phase of disease is very unspecific. It starts with signs of fatigue, loss of appetite, increased perspiration, increased body temperature, loss of weight and insomnia. Joint complaints are not common in the initial phase and appear only after a certain time. Besides joint pain which is most excruciating in the morning, joint stiffness and edema are also features of this disease. Later phases are characterized by joint transformation and characteristic deformities of hand fingers and wrist joints.

Extra-articular disease manifestations appear due to the release of inflammatory mediators which trigger an immune response in different body parts and tissues. Vasculitis, or inflammation of the vessels, results as well as lesions of the heart, lungs, kidneys and the eyes.

Disease diagnosis

Physical exam and laboratory blood testing are of utmost importance in discovering and diagnosing this disease. This blood work includes sedimentation rate, CRP (C-reactive protein), determination of the presence of certain antibodies (rheumatoid factor, anti-dsDNA, anti-cyclic citrullinated peptide antibodies (anti-CCP)). However, the diagnosis remains mostly clinical as no laboratory test is absolutely reliable.

Prevention

Unfortunately, this disease still cannot be prevented. Apart from the known genetic predisposition, the main triggering factor of the disease has not been found yet. Over the years, several theories have been developed as to what could activate the immune system which can no longer distinguish from the self and from the non-self, and make it attack the body's own tissues. Infections were proposed as one possible cause. It has been established that smokers have a greater chance for the development of the disease.

Patients with a confirmed diagnosis can use medications and special exercises to slow down the disease progression. It is important for the patient to be aware that there are ways to fight this disease. With a regular daily physical exercise regime which is adjusted to age and disease activity, the patients can significantly improve their condition, joint flexibility and physical fitness. This can also alleviate pain and reduce the edema. At the same time, fatigue is reduced, muscles and bones strengthened and the overall well-being improved.

Therapy

Unfortunately, rheumatoid arthritis is a chronic disease for which no cure has yet been discovered. The treatment is thus directed at ameliorating the signs and symptoms. The goal is to reduce the inflammatory process in the joints, reduce the pain, protect the joint parts, maintain adequate joint function and exercise control over the systemic symptoms that affect about 40% of all patients such as, anaemia, carpal tunnel syndrome, pleuritis, pneumonitis. Less frequent symptoms include dryness of the mouth and eyes (sicca symptoms) and vasculitis.

Medications used in the treatment of rheumatoid arthritis can be divided into two groups:

Symptomatic drugs

Their aim is to alleviate the symptoms, especially the signs of inflammation and pain. This group includes non-steroidal anti-inflammatory drugs (NSAIDs) with their analgesic, anti-inflammatory and antipyretic activity. Almost all currently known NSAIDs have the same or similar efficacy. However, the long-term use of NSAIDs has side effects exerted on the upper GI tract. 

Glucocorticoids are used for the severe disease forms that exhibit a fast rate of progression, or in cases where other medications have not managed to effectively control the inflammatory process in the joints. They are usually used in combination with other drugs; in the case of NSAIDs, a medicinal product for stomach mucosa protection must be added because the risk of inflammatory changes increases. The preferred use of glucocorticoids is shot-term only. In the case of long-term therapy, Vitamin D and calcium must be added in order to offset the effects of corticosteroids on the bones. 

Isotopic synovectomy is a procedure where an isotope is injected into an inflamed joint that has not suffered extensive damage yet. The isotope has an anti-inflammatory action and may bring about long-term improvement of the joint inflammation. This procedure is especially welcome in the elderly patients because it is less invasive than, say, the surgical removal of the inner synovial membrane; it is less dangerous, cheaper and boasts a faster recovery.

Drugs that affect the immune system and the course of disease

The so called immunomodulatory drugs are used as soon as the diagnosis is confirmed in order to reduce damage caused by the inflammatory process. The first positive effects of these drugs are evident only in weeks or months of instituting the therapy; thus, their use is combined with the symptomatic drugs.

In the recent years, a new type of medication has become available - the biological drug which acts to inhibit certain proteins that are involved in the immune processes and thus act as the mediators of rheumatic inflammation. The effects of these drugs are faster than the effects of immunomodulators. However, due to their high cost and limited knowledge about the long-term consequences of their use, they are reserved for patients who are unresponsive to therapy with immunomodulators or who do not tolerate the required doses to hold inflammation in check.

Surgery

In the event that during the course of disease irreparable damage develops in a joint that consequently becomes less flexible, painful at rest and causes difficulties during walking and other activities, surgery becomes an option. One may perform synovectomy (whereby the inflamed inner synovial membrane is removed), a joint replacement (most often the knee and hip joint), sewing of the severed tendons, releasing of the entrapped nerves (as in the carpal tunnel syndrome), joint cartilage cleansing.