Rheumatoid arthritis

What rheumatoid arthritis is

Joints are lined on the inside by a thin membrane, the synovium, which makes the joint fluid and lubricates the joint. In rheumatoid arthritis the immune system, which normally protects us from infections, mistakenly attacks this membrane. It thickens, fills with inflammatory cells and produces substances that wear away cartilage and the bone beneath. Uncontrolled inflammation causes bone erosions and, with time, weakening of tendons and deformity of the joint.

The exact cause is not known. The disease arises from a combination of genetic predisposition and environmental factors, of which the strongest is smoking, which raises the risk and worsens the course. It affects women more often than men, usually between ages 30 and 60, but can begin at any age.

The most important thing to know is that there is a “window of opportunity” in the first months of the disease: treatment started during this time controls inflammation better and prevents irreversible joint damage. Joint swelling that lasts should therefore not be left to pass.

Symptoms

The disease usually starts slowly and most often affects both sides of the body equally (symmetrically). The most common features are:

• pain and swelling of the small joints of the hands (wrists, the knuckles at the base and middle of the fingers) and toes, often also the ankles and knees;
• morning stiffness lasting longer than 30–60 minutes (in osteoarthritis it usually lasts less than 30 minutes);
• joints that are warm and tender to touch;
• marked fatigue, loss of appetite, sometimes a mild fever and weight loss;
• difficulty making a fist, opening a jar lid or holding objects.

The disease can affect other organs too, because it is inflammation of the whole body: small lumps under the skin (rheumatoid nodules), dry eyes and mouth, lung inflammation, anemia and a higher cardiovascular risk. Symptoms often vary: there are periods of worsening (“flares”) and quieter periods.

How it is diagnosed

The diagnosis of rheumatoid arthritis is not based on one test but on putting together the joint examination and the tests. The rheumatologist:

• examines the joints (which are swollen, how long it has gone on, how much morning stiffness there is);
• requests rheumatoid factor and anti-CCP antibodies (the latter are more specific and are often positive from the start), as well as the erythrocyte sedimentation rate (ESR) and CRP, markers of inflammation; a blood count, and liver and kidney function;
• uses joint ultrasound to see synovitis (inflammation of the membrane) even when the joint does not look swollen, which makes the diagnosis earlier. X-rays show erosions only later; they are done at an imaging center.

Doctors use standardized criteria that weigh the number and location of affected joints, test results and the duration of symptoms (at least 6 weeks). A positive rheumatoid factor without swollen joints does not mean rheumatoid arthritis, and a negative result does not rule out the disease; the assessment is made by the doctor.

Treatment

The aim of treatment today is remission (joints without active inflammation) or, when that is not reached, low disease activity. The doctor adjusts treatment until this target is reached, assessing it regularly by examination and tests.

Disease-modifying drugs (DMARDs). These are the foundation of treatment and are started as early as possible. The most used is methotrexate, taken once a week, usually with folic acid; leflunomide, sulfasalazine and hydroxychloroquine are also used. These drugs work slowly (weeks to months) and need regular blood tests to check the liver and blood cells.

Biologic and targeted drugs. When conventional DMARDs are not enough, newer drugs are added (TNF inhibitors and inhibitors of other molecules, or JAK inhibitors) that block specific substances of inflammation precisely. Before starting, checks are made for tuberculosis and hepatitis B and C, because these drugs lower protection against infections.

Corticosteroids. They are used for short periods during flares or at the start, until DMARDs begin to work, or as an injection (infiltration) into a single active joint. Long-term use of high doses should be avoided because of side effects (osteoporosis, diabetes, high blood pressure).

Ordinary anti-inflammatory drugs (NSAIDs) and painkillers ease pain but do not stop the disease. Stopping smoking, tailored physical activity, physiotherapy and care for the heart, bones and weight also matter. Many of the treatment drugs are not allowed in pregnancy, so planning a pregnancy should be done with the rheumatologist before becoming pregnant.

Follow-up and daily life

Rheumatoid arthritis is followed for life. After treatment starts, check-ups are more frequent (every 1–3 months) until the disease is controlled; then, when the condition is stable, check-ups are every 6 months to a year, or sooner when the doctor considers it reasonable, especially when joints worsen or side effects appear. Blood tests are repeated according to the medicine you take. Do not stop a medicine on your own even when you feel well, because the disease returns; talk to your doctor if you have a fever, an infection or are going to have surgery.

In practice it helps to move regularly (walking, swimming, hand exercises), to rest during flares, to stop smoking, to have recommended vaccines and to control cardiovascular risk. The doctor can give injections into the most active joints under ultrasound guidance. With today’s treatment, most patients keep their ability to work and lead an active life.

When to see a doctor

• joint swelling that lasts more than 6 weeks;
• long morning stiffness (over 30 minutes);
• difficulty making a fist or holding objects;
• pain and swelling in both hands or both feet;
• a single very hot joint with fever: immediately.

Bring earlier tests and, if you have one, a note of when your complaints began. This information is educational and does not replace a medical visit.