Rheumatoid arthritis

Rheumatoid arthritis

A hand affected by rheumatoid arthritis
Classification and external resources
Specialty Rheumatology
ICD-10 M05-M06
ICD-9-CM 714
OMIM 180300
DiseasesDB 11506
MedlinePlus 000431
eMedicine article/331715 article/1266195 article/305417 article/401271 article/335186 article/808419
Patient UK Rheumatoid arthritis
MeSH D001172

Rheumatoid arthritis (RA) is a long-lasting autoimmune disorder that primarily affects joints. It typically results in warm, swollen, and painful joints. Pain and stiffness often worsen following rest. Most commonly, the wrist and hands are involved, with the same joints typically involved on both sides of the body. The disease may also affect other parts of the body. This may result in a low red blood cell count, inflammation around the lungs, and inflammation around the heart. Fever and low energy may also be present.[1] Often, symptoms come on gradually over weeks to months.[2]

While the cause of rheumatoid arthritis is not clear, it is believed to involve a combination of genetic and environmental factors. The underlying mechanism involves the body's immune system attacking the joints. This results in inflammation and thickening of the joint capsule. It also affects the underlying bone and cartilage.[1] The diagnosis is made mostly on the basis of a person's signs and symptoms.[2] X-rays and laboratory testing may support a diagnosis or exclude other diseases with similar symptoms.[1] Other diseases that may present similarly include systemic lupus erythematosus, psoriatic arthritis, and fibromyalgia among others.[2]

The goal of treatment is to reduce pain, decrease inflammation, and improve a person's overall functioning. This may be helped by balancing rest and exercise, the use of splints and braces, or the use of assistive devices. Pain medications, steroids, and NSAIDs are frequently used to help with symptoms. A group of medications called disease-modifying antirheumatic drugs (DMARDs) may be used to try to slow the progression of disease. They include the medications hydroxychloroquine and methotrexate.[1] Biological DMARDs may be used when disease does not respond to other treatments.[3] However, they may have a greater rate of adverse effects.[4] Surgery to repair, replace, or fusion joints may help in certain situations.[1] Most alternative medicine treatments are not supported by evidence.[5][6]

RA affects between 0.5 and 1% of adults in the developed world with between 5 and 50 per 100,000 people newly developing the condition each year.[3] Onset is most frequent during middle age and women are affected 2.5 times as frequently as men.[1] In 2013, it resulted in 38,000 deaths up from 28,000 deaths in 1990.[7] The first recognized description of RA was made in 1800 by Dr. Augustin Jacob Landré-Beauvais (1772–1840) of Paris.[8] The term rheumatoid arthritis is based on the Greek for watery and inflamed joints.[9]

Signs and symptoms

RA primarily affects joints, but it also affects other organs in more than 15–25% of individuals.[10]

Joints

A diagram showing how rheumatoid arthritis affects a joint

Arthritis of joints involves inflammation of the synovial membrane. Joints become swollen, tender and warm, and stiffness limits their movement. With time, multiple joints are affected (it is a polyarthritis). Most commonly involved are the small joints of the hands, feet and cervical spine, but larger joints like the shoulder and knee can also be involved.[11]:1089 Synovitis can lead to tethering of tissue with loss of movement and erosion of the joint surface causing deformity and loss of function.[2]

RA typically manifests with signs of inflammation, with the affected joints being swollen, warm, painful and stiff, particularly early in the morning on waking or following prolonged inactivity. Increased stiffness early in the morning is often a prominent feature of the disease and typically lasts for more than an hour. Gentle movements may relieve symptoms in early stages of the disease. These signs help distinguish rheumatoid from non-inflammatory problems of the joints, often referred to as osteoarthritis. In arthritis of non-inflammatory causes, signs of inflammation and early morning stiffness are less prominent with stiffness typically less than one hour, and movements induce pain caused by mechanical arthritis.[12] The pain associated with RA is induced at the site of inflammation and classified as nociceptive as opposed to neuropathic.[13] The joints are often affected in a fairly symmetrical fashion, although this is not specific, and the initial presentation may be asymmetrical.[11]:1089

As the pathology progresses the inflammatory activity leads to tendon tethering and erosion and destruction of the joint surface, which impairs range of movement and leads to deformity. The fingers may suffer from almost any deformity depending on which joints are most involved. Specific deformities, which also occur in osteoarthritis, include ulnar deviation, boutonniere deformity, swan neck deformity and "Z-thumb." "Z-thumb" or "Z-deformity" consists of hyperextension of the interphalangeal joint, fixed flexion and subluxation of the metacarpophalangeal joint and gives a "Z" appearance to the thumb.[11]:1089 The hammer toe deformity may be seen. In the worst case, joints are known as arthritis mutilans due to the mutilating nature of the deformities.[14]

Skin

The rheumatoid nodule, which is sometimes in the skin, is the most common non joint feature.[15] They occur in 30% of people.[15] It is a type of inflammatory reaction known to pathologists as a "necrotizing granuloma". The initial pathologic process in nodule formation is unknown but may be essentially the same as the synovitis, since similar structural features occur in both. The nodule has a central area of fibrinoid necrosis that may be fissured and which corresponds to the fibrin-rich necrotic material found in and around an affected synovial space. Surrounding the necrosis is a layer of palisading macrophages and fibroblasts, corresponding to the intimal layer in synovium and a cuff of connective tissue containing clusters of lymphocytes and plasma cells, corresponding to the subintimal zone in synovitis. The typical rheumatoid nodule may be a few millimetres to a few centimetres in diameter and is usually found over bony prominences, such as the elbow, the heel, the knuckles, or other areas that sustain repeated mechanical stress. Nodules are associated with a positive RF (rheumatoid factor) titer and severe erosive arthritis. Rarely, these can occur in internal organs or at diverse sites on the body..

Several forms of vasculitis occur in RA. A benign form occurs as microinfarcts around the nailfolds. More severe forms include livedo reticularis, which is a network (reticulum) of erythematous to purplish discoloration of the skin caused by the presence of an obliterative cutaneous capillaropathy..

Other, rather rare, skin associated symptoms include pyoderma gangrenosum, Sweet's syndrome, drug reactions, erythema nodosum, lobe panniculitis, atrophy of finger skin, palmar erythema, diffuse thinning (rice paper skin), and skin fragility (often worsened by corticosteroid use)..

Lungs

Fibrosis of the lungs is a recognized response to rheumatoid disease. It is also a rare but well recognized consequence of therapy (for example with methotrexate and leflunomide). Caplan's syndrome describes lung nodules in individuals with RA and additional exposure to coal dust. Pleural effusions are also associated with RA. Another complication of RA is Rheumatoid Lung Disease. It is estimated that about one quarter of Americans with RA develop Rheumatoid Lung Disease.[16]

Kidneys

Renal amyloidosis can occur as a consequence of chronic inflammation.[17] RA may affect the kidney glomerulus directly through a vasculopathy or a mesangial infiltrate but this is less well documented (though this is not surprising, considering immune complex-mediated hypersensitivities are known for pathogenic deposition of immune complexes in organs where blood is filtered at high pressure to form other fluids, such as urine and synovial fluid[18]). Treatment with penicillamine and gold salts are recognized causes of membranous nephropathy.

Heart and blood vessels

People with RA are more prone to atherosclerosis, and risk of myocardial infarction (heart attack) and stroke is markedly increased.[19][20] Other possible complications that may arise include: pericarditis, endocarditis, left ventricular failure, valvulitis and fibrosis.[21] Many people with RA do not experience the same chest pain that others feel when they have angina or myocardial infarction. To reduce cardiovascular risk, it is crucial to maintain optimal control of the inflammation caused by RA (which may be involved in causing the cardiovascular risk), and to use exercise and medications appropriately to reduce other cardiovascular risk factors such as blood lipids and blood pressure. Doctors who treat people with RA should be sensitive to cardiovascular risk when prescribing anti-inflammatory medications, and may want to consider prescribing routine use of low doses of aspirin if the gastrointestinal effects are tolerable.[21]

Other

Eyes
The eye is directly affected in the form of episcleritis which when severe can very rarely progress to perforating scleromalacia. Rather more common is the indirect effect of keratoconjunctivitis sicca, which is a dryness of eyes and mouth caused by lymphocyte infiltration of lacrimal and salivary glands. When severe, dryness of the cornea can lead to keratitis and loss of vision. Preventive treatment of severe dryness with measures such as nasolacrimal duct blockage is important.
Liver
Liver problems in people with rheumatoid arthritis may be due to the underlying disease process or as a result of the medications used to treat the disease.[22] A coexisting autoimmune liver disease, such as primary biliary cirrhosis or autoimmune hepatitis may also cause problems.[22]
Blood
Anemia is by far the most common abnormality of the blood cells which can be caused by a variety of mechanisms. The chronic inflammation caused by RA leads to raised hepcidin levels, leading to anemia of chronic disease where iron is poorly absorbed and also sequestered into macrophages. RA may also cause a warm autoimmune hemolytic anemia.[23] The red cells are of normal size and colour (normocytic and normochromic). A low white blood cell count usually only occurs in people with Felty's syndrome with an enlarged liver and spleen. The mechanism of neutropenia is complex. An increased platelet count occurs when inflammation is uncontrolled.
Neurological
Peripheral neuropathy and mononeuritis multiplex may occur. The most common problem is carpal tunnel syndrome caused by compression of the median nerve by swelling around the wrist. Atlanto-axial subluxation can occur, owing to erosion of the odontoid process and/or transverse ligaments in the cervical spine's connection to the skull. Such an erosion (>3mm) can give rise to vertebrae slipping over one another and compressing the spinal cord. Clumsiness is initially experienced, but without due care this can progress to quadriplegia.
Constitutional symptoms
Constitutional symptoms including fatigue, low grade fever, malaise, morning stiffness, loss of appetite and loss of weight are common systemic manifestations seen in people with active RA.
Bones
Local osteoporosis occurs in RA around inflamed joints. It is postulated to be partially caused by inflammatory cytokines. More general osteoporosis is probably contributed to by immobility, systemic cytokine effects, local cytokine release in bone marrow and corticosteroid therapy.
Cancer
The incidence of lymphoma is increased in RA, although it is uncommon.[24][25]

Causes

RA is a chronic autoimmune disorder the causes of which are not completely understood. It is a systemic (whole body) disorder principally affecting synovial tissues. There is no evidence that physical and emotional effects or stress could be a trigger for the disease. The many negative findings suggest that either the trigger varies, or that it might in fact be a chance event inherent with the immune response.[26]

Half of the risk for RA is believed to be genetic.[3] It is strongly associated with the inherited tissue type major histocompatibility complex (MHC) antigen HLA-DRB1 (most specifically the shared epitope alleles, including *0401 and born 0404), and the genes PTPN22 and PADI4—hence family history is an important risk factor.[27][28] Inheriting the PTPN22 gene has been shown to double a person's susceptibility to RA. PADI4 has been identified as a major risk factor in people of Asian descent, but not in those of European descent.[29] First-degree relatives prevalence rate is 2–3% and disease genetic concordance in monozygotic twins is approximately 15–20%.[30][31]

Smoking is the most significant non-genetic risk[3] with RA being up to three times more common in smokers than non-smokers, particularly in men, heavy smokers, and those who are rheumatoid factor positive.[32] Modest alcohol consumption may be protective.[33]

Epidemiological studies have confirmed a potential association between RA and two herpesvirus infections: Epstein-Barr virus (EBV) and Human Herpes Virus 6 (HHV-6).[34] Individuals with RA are more likely to exhibit an abnormal immune response to EBV and have high levels of anti-EBV antibodies.[35]

Vitamin D deficiency is more common in people with rheumatoid arthritis than in the general population.[36][37] However, whether vitamin D deficiency is a cause or a consequence of the disease remains unclear.[38] 1α,25-dihydroxyvitamin D3 (1,25D), an active metabolite of vitamin D, affects bone metabolism indirectly through control of calcium and phosphate homeostasis. Interaction between 1,25D and the vitamin D receptor (VDR) affects the production of RANKL and delays osteoclastogenesis.[39] Some trials have found a decreased risk for RA with vitamin D supplementation while others have not.[37]

Pathophysiology

Both genetic as well as environmental factors are implicated in the pathophysiology of the disease. Smoking is the main environmental risk to RA.[3] 50% of the risk of having RA is attributable to genetic factors.[3] No infectious agent has been consistently linked with RA and there is no evidence of disease clustering to indicate its infectious etiology.[40] HLA-DR4 is the major genetic factor implicated - but its relative importance varies across ethnic groups.[40][41] Related allotypes of MHC Class II and the T cell-associated protein PTPN22 has also been found associated in many studies.[41]

RA primarily starts as a state of persistent cellular activation leading to autoimmunity and immune complexes in both joints and other, organs where it manifests. The initial site of disease is the synovial membrane, where swelling and congestion leads to infiltration by immune cells. The various phases of progression of RA are:[14]

The factors that allow an abnormal immune response, once initiated, to become permanent and chronic, are becoming more clearly understood. The genetic association with HLA-DR4, as well as the newly discovered associations with the gene PTPN22 and with two additional genes,[41] all implicate altered thresholds in regulation of the adaptive immune response. It has also become clear from recent studies that these genetic factors may interact with the most clearly defined environmental risk factor for RA, namely cigarette smoking.[32][42] Other environmental factors also appear to modulate the risk of acquiring RA, and hormonal factors in the individual may explain some features of the disease, such as the higher occurrence in women, the not-infrequent onset after child-birth, and the (slight) modulation of disease risk by hormonal medications. Exactly how altered regulatory thresholds allow the triggering of a specific autoimmune response remains uncertain. However, one possibility is that negative feedback mechanisms that normally maintain tolerance of self are overtaken by aberrant positive feedback mechanisms for certain antigens such as IgG Fc (bound by RF) and citrullinated fibrinogen (bound by ACPA) (see entry on autoimmunity).The debate on the relative roles of immune complexes and T cell products in inflammation in RA has continued for 30 years. There is little doubt that both B and T cells are essential to the disease. However, there is good evidence for neither cell being necessary at the site of inflammation. This tends to favor immune complexes (based on antibody synthesised elsewhere) as the initiators, even if not the sole perpetuators of inflammation. The presence of autoantibodies to IgGFc, known as rheumatoid factors (RF), and antibodies to citrullinated peptides (ACPA) is an integral part of RA disease process. As is the case with many other autoimmune diseases, people with RA have abnormally glycosylated antibodies.[43] It is believed that these glycan (oligosaccharide) alterations promote joint inflammation.[43]

Once the abnormal immune response has become established (which may take several years before any symptoms occur), plasma cells derived from B lymphocytes produce rheumatoid factors and ACPA of the IgG and IgM classes in large quantities. These are not deposited in the way that they are in systemic lupus. Rather, they activate macrophages through Fc receptor and complement binding, which seems to play an important role in the intense inflammatory response present in RA.[44] Binding of an autoreactive antibody to the Fc receptors is mediated through the antibody's N-glycans, which are altered to promote inflammation in people with RA.[43] This contributes to inflammation of the synovium, in terms of edema, vasodilation and infiltration by activated T-cells (mainly CD4 in nodular aggregates and CD8 in diffuse infiltrates). Synovial macrophages and dendritic cells further function as antigen presenting cells by expressing MHC class II molecules, leading to an established local immune reaction in the tissue. The disease progresses in concert with formation of granulation tissue at the edges of the synovial lining (pannus) with extensive angiogenesis and production of enzymes that cause tissue damage. Modern pharmacological treatments of RA target these mediators. Once the inflammatory reaction is established, the synovium thickens, the cartilage and the underlying bone begins to disintegrate and evidence of joint destruction accrues.

TNF (alpha) plays a major role in the pathogenesis of RA. There are several theories on how TNF release happens in disease process. If TNF release is stimulated by B cell products in the form of RF or ACPA -containing immune complexes, through activation of immunoglobulin Fc receptors, then RA can be seen as a form of Type III hypersensitivity.[45][46] If TNF release is stimulated by T cell products such as interleukin-17 it might be considered closer to type IV hypersensitivity although this terminology may be getting somewhat dated and unhelpful.[47]

Although TNF appears to be the dominant, other cytokines (chemical mediators) are likely to be involved in inflammation in RA. Blockade of TNF does not benefit all persons or all tissues (lung disease and nodules may get worse). Blockade of IL-1, IL-15 and IL-6 also have beneficial effects and IL-17 may be important. Constitutional symptoms such as fever, malaise, loss of appetite and weight loss are also caused by cytokines released into the blood stream. As with most autoimmune diseases, it is important to distinguish between the cause(s) that trigger the process, and those that may permit it to persist and progress.

Diagnosis

Imaging

X-ray of the hand in rheumatoid arthritis.
Appearance of synovial fluid from a joint with inflammatory arthritis.
Signs of destruction and inflammation on ultrasonography and magnetic resonance imaging in the second metacarpophalangeal joint in established RA. Thin arrows indicate an erosive change; thick arrows indicate synovitis. Ultrasonography (left side of image) in the (a) longitudinal and (b) the transverse planes shows both signs of destruction and inflammation. Axial T1-weighted magnetic resonance images were obtained (c) before and (d) after contrast administration, also demonstrating synovitis. Additionally, a coronal T1-weighted magnetic resonance image (e) before contrast administration visualizes the same bone erosion as shown in panels c and d.

X-rays of the hands and feet are generally performed in people with a many joints affected. In RA, there may be no changes in the early stages of the disease, or the x-ray may demonstrate juxta-articular osteopenia, soft tissue swelling and loss of joint space. As the disease advances, there may be bony erosions and subluxation. X-rays of other joints may be taken if symptoms of pain or swelling occur in those joints.

Other medical imaging techniques such as magnetic resonance imaging (MRI) and ultrasound are also used in RA.[14]

There have been technical advances in ultrasonography. High-frequency transducers (10 MHz or higher) have improved the spatial resolution of ultrasound images; these images can depict 20% more erosions than conventional radiography. Also, color Doppler and power Doppler ultrasound, which show vascular signals of active synovitis depending on the degree of inflammation, are useful in assessing synovial inflammation. This is important, since in the early stages of RA, the synovium is primarily affected, and synovitis seems to be the best predictive marker of future joint damage.[48]

Blood tests

When RA is clinically suspected, testing for the presence of rheumatoid factor (RF, a non-specific antibody) and (ACPAs) may be required.[49] A negative RF does not rule out RA; rather, the arthritis is called seronegative. This is the case in about 15% of people with RA.[50][51] During the first year of illness, rheumatoid factor is more likely to be negative with some individuals converting to seropositive status over time. RF is also seen in other illnesses, for example Sjögren's syndrome, hepatitis C, systemic lupus erythematosus, chronic infections and in approximately 10% of the healthy population, therefore the test is not very specific.[14]

Because of this low specificity, new serological tests have been developed, which test for the presence of the anti-citrullinated protein antibodies (ACPAs) or anti-CCP. Like RF, these tests are positive in only a proportion (67%) of all RA cases, but are rarely positive if RA is not present, giving it a specificity of around 95%.[50] As with RF, there is evidence for ACPAs being present in many cases even before onset of clinical disease.[14]

The most common tests for ACPAs are the anti-CCP (cyclic citrullinated peptide) test and the Anti-MCV assay (antibodies against mutated citrullinated Vimentin). Recently a serological point-of-care test (POCT) for the early detection of RA has been developed. This assay combines the detection of rheumatoid factor and anti-MCV for diagnosis of RA and shows a sensitivity of 72% and specificity of 99.7%.[52][53]

Also, several other blood tests are usually done to allow for other causes of arthritis, such as lupus erythematosus. The erythrocyte sedimentation rate (ESR), C-reactive protein, full blood count, kidney function, liver enzymes and other immunological tests (e.g., antinuclear antibody/ANA) are all performed at this stage. Elevated ferritin levels can reveal hemochromatosis, a mimic of RA, or be a sign of Still's disease, a seronegative, usually juvenile, variant of rheumatoid arthritis.

Classification Criteria

In 2010 the 2010 ACR / EULAR Rheumatoid Arthritis Classification Criteria were introduced.[54][55] The new criterion is not a diagnostic criterion but a classification criterion to identify disease with a high likelihood of developing a chronic form.[14] However a score of 6 or greater unequivocally classifies a person with a diagnosis of rheumatoid arthritis.

These new classification criteria overruled the "old" ACR criteria of 1987 and are adapted for early RA diagnosis. The "new" classification criteria, jointly published by the American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR) establish a point value between 0 and 10. Four areas are covered in the diagnosis:[54]

The new criteria accommodate to the growing understanding of RA and the improvements in diagnosing RA and disease treatment. In the "new" criteria serology and autoimmune diagnostics carries major weight, as ACPA detection is appropriate to diagnose the disease in an early state, before joints destructions occur. Destruction of the joints viewed in radiological images was a significant point of the ACR criteria from 1987.[56] This criterion no longer is regarded to be relevant, as this is just the type of damage that treatment is meant to avoid.

In clinical practice, the following criteria apply:

Differential diagnoses

Several other medical conditions can resemble RA, and usually need to be distinguished from it at the time of diagnosis:[57][58]

Rarer causes that usually behave differently but may cause joint pains:[57]

Monitoring progression

There are many tools available for monitoring remission in rheumatoid arthritis.

DAS28
Disease Activity Score of 28 joints (DAS28) is widely used as an indicator of RA disease activity and response to treatment, but is not always a reliable indicator of treatment effect.[59] The joints included in DAS28 are (bilaterally): proximal interphalangeal joints (10 joints), metacarpophalangeal joints (10), wrists (2), elbows (2), shoulders (2) and knees (2). When looking at these joints, both the number of joints with tenderness upon touching (TEN28) and swelling (SW28) are counted. In addition, the erythrocyte sedimentation rate (ESR) is measured. Also, the affected person makes a subjective assessment (SA) of disease activity during the preceding 7 days on a scale between 0 and 100, where 0 is "no activity" and 100 is "highest activity possible". With these parameters, DAS28 is calculated as:[60]

DAS28=0.56 \times \sqrt{TEN28} + 0.28 \times \sqrt{SW28} + 0.70 \times \ln(ESR) + 0.014 \times SA

From this, the disease activity of the affected person can be classified as follows:[60]

Current
DAS28 		DAS28 decrease from initial value
> 1.2 > 0.6 but ≤ 1.2 ≤ 0.6
≤ 3.2 Inactive Good improvement Moderate improvement No improvement
> 3.2 but ≤ 5.1 Moderate Moderate improvement Moderate improvement No improvement
> 5.1 Very active Moderate improvement No improvement No improvement

One major limitation of use of the DAS28 score in clinical setting is low-grade synovitis may be missed.

Other
Other tools to monitor remission in rheumatoid arthritis are: ACR-EULAR Provisional Definition of Remission of Rheumatoid arthritis, Simplified Disease Activity Index (SDAI) and Clinical Disease Activity Index (CDAI).[61]

Prevention

There is no known prevention for the condition other than the reduction of risk factors.[62]

Management

There is no cure for RA, but treatments can improve symptoms and slow the progress of the disease. Disease-modifying treatment has the best results when it is started early and aggressively.[63]

The goals of treatment are to minimize symptoms such as pain and swelling, to prevent bone deformity (for example, bone erosions visible in X-rays), and to maintain day-to-day functioning.[64] This can often be achieved using two main classes of medications: analgesics such as NSAIDs, and disease-modifying antirheumatic drugs (DMARDs).[65] RA should generally be treated with at least one specific anti-rheumatic medication.[63] The use of benzodiazepines (such as diazepam) to treat the pain is not recommended as it does not appear to help and is associated with risks.[66] Analgesics, other than NSAIDs, offer lesser, but some benefit with respect to pain whilst not causing the same level of gastrointestinal irritation.[3]

Lifestyle

Regular exercise is recommended as both safe and useful to maintain muscles strength and overall physical function.[67] It is uncertain if specific dietary measures have an effect.[68] Physical activity is beneficial for persons with Rheumatoid arthritis complaining of fatigue.[69] Occupational therapy has a positive role to play in improving functional ability of persons with rheumatoid arthritis.[70]

Disease modifying agents

Disease-modifying antirheumatic drugs (DMARDs) are the primary treatment for RA.[3] They are a diverse collection of drugs, grouped by use and convention. They have been found to improve symptoms, decrease joint damage, and improve overall functional abilities.[3] DMARDs should be started early in the disease as they result in disease remission in approximately half of people and improved outcomes overall.[71] The following drugs are considered as DMARDs: methotrexate, hydroxychloroquine, sulfasalazine, leflunomide, TNF-alpha inhibitors (certolizumab, infliximab and etanercept), abatacept, and anakinra. Rituximab and tocilizumab are monoclonal antibodies and are also DMARDs.

The most commonly used agent is methotrexate with other frequently used agents including sulfasalazine and leflunomide. Sodium aurothiomalate (Gold) and cyclosporin are less commonly used due to more common adverse effects. Agents may be used in combinations.[3] Methotrexate is the most important and useful DMARD and is usually the first treatment.[64][65][72] Adverse effects should be monitored regularly with toxicity including gastrointestinal, hematologic, pulmonary, and hepatic.[72] Side effects such as nausea, vomiting or abdominal pain can be reduced by taking folic acid.[73] The most common undesirable effect is that it increases liver enzymes in almost 15% of people.[72] It is thus recommended that those who consistently demonstrate abnormal levels of liver enzymes or have a history of liver disease or alcohol use undergo liver biopsies.[74]

Biological agents should generally only be used if methotrexate and other conventional agents are not effective after a trial of three months.[75] They are associated with a higher rate of serious infections as compared to other DMARDs.[76] These agents used to treat rheumatoid arthritis include: tumor necrosis factor alpha (TNFα) blockers[3] such as infliximab; interleukin 1 blockers such as anakinra, monoclonal antibodies against B cells such as rituximab and tocilizumab,[77] T cell costimulation blocker such as abatacept among others. They are often used in combination with either methotrexate or leflunomide.[3] In those who are well controlled on TNF blockers decreasing the dose does not appear to affect overall function.[78] Persons should be screened for latent tuberculosis before starting any TNF blockers therapy to avoid reactivation.[14]

TNF blockers and methotrexate appear to have similar effectiveness when used alone and better results are obtained when used together. TNF blockers appear to have equivalent effectiveness with etanercept appearing to be the safest.[79] Abatacept appears effective for RA with 20% more people improving with treatment than without but long term safety studies are yet unavailable.[80] However, there is a lack of evidence to distinguish between the biologics available for RA.[81] Issues with the biologics include their high cost and association with infections including tuberculosis.[3]

Anti-inflammatory agents

NSAIDs reduce both pain and stiffness in those with RA.[3] Generally they appear to have no effect on people's long term disease course and thus are no longer first line agents.[3][82] NSAIDs should be used with caution in those with gastrointestinal, cardiovascular, or kidney problems.[83][84][85] Use of methotrexate together with NSAIDS is safe, if adequate monitoring is done.[86]

COX-2 inhibitors, such as celecoxib, and NSAIDs are equally effective.[87] They have a similar gastrointestinal risk as an NSAIDs plus a proton pump inhibitor.[88] In the elderly there is less gastrointestinal intolerance to celecoxib than to NSAIDs alone.[89] There however is an increased risk of myocardial infarction with COX-2 inhibitors.[87] Anti-ulcer medications are not recommended routinely but only in those high risk of gastrointestinal problems.[90]

Glucocorticoids can be used in the short term for flare-ups, while waiting for slow-onset drugs to take effect.[3] Injection of glucocorticoids into individual joints is also effective.[3] While long-term use reduces joint damage it also results in osteoporosis and susceptibility to infections, and thus is not recommended.[3]

Surgery

In early phases of the disease, an arthroscopic or open synovectomy may be performed. It consists of the removal of the inflamed synovia and prevents a quick destruction of the affected joints. Severely affected joints may require joint replacement surgery, such as knee replacement.[3] Postoperatively, physiotherapy is always necessary.

Alternative medicine

In general, there is not enough evidence to support any complementary health approaches for RA, with safety concerns for some of them. Some mind and body practices and dietary supplements may help people with symptoms and therefore may be beneficial additions to conventional treatments, but there is not enough evidence to draw conclusions.[6] A systematic review of CAM modalities (excluding fish oil) found that " The available evidence does not support their current use in the management of RA.".[91] Studies showing beneficial effects in RA on a wide variety of CAM modalities are often affected by publication bias and are generally not high quality evidence such as randomized controlled trials (RCTs).[5]

A 2005 Cochrane review states that low level laser therapy can be tried to improve pain and morning stiffness due to rheumatoid arthritis as there are few side-effects.[92]

There is some evidence that Tai Chi improves the range of motion of a joint in persons with rheumatoid arthritis.[93] The evidence for acupuncture is inconclusive[94] with it appearing to be equivalent to sham acupuncture.[95]

Dietary supplements

Omega-3
Some evidence supports omega-3 fatty acids and gamma-linolenic acid in RA.[96] The benefit from omega-3 appears modest but consistent,[97] though the current evidence is not strong enough to determine that supplementation with omega-3 polyunsaturated fatty acids (found in fish oil) is an effective treatment for RA.[98] Gamma-linolenic acid, which may reduce pain, tender joint count and stiffness, is generally safe.[99]
Herbal
The American College of Rheumatology states that no herbal medicines have health claims supported by high quality evidence and thus they do not recommend their use.[100] There is no scientific basis to suggest that herbal supplements advertised as "natural" are safer for use than conventional medications as both are chemicals. Herbal medications, although labelled "natural", may be toxic or fatal if consumed.[100]

Due to the false belief that herbal supplements are always safe, there is sometimes a hesitancy to report their use which may increase the risk of adverse reaction.[5]

The following are under investigation for treatments for RA, based on preliminary promising results (not recommended for clinical use yet) : boswellic acid,[101] curcumin,[102] Devil's claw,[103][104] Euonymus alatus,[105] and Thunder god vine (Tripterygium wilfordii).[106] NCCIH has noted that, "In particular, the herb thunder god vine (Tripterygium wilfordii) can have serious side effects."[6]

There is conflicting evidence on the role of Erythropoiesis-stimulating agents for treatment of anemia in persons with rheumatoid arthritis.[107]

Pregnancy

More than 75% of people with rheumatoid arthritis have symptoms improve during pregnancy but might have worsenings after delivery.[14] Methotrexate and leflunomide are teratogenic (harmful to foetus) and not used in pregnancy. It is recommended women of childbearing age should use contraceptives to avoid pregnancy and to discontinue its use if pregnancy is planned.[64][72] Low dose of prednisolone, hydroxychloroquine and sulfasalazine are considered safe in pregnant persons with rheumatoid arthritis.

Vaccinations

People with RA have an increased risk of infections and mortality and recommended vaccinations can reduce these risks.[108] The killed influenza vaccine should be received annually.[109] The pneumococcal vaccine should be administered twice for people under the age 65 and once for those over 65.[110] Lastly, the live-attenuated zoster vaccine should be administered once after the age 60, but is not recommended in people on a tumor necrosis factor alpha blocker.[111]

Prognosis

The course of the disease varies greatly. Some people have mild short-term symptoms, but in most the disease is progressive for life. Around 20%–30% will have subcutaneous nodules (known as rheumatoid nodules); this is associated with a poor prognosis.

Prognostic factors

Poor prognostic factors include,

Mortality

RA reduces lifespan on average from three to twelve years.<ref name="Wasserman" According to the UK's National Rheumatoid Arthritis Society, "Young age at onset, long disease duration, the concurrent presence of other health problems (called co-morbidity), and characteristics of severe RA—such as poor functional ability or overall health status, a lot of joint damage on x-rays, the need for hospitalisation or involvement of organs other than the joints—have been shown to associate with higher mortality".[112] Positive responses to treatment may indicate a better prognosis. A 2005 study by the Mayo Clinic noted that RA sufferers suffer a doubled risk of heart disease,[113] independent of other risk factors such as diabetes, alcohol abuse, and elevated cholesterol, blood pressure and body mass index. The mechanism by which RA causes this increased risk remains unknown; the presence of chronic inflammation has been proposed as a contributing factor.[114] It is possible that the use of new biologic drug therapies extend the lifespan of people with RA and reduce the risk and progression of atherosclerosis.[115] This is based on cohort and registry studies, and still remains hypothetical. It is still uncertain whether biologics improve vascular function in RA or not. There was increase in total cholesterol and HDLc levels and no improvement of the atherogenic index.[116]

Epidemiology

Disability-adjusted life year for RA per 100,000 inhabitants in 2004.[117]
  no data
  <40
  40–50
  50–60
  60–70
  70–80
  80–90
  90–100
  100–110
  110–120
  120–130
  130–140
  >140

RA affects between 0.5 and 1% of adults in the developed world with between 5 and 50 per 100,000 people newly developing the condition each year.[3] In 2010 it resulted in about 49,000 deaths globally.[118]

Onset is uncommon under the age of 15 and from then on the incidence rises with age until the age of 80. Women are affected three to five times as often as men.[14]

The age at which the disease most commonly starts is in women between 40 and 50 years of age, and for men somewhat later.[119] RA is a chronic disease, and although rarely, a spontaneous remission may occur, the natural course is almost invariably one of persistent symptoms, waxing and waning in intensity, and a progressive deterioration of joint structures leading to deformations and disability.

History

The first known traces of arthritis date back at least as far as 4500 BC. A text dated 123 AD first describes symptoms very similar to RA. It was noted in skeletal remains of Native Americans found in Tennessee.[120] In Europe, the disease is vanishingly rare before the 17th century.[121] The first recognized description of RA in modern medicine was in 1800 by the French physician Dr Augustin Jacob Landré-Beauvais (1772–1840) who was based in the famed Salpêtrière Hospital in Paris.[8] The name "rheumatoid arthritis" itself was coined in 1859 by British rheumatologist Dr Alfred Baring Garrod.[122]

An anomaly has been noticed from investigation of Pre-Columbian bones. The bones from the Tennessee site show no signs of tuberculosis even though it was prevalent at the time throughout the Americas.[123]

The art of Peter Paul Rubens may possibly depict the effects of RA. In his later paintings, his rendered hands show, in the opinion of some physicians, increasing deformity consistent with the symptoms of the disease.[124][125] RA appears to some to have been depicted in 16th-century paintings.[126] However, it is generally recognised in art historical circles that the painting of hands in the 16th and 17th century followed certain stylised conventions, most clearly seen in the Mannerist movement. It was conventional, for instance to show the upheld right hand of Christ in what now appears a deformed posture. These conventions are easily misinterpreted as portrayals of disease.

Historic treatments for RA have also included: rest, ice, compression and elevation, apple diet, nutmeg, some light exercise every now and then, nettles, bee venom, copper bracelets, rhubarb diet, extractions of teeth, fasting, honey, vitamins, insulin, magnets, and electroconvulsive therapy (ECT).[127] The Prosorba column blood filtering device (removing IgG) was approved by the FDA in 1999 for treatment of RA[128] However it was discontinued at the end of 2006.[129]

Etymology

Rheumatoid arthritis is derived from the Greek word ῥεύμα-rheuma (nom.), ῥεύματος-rheumatos (gen.) ("flow, current"). The suffix -oid ("resembling") gives the translation as joint inflammation that resembles rheumatic fever. Rhuma which means watery discharge might refer to the fact that the joints are swollen or that the disease may be made worse by wet weather.[9]

References

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