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Rheumatoid arthritis

Also listed as: Arthritis - rheumatoid

Signs and Symptoms
Causes
Risk Factors
Diagnosis
 
Treatment Approach
Other Considerations
Supporting Research

Rheumatoid arthritis (RA) is an autoimmune disease where the body’s immune system mistakenly attacks the synovium, a thin membrane that lines the joints. It causes chronic inflammation that leads to pain, swelling, and stiffness. Eventually, bones and joints can be damaged, leading to disability.

RA usually affects joints on both sides of the body equally -- meaning if a joint on one side is affected, the same joint on the opposite side is affected. Wrists, fingers, knees, feet, and ankles, and elbows are most often affected. RA can also affect other organs, and people who have RA are at higher risk for other diseases including heart disease, diabetes, and osteoporosis.

RA is a chronic disease, meaning it lasts a long time and can get worse. Ii is important that people with RA work closely with their doctor .to find a treatment plan that lessens symptoms and joint damage.

There is no cure for RA, but taking medication and making lifestyle changes can help you manage the disease. Alternative and complementary therapies can also help relieve symptoms, but only conventional medications can halt the progression of the disease and stop further joint damage. In some cases, medications can help put RA into remission and symptoms may go away completely.

Signs and Symptoms

Symptoms of RA include:

  • Morning stiffness -- waking up with stiff joints, often the wrists and base of the fingers, ankles, balls of the feet, elbows, or knees
  • Joint pain with warmth, swelling, tenderness, and stiffness of the joint after resting
  • Limited range of motion in the affected joints
  • Fatigue
  • Low-grade fever, when having a flare
  • Small, round, firm bumps called nodules under the skin; you can feel these, but they are generally painless.

Causes

Researchers don't know what causes RA, although both genetics and environment probably play a part. Researchers believe that genetics may make some people more likely to get RA. In those people, environmental factors, bacteria, and viruses may then trigger RA. Some evidence suggests that hormones may also play a role, but researchers aren’t sure.

In RA, the body’s immune system -- which normally fights off foreign invaders -- mistakenly attacks the lining of the joints (called the synovium). That causes inflammation, which makes the synovium thicker and eventually destroys the cartilage and bone in the joints.

RA can occur at any age. It usually occurs in people between 25 - 55 years of age. Women are affected more often than men.

RA usually affects joints on both sides of the body equally. Wrists, fingers, knees, feet, elbows, and ankles are the most often affected.

Risk Factors

  • Age. Although someone can get the disease at any age, RA generally starts in young adulthood usually between ages 25 and 55.
  • Gender. Women get RA two and a half times more often than men, and are more likely to have severe symptoms.
  • Family history. Having relatives with RA increases your risk of getting it yourself.
  • Cigarette smoking. Smoking seems to increases your risk of getting RA.

Diagnosis

RA can be hard to diagnose because it looks like many other conditions, and symptoms may develop so gradually. Even after RA has been diagnosed, it is extremely important to see how the disease is progressing in order to treat it.

Your doctor will take your medical history and do a physical exam. Blood tests, x-rays, and aspiration (the removal of fluid from the joint) may also be needed.

Your doctor may order several blood tests. One test checks for an elevated erythrocyte sedimentation rate (ESR, or sed rate), which is a sign of inflammation in the body. Other blood tests that may be done include checking for certain antibodies, including rheumatoid factor, antinuclear antibodies (ANA), and anti-cyclic citrullinated peptide (anti-CCP) antibodies. Most people with RA -- but not all -- have these antibodies.

Treatment Approach

If you have RA, it is important to get diagnosed and start treatment early. Studies have shown that early, aggressive treatment for RA can stop the destruction of joints. In addition to rest, regular exercise, and taking anti-inflammatory medications, your doctor will start you on disease-modifying anti-rheumatic drugs (DMARDs). These drugs do more than relieve symptoms -- they halt the progression of the disease.

You can use complementary and alternative therapies along with conventional treatment to help relieve pain and stiffness. Studies show that certain dietary supplements, particularly omega-3 fatty acids, may help relieve pain and stiffness. Be sure to tell all your health care providers about any supplements, herbs, or other therapies you are using. Some herbs and supplements can interact with certain medications and should not be taken together.

RA usually requires lifelong treatment, including medications, physical therapy, education, and possibly surgery. Often, a combination of treatments can control the disease.

Lifestyle

Regular exercise -- consisting of aerobic exercise, strengthening exercises, and flexibility or range-of-motion exercises -- can help to maintain joint motion and strength. Exercise also helps you relieve pain and maintain a proper weight, which takes pressure off your joints. A physical therapist can help create an exercise program for you.

Doctors often recommend walking, swimming, warm-water exercise, or biking for people with RA. If you are not used to exercising, start slow and work your way up, aiming for 30 minutes of aerobic exercise 5 or more days a week.

Weight-bearing exercises -- such as lifting weights, using a resistance band, or walking -- are also recommended to keep bones strong. People with RA often take corticosteroids to reduce inflammation. Taking corticosteroids long-term raises the risk of developing osteoporosis.

Joint protection techniques, such as heat and cold treatments and splints or orthotic (straightening) devices to support and align joints, may help as well.

Medications

The following drugs are used to treat RA:

Nonsteroidal anti-inflammatory drugs (NSAIDs) -- NSAIDS are used to relieve joint pain and inflammation. They do not stop progression of RA. Long-term use can cause stomach problems, such as ulcers and bleeding, and possible heart problems. In April 2005, the U.S. Food and Drug Administration (FDA) asked drug manufacturers of NSAIDs to include a warning label on their product to alert users of an increased risk for heart problems and stomach bleeding. These drugs include ibuprofen (Motrin, Advil) and naproxen (Aleve) as well as prescription medications.

Celecoxib (Celebrex) -- Celebrex is a type of drug called a COX-2 inhibitor, which blocks an inflammation-promoting enzyme called COX-2. COX-2 inhibitors were developed to work as well as traditional NSAIDs but with fewer stomach problems. However, many reports of heart attacks and stroke have prompted the FDA to re-evaluate the risks and benefits of the COX-2s. Two drugs in this class were taken off the U.S. market following reports of heart attacks in people who took them. Celebrex is still available, but it is labeled with strong warnings and a recommendation that it be prescribed at the lowest possible dose for the shortest time possible.

Corticosteroids -- Also known as steroids, these medications are used to quickly bring down inflammation, often during a flare. Steroids have side effects including weight gain, nausea, and fluid retention. Long-term use raises the risk of osteoporosis and diabetes.

Disease-modifying antirheumatic drugs (DMARDs) -- These drugs can slow progression of the disease and halt joint damage. Current recommendations are that everyone diagnosed with RA should start taking a DMARD, whether their symptoms are mild or severe. Side effects can include liver damage and being prone to infection. Methotrexate (Rheumatrex) is used most often for RA. Other DMARDs include:

  • Leflunomide (Arava)
  • Sulfasalazine (Azulfidine)
  • Hydroxychloroquine (Plaquenil)
  • Minocycline (Minocin)

Immune suppressants -- These medicines suppress the immune system, which is overactive in people with RA. Side effects include being prone to infection. These drugs include:

  • Azathioprine (Imuran)
  • Cyclosporine (Neoral)
  • Cyclophosphamide (Cytoxan)

Biologic agents -- Biologics are newer drugs that target a specific part of the inflammation process and can slow or halt progression of joint damage. Etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira), and certolizumab pegol (Cimzia) block production of TNF-alpha, or tumor necrosis factor-alpha, a chemical produced by your body that is involved in inflammation. Anakinra (Kineret) stops a protein called interleukin-1 (IL-1). Abatacept (Orencia) stops the activation of T cells, a type of white blood cell, in the body. Rituximab (Rituxan) blocks B cells, another type of white blood cell involved in the immune system response.

Biologics are often used after other treatments have failed, and are often combined with a DMARD (usually methotrexate).

Surgery and Other Procedures

If a joint is severely affected, you may need surgery. The most successful surgeries are those on the knees and hips.

Sometimes people with RA need total joint replacement with an artificial joint. Surgeries may relieve pain, correct deformities, and modestly improve joint function. In some cases, total knee or hip replacement can restore mobility and improve quality of life.

Nutrition and Dietary Supplements

For anyone with a chronic illness, eating a healthy diet that's high in antioxidant foods -- fruits and vegetables -- is essential. Eating a poor diet may contribute to inflammation in the body.

Also, people with RA are at higher risk of developing heart disease and diabetes. A healthy diet and regular exercise can lower that risk.

Although diet cannot cure RA, some people report that they have less pain, stiffness, and fatigue when they switched from a typical Western diet to a vegan diet with lots of uncooked berries, fruits, vegetables, nuts, roots, seeds, and sprouts. Vegan diets contain no animal products and get protein from vegetable sources.

Some people think food allergies may play a part in the inflammation common in RA, and say that their symptoms get worse after they eat certain foods. Although researchers aren't sure if food allergies are to blame, you may want to try an elimination diet, which removes certain foods from your diet and then adds them back in, one by one. You will need to keep careful track of your symptoms in a food diary. Usually it's best to try an elimination diet under the supervision of your doctor or a registered dietitian.

These general nutritional tips can help you eat a healthy diet:

  • Avoid refined foods such as white breads, pastas, and sugar.
  • Eat fewer red meats and more lean meats, cold-water fish, tofu (soy, if no allergy) or beans for protein.
  • Use healthy cooking oils, such as olive oil or vegetable oil.
  • Reduce or eliminate trans-fatty acids, found in commercially baked goods such as cookies, crackers, cakes, French fries, onion rings, donuts, processed foods, and margarine.
  • Avoid caffeine and other stimulants, alcohol, and tobacco.
  • Drink 6 - 8 glasses of filtered water daily.
  • Exercise 30 minutes daily, 5 days a week.

Some supplements may help relieve pain and inflammation when you have RA, but none have been shown to stop joint damage. Supplements may also interact with some of the medications used to treat RA. Ask your doctor before taking any supplements.

These supplements may help relieve inflammation and pain:

  • Omega-3 fatty acids, such as fish oil, up to 2.6 g daily -- Omega-3 fatty acids may help reduce inflammation. A review of studies where people with RA took omega-3 fatty acids found they had fewer tender joints but no difference in joint damage. In some studies, people who take omega-3s are able to reduce the dose of NSAIDs or corticosteroids they take for RA. Omega-3 fatty acids may also reduce the risk of heart disease, which is higher in people with RA. Omega-3 fatty acid supplements may raise the risk of bleeding, especially if you also take blood-thinners such as clopidogrel (Plavix), warfarin (Coumadin), or aspirin.
  • Vitamin E -- One study suggests that taking vitamin E along with standard medications for rheumatoid arthritis may help reduce pain -- but not inflammation -- better than standard medications alone. Vitamin E may increase the risk of bleeding, especially if you already take blood thinners such as warfarin (Coumadin), clopidogrel (Plavix), or aspirin. People with heart disease, diabetes, retinitis pigmentosa -- or with cancer of the head, neck, or prostate -- should avoid high doses of vitamin E without first asking their doctor.
  • Bromelain (500 mg - 2,000 mg three times daily) -- This enzyme derived from pineapples may help reduce inflammation and pain. Bromelain increases the risk of bleeding, especially if you also take blood thinners such as clopidogrel (Plavix), warfarin (Coumadin), or aspirin. People with stomach ulcers should avoid bromelain. Turmeric is sometimes combined with bromelain because it makes the effects of bromelain stronger.
  • Gamma linolenic acid (GLA) -- found in borage oil, evening primrose oil, and black currant seed oil, 1.1 g - 2.6 g daily -- may help reduce pain, stiffness, and swelling. One study found that people with RA who took 2.8 g of GLA for six months reduced pain and swelling and improved their grip strength. People with a history of seizures should not take GLA. GLA may increase the risk of bleeding, especially if you already take blood-thinners.
  • Folic acid -- People who take methotrexate for RA may need additional folic acid because methotrexate makes it hard for the body to absorb folic acid. In addition, one study found that folic acid supplements helped reduce side effects (including liver problems) from methotrexate. High doses of folic acid can hide a vitamin B-12 deficiency and may interact with other medications, so ask your doctor if you need folic acid supplements -- don’t just start taking them on your own.

Herbs

You can use herbs in the form of dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, make teas with 1 tsp. herb per cup of hot water. Steep covered 5 - 10 minutes for leaf or flowers, and 10 - 20 minutes for roots. Drink 2 - 4 cups per day.

Herbs may be a helpful addition to conventional treatment for RA, but you should never use them alone to treat RA. Herbs do not halt joint damage and progression of the disease, as some conventional medications can.

  • Boswellia (Boswellia serrata), 400 mg - 800 mg three times daily -- Boswellia has been used traditionally to treat arthritis in Ayurvedic medicine. Studies using it to treat RA have been mixed. Some found that it relieved pain and swelling, but others found it was no better than placebo.
  • Ginger (Zingiber officinale), up to 2 g per day in divided doses, may reduce joint inflammation and pain. One study found that ginger extract blocked COX-2, a chemical in the body that causes pain. Ginger may increase the risk of bleeding, especially if you also take blood thinners such as clopidogrel (Plavix), warfarin (Coumadin), or aspirin.
  • Green tea (Camelia sinensis) standardized extract, 250 - 500 mg daily -- Green tea is loaded with antioxidants, and test tube studies found that it may block inflammatory chemicals that are involved in RA. Use caffeine-free products. You may also prepare teas from the leaf of this herb.
  • Cat's claw (Uncaria tomentosa) standardized extract, 20 mg three times a day -- may help reduce inflammation. One study found that people with RA who took cat's claw experienced a modest reduction in pain and swelling. Cat's claw may stimulate the immune system, which could cause problems in a disease like RA where the immune system is already overactive. For that reason, do not take cat's claw except under the supervision of your doctor.
  • Turmeric (Curcuma longa) standardized extract, 400 mg three times a day -- may help reduce pain and inflammation. It is sometimes combined with bromelain, because it makes the effects of bromelain stronger. Turmeric can increase the risk of bleeding, especially if you also take blood-thinners or NSAIDs.
  • Devil's claw (Harpagophytum procumbens) standardized extract, 100 - 200 mg one to two times daily -- may reduce inflammation. One study found that people with RA who took devil's claw reduced pain and improved their mobility. But not all studies have found that devil's claw was effective for RA; evidence is mixed. People with heart disease, diabetes, gallstones, or stomach ulcers should not take devil's claw without talking to their doctor. Theoretically, devil's claw may interact with several medications processed by the liver.
  • Capsaicin (Capsicum frutescens) cream, applied to the skin (topically) -- Capsaicin is the main component in hot chili peppers (also known as cayenne). Applied to the skin, it is believed to temporarily reduce amounts of "substance P," a chemical that contributes to inflammation and pain in arthritis. Pain reduction generally starts 3 - 7 days after applying the capsaicin cream to the skin. Wash hands well with vinegar after use and avoid touching the eyes.

Acupuncture

There is little to no scientific evidence supporting the use of acupuncture for RA. However, some people with RA say that acupuncture helps relieve their pain and improves their quality of life. Acupuncturists treat people with RA based on an individualized assessment of the excesses and deficiencies of qi, or energy, located in various meridians. A qi deficiency is usually detected in the spleen and kidney meridians.

Acupuncturists may use moxibustion (a technique in which the herb mugwort is burned over specific acupuncture points) to strengthen the entire energy system. Qualified acupuncturists may also provide lifestyle, dietary, and herbal advice to people with RA. Practitioners may apply local treatment to the painful areas and related sore points, either with a needle or moxibustion. You should not rely on acupuncture alone to treat RA, as it does not halt progression of the disease. It may help along with conventional medical therapy.

Exercise

Regular exercise is important for people with RA. It boosts overall health, helps you maintain a proper weight (which takes pressure off joints), and helps prevent heart disease, diabetes, and osteoporosis. It also reduces pain and can boost your mood.

While you may choose to rest during an active flare, it's important to stay in good shape and maintain range of motion in your joints. Ask your doctor or physical therapist to design an exercise program for you. Many people with RA find that walking, swimming, or warm-water exercise are helpful.

Doctors used to advise people with RA do only gentle exercises, fearing more joint damage. But recent research suggests that more intense exercise may not only be safe, but may actually produce greater muscle strength and overall functioning. To know how long or hard you should exercise, ask your doctor and pay attention to signs from your body:

If you feel sharp pains while exercising, stop immediately.

Some soreness after exercising is normal. If aches and pains continue for more than 2 hours afterwards, try a lighter exercise program for a while.

Be sure to warm up and cool down.

Using large joints instead of small ones for ordinary tasks can help relieve pain. For example, use your hip to close doors or the palm of your hand to push buttons.

Balneotherapy (Hydrotherapy or spa therapy)

Balneotherapy is one of the oldest forms of therapy for pain relief for people with arthritis. The term "balneo" comes from the Latin word for bath (balneum) and refers to bathing in thermal or mineral waters. For example, sulfur-containing mud baths have been shown to relieve symptoms of arthritis. Sulfur-containing mud baths, for example, have been shown to relieve symptoms of arthritis. However, hydrotherapy, which can be done under the guidance of certain physical therapists, is sometimes referred to with the word balneotherapy. The goals of balneotherapy for RA include:

  • Improving range of joint motion
  • Increasing muscle strength
  • Stopping muscle spasm
  • Enhancing functional mobility
  • Easing pain

Exercising and swimming in a heated pool may also help.

Mechanical Aids

Many devices, called orthoses, are available for people with RA to help support and protect joints. Made from lightweight metal leather, elastic, foam, and plastic, they allow the affected joint to move a little while not restricting nearby joints. For example, splints or braces help align joints and properly distribute weight.

Shock-absorbing soles in shoes can help in daily activities and during exercise. Physical therapists use these mechanical aids most frequently to treat hands, wrists, knees, ankles, and feet. Orthoses should be custom-fitted by a physical or occupational therapist.

Compression gloves may help some people. Two studies on the overnight use of compression gloves -- close-fitting nylon-spandex gloves -- concluded that the gloves reduced pain and stiffness in people with RA in the fingers.

Other possibilities for symptom relief include:

  • Transcutaneous nerve stimulation (TENS) -- small clinical studies show that TENS, a technique used by many physical therapists, may provide short-term pain relief for people with RA.
  • Heat and cold applications -- may reduce pain

Homeopathy

Recent trials evaluating homeopathy to treat RA found that the remedies were no better than placebo in reducing symptoms. These studies contradict an older trial that showed positive effects with homeopathic treatment. Despite the lack of definitive evidence, professional homeopaths might recommend one of the following treatments for RA based on their knowledge and clinical experience. Before prescribing a remedy, homeopaths take into account an individual's constitutional type -- your physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a particular individual.

Potential remedies include:

  • A topical homeopathic gel containing comfrey (Symphytum officinale), poison ivy (Rhus toxicodendron), and marsh-tea (Ledum palustre)
  • A combination homeopathic preparation containing R. toxicodendron, Arnica montana (arnica), Solanum dulcamara (climbing nightshade), Sanguinarra canadensis (bloodroot), and Sulphur
  • A liquid homeopathic preparation containing R. toxicodendron, Causticum (potassium hydrate), and Lac vaccinum (cow's milk)

Mind-Body Medicine

Chronic pain and disability can make daily life difficult, and stress can make an RA flare worse. Many people report that relaxation techniques, such as guided imagery and meditation, help improve quality of life and reduce pain and other symptoms of RA.

Yoga

This ancient Indian practice is well known for its physical, psychological, emotional, and spiritual benefits. In the West, it is often recommended to relieve musculoskeletal symptoms and some studies have found it can help relieve RA pain.

Some yoga "asanas" (postures) strengthen the quadriceps and emphasize stretching, both of which help people with RA of the knee. People with arthritis should begin asanas slowly and they should be performed only after a warm up. Look for a reputable instructor who knows how to modify postures for people with RA.

Tai Chi

This gentle exercise program practiced in China for centuries has been shown to produce a number of benefits, including the following:

  • Better fitness
  • Increased muscular strength
  • Better flexibility
  • Reduced percentage of body fat
  • Reduced risk of falls in the elderly

Tai chi is generally safe for people with RA, and a review of scientific studies has found that it may help improve flexibility and range of motion, especially for people with RA in their ankles.

Other Considerations

Prognosis and Complications

RA can have many complications.

  • Joint deformities
  • Cervical spine problems (can be life threatening)
  • Painless, hard, round or oval masses called nodules that appear under the skin
  • Pleuritis, inflammation of the lungs
  • Anemia
  • Rheumatoid vasculitis, inflammation of the blood vessels
  • Pericarditis, inflammation of the outer lining of the heart
  • Myocarditis, inflammation of the heart muscle
  • Heart failure
  • Eye inflammation
  • Osteoporosis
  • Heart disease
  • Diabetes

RA is different for everyone. People with a certain antibody in the blood (anti-CCP) or nodules may be at risk for faster progression of the disease. People who develop RA at younger ages also tend to have faster disease progression.

Although complications may shorten the life expectancy of people with RA, treatment is constantly improving and newer medications offer better chances for remission.

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Review Date: 1/15/2012
Reviewed By: Steven D. Ehrlich, NMD, Solutions Acupuncture, a private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network.
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