RHEUMATOID ARTHRITIS (RA)

BACKGROUND

Rheumatoid arthritis is a chronic inflammatory condition. Rheumatoid arthritis symptoms develop gradually and may include joint pain, stiffness, and swelling. The condition can affect many tissues throughout the body, but the joints are usually most severely affected. The cause of rheumatoid arthritis is unknown.

DISEASE OCCURRENCE IN POPULATION:

Worldwide, the annual incidence of RA is approximately 3 cases per 10,000 populations, and the prevalence rate is approximately 1%, increasing with age and peaking between the ages of 35 and 50 years.

In the urban population of southern Pakistan, Karachi, the prevalence of RA is reported to be 0.142%, whereas in northern Pakistan the estimated prevalence is 0.55%.

RISK FACTORS:

The specific cause of rheumatoid arthritis is not known. Researchers suspect that two types of factors affect a person's risk: susceptibility factors and initiating factors.

Rheumatoid arthritis most likely occurs when a susceptible person is exposed to factors that start the inflammatory process. Approximately 1 in every 100 individuals has rheumatoid arthritis.

Gender, heredity, and genes largely determine a person's risk of developing rheumatoid arthritis.

GENDER: Gender appears to play a major role in a person's susceptibility to rheumatoid arthritis. Women are about three times more likely than men to develop rheumatoid arthritis.

HEREDITY: Rheumatoid arthritis is not an inherited disease. Genes do not cause rheumatoid arthritis; they merely affect the risk of its development.

SPECIFIC GENES: People with specific variants of human leukocyte antigen (HLA) genes are more likely to develop rheumatoid arthritis than people with other gene variants.

INITIATING FACTORS: Many individuals who carry HLA genes never develop the condition. Indeed, when one identical twin has rheumatoid arthritis, the chance that the other will develop disease is only about 1 in 3. This suggests that additional factors must be necessary for a person to develop RA.

INFECTION: Researchers suspect that, alterations of bacterial populations in the gut or within the mouth may be among the environmental factors that initiate rheumatoid arthritis. However, at this time, there is no definite evidence linking infection to rheumatoid arthritis.

CIGARETTE SMOKING: Cigarette smoking is a recognized factor that increases the risk of developing rheumatoid arthritis. There is also some evidence that cigarette smoking increases the likelihood that rheumatoid arthritis will be severe when it occurs.

STRESS: Patients often report episodes of stress or trauma preceding the onset of their rheumatoid arthritis. Stressful “life events” (e.g. divorce, accidents, grief, etc.) are more common in people with RA in the six months before their diagnosis compared with the general population.

SIGN AND SYMPTOMS:

Joint pain can be an early symptom of many different diseases. In rheumatoid arthritis, symptoms often develop slowly over a period of weeks or months. Fatigue and stiffness are usually early symptoms. Weight loss and a low-grade fever can also occur.

Joint symptoms include:

• Painful, swollen, tender, stiff joints. The same joints on both sides of the body (symmetrical) are usually affected, especially the hands , wrists, elbows, feet, ankles, knees, or neck.
• Morning stiffness: Joint stiffness may develop after long periods of sleeping or sitting. It lasts at least 60 minutes and often up to several hours.
• Bumps (nodules): Rheumatoid nodules ranging in size from a pea to a mothball develop in nearly one-third of people who have rheumatoid arthritis. Nodules usually form over pressure points in the body such as the elbows, knuckles, spine, and lower leg bones.

In addition to specific joint symptoms, rheumatoid arthritis can cause symptoms throughout the body (systemic). These include:

• Fatigue
• A loss of appetite
• Weight loss
• Mild fever.

Some of the symptoms of rheumatoid arthritis may be similar to symptoms of other health conditions.

DIAGNOSTIC TEST:

There is no single test used to diagnose rheumatoid arthritis. Instead, the diagnosis is based upon many factors, including the characteristic signs and symptoms, the results of laboratory tests, and the results of X-rays.

A person with well-established rheumatoid arthritis typically has or has had at least several of the following:

• Morning stiffness that lasts at least one hour and that has been present for at least six weeks
• Swelling of three or more joints for at least six weeks
• Swelling of the wrist, hand, or finger joints for at least six weeks
• Swelling of the same joints on both sides of the body
• Changes in hand X-rays that are characteristic of rheumatoid arthritis
• Rheumatoid nodules of the skin
• Blood test positive for rheumatoid factor and / or anti-citrullinated peptide/ protein antibodies (ACPA)

Not all of these features are present in people with early RA, and these problems may be present in some people with other rheumatic conditions.

In some cases, it may be necessary to monitor the condition over time before a diagnosis of rheumatoid arthritis can be made with certainty.

LABORATORY TESTS: Laboratory tests help to confirm the presence of rheumatoid arthritis, to differentiate it from other conditions, and to predict the likely course of the condition and its response to treatment.

RHEUMATOID FACTOR: An antibody called rheumatoid factor is present in the blood of 70 to 80 percent of people with rheumatoid arthritis. However, rheumatoid factor is also found in people with other types of rheumatic disease and in a small number of healthy individuals.

ANTI-CITRULLINATED PEPTIDE / PROTEIN ANTIBODY (ACPA) TEST: Blood tests for ACPA are more specific than rheumatoid factor for diagnosing rheumatoid arthritis. Anti-ACPA antibody tests may be positive very early in the course of disease. The test is positive in most patients with rheumatoid arthritis.

TREATMENT OPTIONS:

There are dozens of medicines for rheumatoid arthritis. The right one for you will depend on:

• How bad your symptoms are?
• How many of your joints are affected?
• How your disease has changed over time?
• What side affects you feel with the medicines you try?
• What your X-rays look like?
• The results of certain blood tests.

In general the treatment options include:

• Medicines called “non-steroidal anti-inflammatory drugs,” also known as NSAIDs
• Medicines called steroids
• Medicines called “disease modifying anti-rheumatic drugs” also known as “DMARDs”

NON-STEROIDAL ANTI-INFLAMMATORY DRUGS: Non-steroidal anti-inflammatory drugs, also called "NSAIDs," are medicines that relieve pain and reduce inflammation. They are one of the most commonly used kinds of medicines.

NSAIDs can help people who have conditions that cause ongoing pain, such as arthritis. They can also help people heal more quickly after an injury. But NSAIDs can cause problems of their own, so it's important to take the lowest dose you need for the shortest time.

STEROID: Steroid medicines are a group of medicines that can treat a wide range of medical conditions. Steroid medicines are a man-made form of a hormone the body makes naturally in the adrenal glands. This hormone is called "cortisol."

The medical terms for steroid medicines are "glucocorticoids" and "corticosteroids." These are not the same as the steroids some athletes take illegally.

DISEASE MODIFYING ANTI-RHEUMATIC DRUGS (DMARD’S): DMARDs are medicines that partly turn off the body's infection-fighting system, called the "immune system." Doctors prescribe DMARDs for some diseases that happen when the immune system mistakenly attacks the body's own healthy tissues, such as your joints or your kidneys. These are called "autoimmune" diseases. Examples include rheumatoid arthritis and psoriatic arthritis.

PRECAUTIONS:

Because RA damages joints, an RA patient could very well have weakened joints that can increase the risk of injury during strenuous exercises. Therefore, lower-impact exercises are best. These include activities like stretching to help maintain flexibility, walking and swimming. If arthritis is centered in the hips or knees, climbing activities like stair-step machines should be limited so that excess strain is not placed on the hip or knee joints.

REFERENCES:

• https://www.uptodate.com/contents/disease-modifying-antirheumatic-drugs-dmards-the-basics?source=see_link
• Farooqi A, Gibson T, Prevalence of the major rheumatic disorders in the adult population of North Pakistan. Br J Rheumatol 1998; 37: 491-5.
• http://www.webmd.com/rheumatoid-arthritis/tc/rheumatoid-arthritis-symptoms
• http://www.health.com/health/gallery/0,,20464354,00.html
• Ahlmen M, Svensson B, Albertsson K, Forslind K, Hafstrom I. Influence of gender on assessments of disease activity and function in early rheumatoid arthritis in relation to radiographic joint damage.Ann Rheum Dis. 2010 Jan. 69(1):230-3.
• Areskoug-Josefsson K, Oberg U. A literature review of the sexual health of women with rheumatoid arthritis.Musculoskeletal Care. 2009 Dec. 7(4):219-26.