Though there are more than 100 types of arthritis, rheumatoid arthritis is most often referred to as “the crippling” kind. Rheumatologists (physicians who are specially trained to identify and manage muscle, bone and joint disorders) see this variety more than any other autoimmune joint disease. It falls into a spectrum of diseases that include lupus, mixed connective tissue disease and swollen joints associated with other autoimmune diseases (such as enteropathic arthritis seen occasionally in Crohn’s disease of the bowel or psoriatic arthritis seen with skin psoriasis).

More than 200,000 cases are diagnosed per year in the United States alone. It affects as many as 2 million Americans. It is considered the most common of the autoimmune arthritis types. Autoimmune implies that the defense systems that normally protect us from infections or cancers do not work properly and cause the joint pain, swelling, redness and inflammation associated with the disorder.

RA most commonly starts between 30-60 but does rarely start in young children and the elderly. Around 75-80% of patients are female and around 1-3% of women can develop RA in their lifetime. It may begin suddenly or slowly over time, often with stiffness, aching, fevers, weight loss and fatigue early on. But eventually it will produce joint swelling, tenderness and pain.

While the precise cause is unknown, I have seen it develop after human parvo virus and after hepatitis. It is associated with smoking, obesity and a higher risk of cancer. It often involves the hands and feet, especially the knuckles, wrists and balls of the feet, but may widely involve the shoulders, elbows, hips, knees and ankles. Most of the time, it is symmetrical and poly-articular (involves multiple joints) as opposed to one or a few joints, or just on one side of the body or the other. It runs in families, and those with relatives who have had RA are more likely to contract it or have abnormal blood tests suggesting it. It is often seen with other forms of arthritis, especially osteoarthritis.

The specific diagnosis is made by using a number of factors: distribution of joint pain, physical examination and findings, behavior of the symptoms over time and laboratory and imaging tests. There is no one test that can make the diagnosis with absolute certainty, although some abnormal tests are much more specific than others to make the diagnosis. Depending on activity, distribution and lab studies when you are seen by a physician, it can be difficult to make even for an experienced physician. Differentiating it from viral arthritis or other diseases can be especially difficult early on.

Despite its universal tendency to cause warm, red, swollen joints and deformity and destruction if not controlled or if aggressive, it is actually a systemic (all over or multiple system) disease. About 40% of patients have systemic or non-articular (not joint) involvement. This can cause complications involving the lungs, skin, eyes, heart, kidney, blood vessels, bone marrow, exocrine glands (such as tear glands, saliva glands) and even nerves. Rheumatoid nodules (which may be hard round masses the size of a pea or apple) are still seen in many severe cases or in about 30%. Disturbingly, these extra-articular complications are associated with more severe involvement and premature death. In all cases, the presence of chronic RA associates with other morbidity (illness), increased cancer risk and reduced quality of life.

 

Fortunately, the treatment of RA has dramatically improved over the last 20 years. It remains incurable at this stage, but nearly all can be helped with proper and early treatment and monitoring. As many as 30% can be coaxed into remission (complete control) with no activity, and functioning at or near a normal level is always the goal. Delays in diagnosis, access to a rheumatologist or the best therapies always result in a worse outcome, including, on occasion, crippling or complete incapacitation and early death.

Initial therapies are often simple and include the use of heat or cold, gentle exercise and the use of anti-inflammatory drugs such as aspirin, ibuprofen, naproxen, meloxicam or celecoxib (Celebrex). There are nearly 20 of these agents, which are also used for a wide variety of other pain (including headaches, body aches, injuries). But these products provide little, if any, long-term protection and have a variety of side effects including stomach and kidney problems, allergies and rashes and, on occasion, severe bleeding, kidney failure or other issues. Many supplements are taken, such as glucosamine, chondroitin, turmeric and cumin but there is little evidence they provide meaningful relief or any protection in most. CBD oil is the latest supplement fad.

Disease modifying anti-rheumatic drugs, or DMARDS, are often started early as they do convey additional control of inflammation and can prevent damage. These include methotrexate, hydroxychloroquine, azulifidine, azathioprine, leflunomide, cyclosporine, minocycline and others. They are typically pills and are usually well-tolerated but can cause a variety of toxicities, and thus must be monitored closely. They can be mixed with other agents under proper supervision. Older therapies, including injectable gold have been abandoned due to marked improvement and choices in therapy. Methotrexate remains the most commonly used of these agents. Although still commonly used in cancer at high doses, it is often used at low doses for RA and related conditions. Physical and occupational therapy can also be helpful.

In 1998, a novel class of drugs was approved for using in RA. The first two were enbrel and remicade. Humira and kineret came out in 2002; orencia and rituxan in 2006. Since then, many biologic or targeted immune therapies have come to the forefront of RA treatment and revolutionized the management of moderate-to-severe RA. Actemra, cimzia, xeljanz, olumiant, kevzara, and simponi are other very specific agents developed and released over the last 10 years or so.

These agents can be used with other medications to provide maximum protection and provide control, resulting in improved quality of life and functional capacity. Many of these products are used in other autoimmune disease. Only xeljanz and olumiant are pills, the others are provided by infusion therapy or by self-injection. They are well-tolerated but very expensive. They act as immunosuppressants, which control the overactive immune symptoms of RA. The primary risks are that they increase the risk of infections, and rarely cause unusual or severe reactions. They have never been shown to clearly cause cancer but are often held when cancer treatments are needed in a given patient.

Orthopedic surgery offers joint replacements or surgical assistance in more severe cases.

There is no cure for RA clearly on the horizon, but anticipate a time when your physician draws your blood, sequences your DNA and matches your RA therapy to the one most likely to cure you or put you in a sustained remission. It may well also be possible to predict and prevent RA in those destined to develop this chronic and, at times, crippling disorder.

Randal White, M.D., FACP, FACR, is the director of Vidant Rheumatology.