Understanding Rheumatoid Arthritis: Comprehensive Insights into its Causes, Symptoms, Diagnosis, and Treatment Options

Rheumatoid arthritis (RA) is an autoimmune disease and one of the inflammatory forms of arthritis (inflammation of the joints). In RA, the immune cells, typically involved in defending against outside attackers like infectious agents, start recognizing the normal cells in the body as potential hazards and initiate their defensive mechanisms against the normal cells. This causes widespread inflammation resulting in a wide range of signs and symptoms affecting different systems of the human body.

Rheumatoide Arthritis. Image Courtesy of Bernd Brägelmann

Is Rheumatoid arthritis common?

Rheumatoid arthritis affects 0.5 to 1% of the US population which is around 1.3 million people. The estimated number of new cases of RA is approximately 40 for every 100,000 people in the US. Women are more affected by RA with a ratio of 3:1. Although RA can occur at any age, most people are diagnosed with this condition in the 40-60 age range.

What causes Rheumatoid arthritis?

The exact cause for the activation of the autoimmune response in Rheumatoid arthritis is not well-known. Many genetic and environmental factors are understood to play a role in the initial activation of the disease process. Many genetic factors make individuals susceptible which can lead to the activation of an immune response in the presence of an environmental trigger like an infection, smoking, etc.

Risk factors

Many factors can enhance the risk of developing RA for an individual. Some of those factors are mentioned below:

Smoking: Many scientific studies point towards the role of smoking in RA. It increases the risk mainly if you are genetically susceptible. It also makes the disease more severe and resistant to treatment.
Age: RA can occur at any stage, but age increases the risk of developing it. The highest number of people who develop RA are in their sixties.
Sex: Women are two to three times more likely to develop RA.
Genetic factors: Genes play a minor role in increasing the risk of developing RA. When coupled with an environmental insult, these genetic vulnerabilities are known to increase risk. Specifically, the HLA genes make you more susceptible to developing RA.
Family history: If you have a family history of RA, you may be more likely to develop RA.
Excess weight: People who are overweight/obese are more likely to develop RA.

Symptoms

The symptoms of rheumatoid arthritis follow a pattern of worsening and getting better. The flares can occur when the condition worsens, and symptoms improve during remission. The symptoms usually develop slowly over many weeks but sometimes, they can appear more quickly.

RA primarily affects joints, but it can affect other tissues in the body. The typical symptoms are pain and swelling of the small joints of the hand, feet, and wrist. There is also stiffness of the affected joints.

Rheumatoid arthritis may also cause symptoms in other areas of the body in around 40 percent of the affected people. Common areas are the eyes, heart, lungs, kidneys, bone marrow, and blood vessels.

Generally, RA may cause a general lack of energy, fatigue, dry eyes, and sweating in addition to the symptoms in the joints.

Types of Rheumatoid arthritis

There are two main types of RA. Seropositive rheumatoid arthritis is characterized by positive anti-CCP and /or RF blood tests. These tests detect the presence of antibodies in RA. This type is more progressive, and it is associated with more severe damage to the joints.

In seronegative RA, anti-CCP and/or RF blood tests are negative. It is less common than the other type. It is estimated that out of every 100000 RA patients, 20 have a seronegative type.
Another form of RA that only manifests in children is juvenile idiopathic arthritis. It primarily affects children aged 16 and under.

Stages

The four stages of rheumatoid arthritis are as follows:

Stage 1: It is the initial stage of RA. Mild symptoms start to appear including joint pain and stiffness and inflammatory changes in the lining of joints have started to occur. It is called synovitis.
Stage 2: It is called pannus. During this stage, the inflammatory changes have damaged the cartilage between joint surfaces leading to worsening of symptoms. Without the cushion of cartilage, the pain and stiffness get worsened. This stage also makes joints vulnerable to erosive damage.
Stage 3: Bones have started to fuse with the fibrous connective tissue. In this stage, the joints’ range of motion significantly decreases and joints may appear out of their typical orientation. It is called fibrous ankylosis (fusion of bone with fibrous conductive tissue).
Stage 4: In this stage, the joint surfaces have fused, and the typical movements of the joint are no longer possible. Pain also goes away. But the lack of movements in the joints impairs most daily activities. It is called bony ankylosis.

Diagnosis

The diagnosis of rheumatoid arthritis is mainly clinical but many blood tests and radiological exams are used to confirm and analyze the severity of the disease process. There is no definitive test to diagnose RA. A clinical criterion is used to diagnose RA involving the number of joints affected, few blood tests, and the duration of symptoms. RA can be very difficult to diagnose as its symptoms overlap with those of many other diseases so a doctor specializing in arthritis called a rheumatologist should diagnose RA. The diagnosis of RA should be made early after the onset of symptoms to limit the widespread damage to the joints and impair the progression of the disease.

History and physical exam

A doctor will initially ask detailed questions about your symptoms, and he/she will then perform a physical examination assessing the swelling of the affected joints. The doctor will also assess joints for tenderness, warmth, and range of motion. As RA can affect other systems of the body, the doctor may examine different systems of the body to gauge if you have any other symptoms.

Blood tests

- Inflammatory blood markers: Two tests, ESR and CRP, are done to check for inflammation in the body. These tests, if positive, are indicative of the presence of inflammation but as RA is only of the causes of inflammation in the body, these tests are only helpful to establish the presence of inflammation and they can’t reveal specific information about the diagnosis of RA.
- Complete blood count (CBC): This test can be used to determine if the patient has anemia as anemia is common in people with RA.
- Anti-CCP and RA factor: Anti-CCP antibodies are produced by the immune system. The presence of Anti-CCP in your blood makes you more likely to develop RA but not all patients with RA have Anti-CCP antibodies. RA factors are proteins produced by the immune system. These factors can be detected in half of the patients with RA but around 1 in 20 may not have detectable RA factors in their blood. Patients who are positive for both anti-CCP and RA factors are likely to develop severe forms of arthritis.

Radiological scans

The doctor may recommend many radiological exams like X-rays and MRIs to assess the severity and damage to the affected joints, monitor the progression of the disease, and assess the effects of medications on the course of the disease process.

Assessment of abilities to perform daily tasks

This assessment may be done to analyze how well you can perform daily tasks like walking, dressing, and eating. It can be repeated once you have been taking medicines for a while to gauge if your condition has improved at all.

Treatment

There is no curative treatment for RA, so the treatment aims to relieve symptoms, slow the progression of the disease, and restore the ability to perform daily activities. Typically, a combination of medications with supportive therapies and surgery is used in RA. Common medicines prescribed for the treatment of RA are as follows:

DMARDs: These are disease-modifying anti-rheumatic drugs, and they work by inhibiting the effects of chemicals released by the immune system during RA. Common DMARDS are methotrexate, sulfasalazine, and leflunomide. These drugs may be used in combination with steroids and other medicines. DMARDs are used to relieve symptoms and slow the progression of the disease.
Pain relief: Many types of medicines are used for pain relief in RA.
NSAIDs are non-steroidal anti-inflammatory drugs that are used to reduce inflammation as well as to relieve pain. Common NSAIDs are ibuprofen, diclofenac, and naproxen. Painkillers like paracetamol can be used to reduce pain too. These types of medicines don’t reduce inflammation.
Steroids can also be used to reduce joint stiffness and pain. They are typically used for short-term relief as their long-term use has serious side effects. They can be given in the form of a tablet or an injection.
Newest medications: Conventional DMARDs are effective in RA but they suppress many parts of the immune system. With the newest medications, it has become available to target specific steps of immune system activation. Biological drugs are one such option. They target specific mechanisms involved in the activation of the immune cells and they may be used in combination with DMARDs. They are given by injection. Adalimumab and infliximab are the newer available biological treatments. JAK inhibitors are another newly available class of medicine. They also aim at inhibiting specific mechanisms in the immune system. They can be taken in the form of tablets. Upadacitinib and Tofacitinib are some of the JAK inhibitors.

Surgical treatment

Surgery can be used to relieve pain, restore joint function, and repair the damaged surfaces of joints. It can also be used in the case that medical treatments don’t produce the desired results. Different types of surgeries can be used in RA.

Synovectomy: In this surgery, the damaged lining of the joint is removed.
Joint replacement: The affected joints can also be replaced by a prosthetic made of plastic or metal parts.
Tendon repair: Sometimes, the inflammation may have damaged the tendons around the joint. In tendon repair, those damaged tendons are repaired or parts of them are removed.

Supportive treatment options

These treatment strategies include utilizing physical and occupational therapies. Physical therapy helps to improve physical strength, improve joint mobility, and restore joint function after surgery while occupational therapy helps to improve abilities to perform daily activities and prevent further damage to joints by adapting different techniques in daily life. Furthermore, podiatric, massage, and chiropractic therapies may be of help.

Complications of Rheumatoid arthritis

RA can result in a wide range of issues in one’s personal and professional life.

Heart disease: RA can increase the risk of developing heart disease. Preventive measures like an active lifestyle, stopping smoking, and eating a healthy diet can help prevent this development.

Carpal tunnel syndrome: It is the compression of the median nerve (that controls movement and sensation in the hand) resulting in aching pain and tingling sensation in your thumb and other parts of the hand.

Furthermore, RA can result in inflammation in many other areas of the body like eyes, lungs, and blood vessels. It can also make you susceptible to developing obesity.

Patients with RA can have difficulty doing their job-related tasks resulting in unemployment. With the progression of the disease, these social consequences tend to be more frequent.

Maintaining the quality of life

It is important to develop strategies in your life to manage the condition in the long term. Eating healthy and remaining physically active can help prevent many of the adverse complications associated with RA. One should also quit smoking.

Developing a self-management plan can help one understand the effect of medicines, the need for self-regulation of a healthy lifestyle, and managing symptoms.

Finding social support in the form of social groups for people with similar conditions can help you achieve a healthy mental health level in the long run.

It is also important to look at state benefits for people with this condition. There may be many programs that can help financially during periods of unemployment.