10 RA (rheumatoid arthritis) facts

10 RA (rheumatoid arthritis) facts

In this article we will describe 10 rheumatoid arthritis (RA) facts. Let’s start with the basics.

Typical rheumatoid hands

Key points

• RA can occur at any age, but most often appears between the ages of 30 and 50 years old
• It is a disease of the immune system. It occurs when your body’s immune system attacks the joints between your bones, usually affecting the hands, feet and wrists. In this way, it is called an ‘autoimmune’ disease
• As well as pain and stiffness in the joints, RA can affect most parts of the body
• Is a common form of arthritis, affecting 1% of the population; affecting women 3 times more often than men; smokers have a higher rate than non-smokers
• Early treatment can slow the progression of rheumatoid arthritis, minimise joint damage and even lead to complete remission

1. What is RA?

Rheumatoid arthritis is an autoimmune disease, where your body’s defence system (the immune system) is confused and attacks its own healthy tissues. The exact cause is not fully understood.

In this way, RA is not just a ‘joint disease’. It can affect most other tissues in the body, and cause problems in the lungs, heart, and eyes, for example.

2. Who gets RA?

• Rheumatoid arthritis (RA) affects about 1% of the UK population — it is the most common inflammatory arthritis.
• RA onset can occur at any age, but it peaks between people aged 30–50 years.
• Approximately 1/3 of people stop work because of RA within 2 years of its onset and this increases thereafter.
• Genes that you inherit from your parents don’t cause rheumatoid arthritis but may play a role. It can increase your chance of developing it.
• Women are affected 3 times more often than men.
• Smokers have a higher rate of getting rheumatoid arthritis than non-smokers. Smoking can increase the chances of developing rheumatoid arthritis by 40 fold. It may also worsen joint damage and contribute to osteoporosis (thinning of the bones).
• Some people find that cold, damp conditions and changes in the weather can affect their symptoms, but there is no evidence that the weather causes rheumatoid arthritis or affects its progression.

What happens in RA?

With continuous swelling and inflammation of your joints, the joint capsule remains stretched and can no longer hold the joint in its proper position. As a result, the joint may become unstable and this can lead to joint damage.

The joints affected and the extent to which this happens varies a great deal from person to person.

RA usually affects the small joints in your hands and feet, but it can affect many joints including your ankles, elbows, wrists, hips, knees, neck and shoulders. It usually affects both sides of your body.

The pain, stiffness, fatigue and whole-body (systemic) symptoms of rheumatoid arthritis can be disabling and can lead to significant difficulty with daily activities.

Effective treatment by your GP or rheumatologist (hospital specialist doctor, and his/her specialist nurse) can prevent joint damage and reduce other symptoms of RA.

So, tell me some more facts about RA.

3. What are the risk factors for RA? 

Characteristics that increase risk

• Age. RA can begin at any age, but the likelihood increases with age.
• Genetics. People born with specific genes are more likely to develop RA. These genes, called HLA (human leukocyte antigen) class II genotypes, can also make your arthritis worse. The risk of RA may be highest when people with these genes are exposed to environmental factors like smoking or when a person is obese.
• Smoking. This increases the risk of developing RA and can make the disease worse.
• Not having children. Women who have never given birth may be at greater risk of developing RA.
• Obesity. Being obese increases the risk of developing RA. Studies examining the role of obesity also found that the more overweight a person was, the higher is the risk of RA.
• Environment. Some early life exposure to risk factors increase the likelihood of RA in adulthood. For example, one study found that children whose mothers smoked had double the risk of developing RA as adults. Children of lower income parents are at increased risk of developing RA as adults.

Characteristics that can decrease risk

Breastfeeding. Women who have breastfed their infants have a decreased risk of developing RA.

4. What are the symptoms of RA?

Rheumatoid arthritis usually starts quite slowly and you may first notice:

• Joints of your fingers, wrists or the balls of your feet become uncomfortable or tender
• Swelling in your joints, which often comes and goes
• Joints are affected symmetrically – you will notice symptoms in the same joints on both sides of the body.
  feeling stiff when you wake up in the morning.

For some people, the disease develops very rapidly and there may be a sudden onset of pain and swelling in a lot of joints.

Flare-ups

With RA, there are times when symptoms get worse, known as ‘flare-ups’, and times when symptoms get better, known as ‘remission’.

In other words, symptoms tend to come and go with no particular pattern. You may have periods of time when your joints become more inflamed and painful (flare-ups). Sometimes these flare-ups have an obvious cause, such as physical injury, illness or emotional stress but usually, there is no obvious cause. This unpredictability is frustrating and can make it difficult to plan.

Flare-ups can involve the following symptoms.

• Pain or aching in more than one joint
• Stiffness in more than one joint
• Tenderness and swelling in more than one joint
• Symptoms are often on both sides of the body (such as in both hands or both knees)
• Weight loss
• Fever
• Fatigue, tiredness, or weakness
• Symptoms relating to the non-joints involved – e.g. chest pain if lungs or heart involved.

5. What are the complications of RA?

Joint damage

If rheumatoid arthritis is not treated early or is not well controlled, the inflammation in your joints could lead to significant and permanent damage. Problems that can affect the joints include:

• Damage to nearby bone and cartilage (a tough, flexible material that covers the surface of joints)
• Damage to nearby tendons (flexible tissue that attach muscle to bone), which could cause them to break (rupture)
• Joint deformities.

These problems sometimes need to be treated with surgery to prevent loss of function in the affected joints.

Nerve damage

Carpal tunnel syndrome
Carpal tunnel syndrome is a common condition in people with rheumatoid arthritis. It is caused by compression of the nerve that controls sensation and movement in the hands (median nerve) and has symptoms such as:

• Aching
• Numbness
• Tingling in your thumb, fingers and part of the hand.

Symptoms of carpal tunnel syndrome can sometimes be controlled with wrist splints or steroid injections, although surgery to release the pressure on the median nerve may be needed in severe cases.

Cervical myelopathy
If you’ve had rheumatoid arthritis for some time, you’re at increased risk of developing a problem at the top of your spine known as cervical myelopathy.

Your may need a special assessment of your neck before any operation where you’re given general anaesthetic.

This condition leads to dislocation of joints at the top of the spine, which puts pressure on the spinal cord. Although uncommon, it’s a serious condition that can greatly affect your mobility and lead to permanent spinal cord damage if not treated quickly with surgery.

Non-joint (or nerve) 

In 40% of patients, inflammation may occur in other organs. Here are some specific conditions:

• Rheumatoid nodules (fleshy lumps) – may sometimes appear, usually just below your elbows, but may also occur on your hands and feet.
• Anaemia (low red blood cell count) is common. Occasionally this can be a side effect of the drugs used to treat rheumatoid arthritis, but it is more often caused by the disease itself
• Lungs – inflammation of the lungs or lung lining can lead to ‘pleuritic disease’ which can cause chest pain. Another long-term lung disease called ‘pulmonary fibrosis’ can cause persistent cough and shortness of breath
• Heart – inflammation of the tissue around the heart can lead to pericarditis, which causes chest pain
• Eyes – inflammation of the eyes can lead to scleritis or Sjögren’s syndrome. Scleritis can cause eye redness and pain, whereas Sjögren’s syndrome can cause dry eyes
• Blood vessels – inflammation of the blood vessels, known as ‘vasculitis’, is the thickening, weakening, narrowing and scarring of blood vessel walls. In serious cases, it can affect blood flow to your body’s organs and tissues and can be life threatening
• Chronic kidney disease (CKD) – this may be secondary to NSAID use, or other drugs.

Cardiovascular disease
If you have rheumatoid arthritis, you’re at a higher risk of developing cardiovascular disease (CVD). CVD is a general term that describes conditions affecting the heart or blood vessels, and it includes life-threatening problems such as heart attack and stroke.

However, with early treatment, inflammation in other parts of the body from rheumatoid arthritis is less likely.

6. How do you diagnose RA? 

If you have painful or swollen joints, see your doctor. Early diagnosis is important as treatment does help and reduces long-term damage to your joints.

There is no single test that can make a certain diagnosis of early rheumatoid arthritis.

Doctors make a diagnosis by pulling together all the information from listening to you and examining you, alongside blood tests and sometimes x-rays.

Investigations

• Full blood count. This test measures how many of each type of blood cell are in your blood. This may show anaemia as well as abnormalities in white blood cell counts or platelet counts that can be part of RA.
• Markers of inflammation. C-reactive protein (CRP) levels may be high in RA, but not always.
• Immunological tests. Levels of an antibody called rheumatoid factor (RF) and other antibodies (anti-CCP) will be checked. About 80% of people have a positive RF. And you can be positive for RF and not have RA.
• X-rays and other imaging techniques. X-rays can reveal damage caused to the joints by RA. Magnetic resonance imaging (MRI) and ultrasound scanning may also be used. They are more sensitive in picking up changes and are being studied to see how useful they are for diagnosing early disease and for monitoring its progress.

Who should diagnose and treat RA?

If RA is mild, your GP and practice nurses will be able to look after you. But if more severe, your GP should refer you to a hospital specialist doctor called a rheumatologist. They specialise in the care of RA patients. This is especially important because the signs and symptoms of RA are not specific and can look like signs and symptoms of other inflammatory joint diseases.

Also rheumatologists will be more confident than a GP to prescribe stronger medication like disease-modifying antirheumatic drugs (DMARDs) and biological agents (see below).

7. What is the treatment for RA? 

Starting treatment as soon as possible after a diagnosis has been made can help prevent permanent joint damage.

Although there is no cure for rheumatoid arthritis as yet, a variety of treatments are available that can slow down the disease and reduce the damage to your joints. These are the commonly used groups of drugs.

Disease-modifying antirheumatic drugs (DMARDs)
Conventional DMARDs include methotrexate, hydroxychloroquine, sulfasalazine, leflunomide and azathioprine.

• The choice of medicine depends on you and your illness.
• Your rheumatologist will discuss the choices, so you get the medicine best suited for you.
• Most people are started on methotrexate. It is often the most effective and is well studied.
• Some people are only prescribed one DMARD. Others try several before one or more are found to suit.
• It may take 2–6 months of treatment for a full response.

Biological agents
Biological therapies include TNF inhibitors (infliximab, adalimumab, etanercept), rituximab and tocilizumab.

These are also called ‘biologics’. They can be used if other treatments have not worked well, but they don’t work for everyone. Mostly they are used in combination with other DMARDs.

Targeted synthetic (ts) DMARDs

Targeted DMARDs are the newest type of DMARDs. They are taken orally and target specific immune system molecules – the Janus kinase (Jak) inhibitors – tofacitinib, baricitinib, filgotinib and upadacitinib.

Pain relief medicines
Examples of pain relief medicines include paracetamol and codeine. They are used to relieve pain but do not treat rheumatoid arthritis. They are often used with other medication and are generally used until an effective DMARD is found.

Non-steroidal anti-inflammatory drugs (NSAIDs)
Examples of NSAIDs include ibuprofen, diclofenac and naproxen. These medicines reduce inflammation and swelling of your joints. They start working quickly. They relieve pain and swelling but do not reduce damage to your joints.

For most people, taking NSAIDs is safe. However, extra care is needed if you have high blood pressure, high cholesterol, diabetes, stomach ulcers, kidney problems or if you smoke. Discuss with your doctor whether taking NSAIDs is suitable for you. NSAIDs should be used until an effective DMARD is found and then the dose reduced or stopped if possible.

Corticosteroids (also called steroids)
Corticosteroids are used at the start of treatment to reduce the pain and swelling of your joints, while waiting for other medication to take effect. They may also be used to treat sudden flare-ups but are not usually needed after the flare-up has settled. These may be given as tablets, such as prednisone, or as injections directly into the joint itself or into a muscle or vein.

A combination of both medications and non-medication approaches are best.

8. What are the non-medication approaches to RA? 

• If you are a smoker, stop smoking. There is information that shows that continuing smoking can make it less likely that you will have a good response to medications for RA.
• Physiotherapy – helps preserve and improve the range of joint motion, increase your muscle strength, and reduce your pain.
• Hydrotherapy – involves exercising and relaxing in warm water. Being in water reduces the weight on your joints. The warmth relaxes your muscles and helps relieve pain.
• Occupational therapy – teaches you ways to use your body efficiently to reduce stress on your joints
• Self-management skills – arthritis educator clinics, seminars and self-management programmes will equip you with tools and techniques to self-manage your RA.
• Surgery is occasionally needed. Operations vary from quite minor ones such as the release of a nerve or a tendon to major surgery such as joint replacement.
• Regular medical check-ups – are an important part of managing RA, including checking blood pressure and monitoring cholesterol and other risk factors for heart disease.

9. Self-care of RA

Lifestyle measures are an important part of self-management.

• Take care of your joints. Find the balance between rest and physical activity; rest may make your inflamed joints comfortable but without movement your joints will stiffen and your muscles will weaken.
• Exercise – is a very important part of a complete treatment plan for RA. It helps reduce your pain and fatigue, increases a range of joint motion and strength, and keeps you feeling better overall. Talk to your physiotherapist about the most appropriate exercise regime for you.
• Make your working life easier. You need to find a way to carry out your work tasks that allows you to manage your pain and tiredness and reduce the strain on your joints. The key to success is to do a variety of tasks, stages, and with rest breaks.
• Both heat and cold treatments – can relieve pain and reduce inflammation. Some people’s pain responds better to heat and other’s to cold.
• Relaxation techniques – are beneficial for releasing muscle tension, which helps relieve pain.
• Live a healthy life. Stay physically active, eat a healthy diet, stop smoking and reduce stress to help your overall health and wellbeing.
• Fish oil. Ask your doctor about fish oil; some studies have demonstrated beneficial effects of fish oil supplementation in decreasing pain.

10. What is the long-term impact of RA? 

Long-term, rheumatoid arthritis affects people differently:

• For some people, it lasts only a year or two and goes away without causing any noticeable damage.
• Other people have mild or moderate forms of the disease, with periods of worsening symptoms (flare-ups) and periods in which they feel better (remissions).
• For some people, ongoing inflammation can increase their chance of heart disease, and other complications.

Summary

We have described 10 rheumatoid arthritis (RA) facts. There is a lot you can do to get better care. Combining medical and non-medical treatment is the best way of keeping well with RA.

Other resources

This is a doctors article about the systemic (non-joint) complications of RA.
This is good information from NICE.
This is good information from a NZ patient website, on which this article is partially based.