RA is the most common form of autoimmune arthritis affecting 0.5 to 1% of Indians. About 75% of RA patients are women. The disease most often begins between the ages of 30 and 50. However, RA can start at any age.
RA is a chronic disease that causes joint pain, stiffness, swelling and decreased movement of the joints. Small joints in the hands and feet are most commonly affected. Sometimes RA can affect your organs, such as eyes, skin or lungs.
The joint stiffness in active RA is often the worst in the morning. It may last one to two hours (or even the whole day). It generally improves with movement of the joints. Other signs and symptoms that can occur in RA include:
• Loss of energy
• Low fevers
• Loss of appetite
• Dry eyes and mouth from a related health problem, Sjogren's syndrome
• Firm lumps, called rheumatoid nodules, which grow beneath the skin in places such as the elbow and hands
The cause of RA is not known. RA is an autoimmune disease. Your immune system is supposed to attack foreigners in your body, like bacteria and viruses, by creating inflammation. In an autoimmune disease, the immune system mistakenly sends inflammation (redness, pain, swelling) to your own healthy tissue. The immune system creates a lot of inflammation that is sent to your joints causing joint pain and swelling. If the inflammation remains present for a long period of time, it can cause damage to the joint. There is evidence that autoimmune conditions run in families.
RA is diagnosed by examining blood test results, examining the joints and organs, and reviewing x-ray or ultrasound images. There is no one test to diagnose RA. Blood tests are run to look for antibodies in the blood that can been seen in RA. Antibodies are small proteins in the bloodstream that help fight against foreign substances called antigens. Sometimes these antibodies are found in people without RA. This is called a false positive result. Blood tests are also run to look for high levels of inflammation. The symptoms of RA can be very mild making the diagnosis more difficult. Some viral infections can cause symptoms that can be mistaken for RA. A rheumatologist is a physician with the skill and knowledge to reach a correct diagnosis of RA and to recommend a treatment plan.
Abnormal blood tests commonly seen in RA include:
• Anemia (a low red blood cell count)
• Rheumatoid factor (an antibody, or blood protein, found in about 80% of patients with RA in time, but in as few as 30% at the start of arthritis)
• Antibodies to cyclic citrullinated peptides (pieces of proteins), or anti-CCP for short (found in 60 - 70% of patients with RA)
• Elevated erythrocyte sedimentation rate (a blood test that, in most patients with RA, confirms the amount of inflammation in the joints)
X-rays can help in detecting RA, but may be normal in early arthritis. Even if normal, initial X-rays may be useful later to show if the disease is progressing. MRI and ultrasound scanning can be done to help confirm or judge the severity of RA.
There is no cure for RA. The goal of treatment is to improve your joint pain and swelling and to improve your ability to perform day-to-day activities. Starting medication as soon as possible helps prevent your joints from having lasting or possibly permanent damage. With the right medications, many patients can have no signs of active disease. When the symptoms are completely controlled, the disease is in “remission”. No single treatment works for all patients.
RA patients should begin their treatment with disease-modifying antirheumatic drugs — referred to as DMARDs. These drugs not only relieve symptoms but also slow progression of the joint damage. Often, doctors prescribe DMARDs along with nonsteroidal anti-inflammatory drugs or NSAIDs and/or low-dose corticosteroids, to lower swelling and pain. DMARDs have greatly improved the pain, swelling, and quality of life for nearly all patients with RA. Common DMARDs include methotrexate, leflunomide, hydroxychloroquine and sulfasalazine.
Patients with more serious disease may need medications called biologic response modifiers or “biologic agents.” They can block immune system chemical signals that lead to inflammation and joint/tissue damage. FDA-approved drugs of this type include abatacept, adalimumab, anakinra, certolizumab, etanercept, golimumab, infliximab, rituximab and tocilizumab. Most often, patients take these drugs with methotrexate, as the mix of medicines is more helpful.
The best treatment of RA needs more than medicines alone. Patient education, such as how to cope with RA, also is important. Proper care often requires a team of providers, including rheumatologists, primary care physicians, and physical and occupational therapists. You will need frequent visits through the year with your rheumatologist. These checkups let your doctor track the course of your disease and check for any side effects of your medications. Also, you likely will need to repeat blood tests and X-rays or ultrasounds from time to time.
It is important to be physically active most of the time, but to sometimes scale back activities when the disease flares. In general, rest is helpful when a joint is inflamed, or when you feel tired. At these times, do gentle range-of-motion exercises, such as stretching. This will keep the joint flexible.
When you feel better, you should do low-impact aerobic exercises, such as walking, and exercises to boost muscle strength. This will improve your overall health and lower the pressure on your joints. A physical or occupational therapist can help you find which types of activities are best for you, and at what level or pace you should do them.
Finding that you have a chronic illness is a life-changing event. It can cause worry and sometimes feelings of isolation or depression. Thanks to greatly improved treatments, these feelings tend to decrease with time as energy improves, and pain and stiffness decrease. Discuss these normal feelings with your health care providers. They can provide helpful information and resources.
Spondyloarthritis (or spondyloarthropathy) is the name for a family of inflammatory rheumatic diseases that cause arthritis. It differs from other types of arthritis, because it involves the sites are where ligaments and tendons attach to bones called “entheses.” Symptoms present in two main ways. The first is inflammation causing pain and stiffness, most often of the spine. Some forms can affect the hands and feet or arms and legs. The second type is bone destruction causing deformities of the spine and poor function of the shoulders and hips.
The most common is ankylosing spondylitis, which affects mainly the spine. Others include:
• Axial spondyloarthritis, which affects mainly the spine and pelvic joints
• Peripheral spondyloarthritis, affecting mostly the arms and legs
• Reactive arthritis (formerly known as reiter's syndrome)
• Psoriatic arthritis
• Enteropathic arthritis/spondylitis associated with inflammatory bowel diseases (ulcerative colitis and crohn's disease).
Ankylosing spondylitis is hereditary. Many genes can cause it. Up to 30 of these genes have been found. The major gene that causes this disease is HLA-B27.
Enteropathic arthritis is a form of chronic, inflammatory arthritis. The two most common types are ulcerative colitis and Crohn's disease. The cause of enteropathic arthritis is unclear. It may be due to bacteria that enter the bowel when inflammation damages it. People with HLA-B27 are more likely to have this form of arthritis than those without the gene.
Ankylosing spondylitis tends to start in the teens and 20s and strikes males two to three times more often than females. Family members of affected people are at higher risk, depending partly on whether they inherited the HLA-B27 gene.
Correct diagnosis requires a physician to assess the patient’s medical history and do a physical examination. The doctor also may order imaging tests or blood tests. You may need an X-ray of the sacroiliac joints, a pair of joints in the pelvis. X-ray changes of the sacroiliac joints, known as sacroiliitis, are a key sign of spondyloarthritis. If X-rays do not show enough changes, but the symptoms are highly suspicious, your doctor might order magnetic resonance imaging, or MRI, which shows these joints better and can pick up early involvement before an X-ray can.
Among the blood tests you may need is a test for the HLA-B27 gene. However, having this gene does not mean spondyloarthritis will always develop. Some people have the HLA-B27 gene but do not have arthritis and never develop arthritis. In the end, the diagnosis relies on the doctor’s judgment.
All patients should get physical therapy and do joint-directed exercises. Most recommended are exercises that promote spinal extension and mobility.
There are many drug treatment options. The first lines of treatment are the NSAIDs, such as naproxen, ibuprofen, meloxicam or indomethacin. Given in the correct dose and duration, these drugs give great relief for most patients.
For joint swelling that is localized (not widespread), injections, or shots, of corticosteroid medications into joints or tendon sheaths (the membrane around a tendon) can be effective quickly.
For patients who do not respond to the above lines of treatment, disease modifying antirheumatic drugs (commonly called DMARDs) such as sulfasalazine might be effective. These drugs relieve symptoms and may prevent damage to the joints. This class of drugs is helpful mainly in those with arthritis that also affects the joints of the arms and legs.
Although they may be effective, corticosteroids taken by mouth are not advised. This is because the high dose required will lead to many side effects.
TNF alpha blockers (a newer class of drugs known as biologics) are very effective in treating both the spinal and peripheral joint symptoms of spondyloarthritis. TNF alpha blockers that the FDA has approved for use in patients with ankylosing spondylitis are Infliximab, Etanercept, Adalimumab and Golimumab.
However, anti-TNF treatment is expensive and not without side effects, including an increased risk for serious infections. Biologics can cause patients with latent tuberculosis (no symptoms) to develop an active infection. Therefore, you and your doctor should weigh the benefits and risks when considering treatment with biologics. Those with arthritis in the knees, ankles, elbows, wrists, hands and feet should try DMARD therapy before anti-TNF treatment.
Surgical treatment is very helpful in some patients. Total hip replacement is very useful for those with hip pain and disability due to joint destruction from cartilage loss. Spinal surgery is rarely necessary, except for those with traumatic fractures (broken bones due to injury) or to correct excess flexion deformities of the neck, where the patient cannot straighten the neck.
Other problems can occur in patients with spondyloarthritis. These can include:
• Osteoporosis, which occurs in up to half of patients with ankylosing spondylitis, especially in those whose spine is fused. Osteoporosis can raise the risk of spinal fracture.
• Inflammation of part of the eye, called uveitis, which occurs in about 40% of those with spondyloarthritis. Symptoms of uveitis include redness and pain of the eye. Steroid eye drops most often are effective, though severe cases may need other treatments from an ophthalmologist (eye MD).
• Inflammation of the aortic valve in the heart, which can occur over time in patients with spondylitis. Your doctor should check your heart to make sure you do not have this problem.
• Psoriasis, a patchy skin disease, which if severe will need treatment by a dermatologist (skin doctor).
• Intestinal inflammation, which may be so severe that it requires treatment by a gastroenterologist (doctor who specializes in digestive diseases).
Several types of arthritis, all involving chronic (long-term) joint inflammation, fall under the JIA heading. This inflammation begins before patients reach the age of 16, and symptoms must last more than 6 weeks to be called chronic. JIA may involve one or many joints, and may also affect the eyes. It can cause other symptoms such as fevers or rash.
Systemic onset JIA affects about ten percent of children with arthritis. It begins with repeating fevers that can be 103°F or higher, often accompanied by a pink to orange rash that comes and goes. Systemic onset JIA may cause inflammation of the internal organs as well as the joints, though joint swelling may not appear until months or even years after the fevers began. Anemia (a low red blood cell count) and elevated white blood cell counts are also typical findings in blood tests ordered to evaluate the fevers and ongoing symptoms. Arthritis may persist even after the fevers and other symptoms have disappeared.
Oligoarticular JIA, which involves fewer than five joints in its first stages, affects about half of all children with arthritis. Girls are more at risk than boys. Some older children with oligoarticular JIA may develop “extended” arthritis that involves many joints and lasts into adulthood. Children who develop the oligoarticular form of JIA when they are younger than seven years old have the best chance of having their joint disease subside with time. They are, however, at increased risk of developing an inflammatory eye problem (iritis or uveitis). Eye inflammation may persist independently of the arthritis. Because this eye inflammation usually does not cause symptoms, regular exams by an ophthalmologist (eye doctor) are essential to detect these conditions and identify treatment to prevent vision loss.
Polyarticular JIA affects five or more joints and can begin at any age. Children diagnosed with polyarticular JIA in their teens may actually have the adult form of rheumatoid arthritis at an earlier-than-usual age.
With psoriatic arthritis, children have both arthritis and a skin disease called psoriasis or a family history of psoriasis in a parent or sibling. Typical signs of psoriatic arthritis include nail changes and widespread swelling of a toe or finger called dactylitis.
Enthesitis-Related Arthritis is a form of JIA that often involves attachments of ligaments as well as the spine. This form is sometimes called a spondyloarthritis. These children may have joint pain without obvious swelling and may complain of back pain and stiffness. There is sometimes a family history of arthritis of the spine.
Malfunctioning of the immune system in JIA targets the lining of the joint, known as the synovial membrane. This causes inflammation. When the inflammation is untreated, joint damage may occur.
It is not known what causes the immune system to malfunction in JIA. In rare cases (such as in psoriatic arthritis or enthesitis-related arthritis) a parent has the same form of arthritis. Dietary and emotional factors do not appear to play a role in the development of JIA.
Because the causes of JIA are unknown, no one knows how to prevent these conditions.
JIA may be difficult to diagnose because some children may not complain of pain at first and joint swelling may not be obvious. There is no blood test that can be used to diagnose the condition. Adults with rheumatoid arthritis typically have a positive rheumatoid factor blood test, but children with JIA typically have a negative rheumatoid factor blood test. As a result, diagnosis of JIA depends on physical findings, medical history, and the exclusion of other diagnoses.
Typical symptoms include:
• stiffness when awakening
• reluctance to use an arm or leg
• reduced activity level
• persistent fever
• joint swelling
• difficulty with fine motor activities
Other conditions that can look like JIA, including infections, childhood cancer, bone disorders, Lyme disease, and lupus also must be ruled out before a diagnosis of JIA can be confirmed.
The best care for children with arthritis is provided by a pediatric rheumatology team that has extensive experience and can diagnose and manage the complex needs of the child and family most effectively. The core team may consist of a pediatric rheumatologist, physical and occupational therapist, social worker, and nurse specialist. This core team can coordinate care with a child's pediatrician, adult rheumatologists, other physicians (such as an ophthalmologist or orthopedic surgeon), and other health professionals (dentist, nutritionist or psychologist) as well as reach out to schools and additional community resources to ensure that the child receives the best care possible.
The overall treatment goal is to control symptoms, prevent joint damage, and maintain function. When only a few joints are involved, a steroid can be injected into the joint before any additional medications are given. Steroids injected into the joint do not have significant side effects. Oral steroids such as prednisone may be used in certain situations, but only for as short a time and at the lowest dose possible. The long-term use of steroids is associated with side effects such as weight gain, poor growth, osteoporosis, cataracts, avascular necrosis, hypertension, and risk of infection.
Disease modifying drugs - commonly called DMARDs - are added as a second-line treatment when arthritis involves many joints or does not respond to steroid joint injections. DMARDs include methotrexate, leflunamide, and more recently developed medications known as biologics. The biologics include anti-tumor necrosis factor agents such as etanercept, infliximab, adalimumab, abatacept, tocilizumab and rituximab. Each of these medications may cause side effects that need to be monitored and discussed with the pediatric rheumatologist treating your child. Many of these treatments are approved for use in children as well as adults.
Children with JIA should attend school, participate in extra-curricular and family activities, and live life as normally as possible. To foster a healthy transition to adulthood, adolescents with JIA should be allowed to enjoy independent activities, such as taking a part-time job and learning to drive.
A positive outlook and continued physical activity will help. Physical and occupational therapy can increase joint motion, reduce pain, improve function, and increase strength and endurance. Therapists may construct splints to prevent permanent joint tightening or deformities, and work with school-based therapists to address issues at school.
Psoriasis is a disease in which scaly red and white patches develop on the skin. Psoriasis is caused by the body's immune system going into overdrive to attack the skin. Some people with psoriasis can also develop psoriatic arthritis, manifested by painful, stiff and swollen joints. Like psoriasis, psoriatic arthritis symptoms flare and subside, vary from person to person, and even change locations in the same person over time.
Psoriatic arthritis can affect any joint in the body, and it may affect just one joint, several joints or multiple joints. For example, it may affect one or both knees. Affected fingers and toes can resemble swollen sausages, a condition often referred to as dactylitis. Finger and toe nails also may be affected.
Psoriatic arthritis in the spine, called spondylitis, causes stiffness in the back or neck, and difficulty bending. Psoriatic arthritis also can cause tender spots where tendons and ligaments join onto bones. This condition, called enthesitis, can result in pain at the back of the heel, the sole of the foot, around the elbows or in other areas. Enthesitis is one of the characteristic features of psoriatic arthritis.
Recent research suggests that persistent inflammation from psoriatic arthritis causes joint damage later, so early accurate diagnosis is essential. Fortunately, treatments are available and effective for most people.
What causes psoriatic arthritis is not known exactly. Of those with psoriatic arthritis, 40% have a family member with psoriasis or arthritis, suggesting heredity may play a role. Psoriatic arthritis can also result from an infection that activates the immune system.
To diagnose psoriatic arthritis, rheumatologists look for swollen and painful joints, certain patterns of arthritis, and skin and nail changes typical of psoriasis. X-rays often are taken to look for joint damage. MRI, ultrasound or CT scans can be used to look at the joints in more detail.
Blood tests may be done to rule out other types of arthritis that have similar signs and symptoms, including gout, osteoarthritis, and rheumatoid arthritis. In patients with psoriatic arthritis, blood tests may reveal high levels of inflammation and mild anemia but labs may also be normal. Anemia is a condition that occurs when the body lacks red blood cells or has dysfunctional red blood cells. Occasionally skin biopsies (small samples of skin removed for analysis) are needed to confirm the psoriasis.
Treating psoriatic arthritis varies depending on the level of pain, swelling and stiffness. Those with very mild arthritis may require treatment only when their joints are painful and may stop therapy when they feel better. Non-steroidal anti-inflammatory drugs such as ibuprofen or naproxen are used as initial treatment.
If the arthritis does not respond, disease modifying anti-rheumatic drugs may be prescribed. These include sulfasalazine, methotrexate, cyclosporine, and leflunomide. Sometimes combinations of these drugs may be used together. There are several biologic type medications available to treat psoriatic arthritis via infusion or injection.
• The TNF Inhibitors such as adalimumab, etanercept, golimumab, certolizumab and infliximab are also available and can help the arthritis as well as the skin psoriasis.
• Abatacept is given to patients who have not responded to one or more DMARDs or other biologic drugs. Abatacept may be used alone or in combination with DMARDs.
• For swollen joints, corticosteroid injections can be useful. Surgery can be helpful to repair or replace badly damaged joints.
The impact of psoriatic arthritis depends on the joints involved and the severity of symptoms. Fatigue and anemia are common. Some psoriatic arthritis patients also experience mood changes. Treating the arthritis and reducing the levels of inflammation helps with these problems. People with psoriasis are slightly more likely to develop high blood pressure, high cholesterol, obesity or diabetes. Maintaining a healthy weight and treating high blood pressure and cholesterol are also important aspects of treatment.
Many people with arthritis develop stiff joints and muscle weakness due to lack of use. Proper exercise is very important to improve overall health and keep joints flexible. This can be quite simple. Walking is an excellent way to get exercise. A walking aid or shoe inserts will help to avoid undue stress on feet, ankles, or knees affected by arthritis. An exercise bike provides another good option, as well as yoga and stretching exercises to help with relaxation.
Some people with arthritis find it easier to move in water. If this is the case, swimming or walking laps in the pool offers activity without stressing joints. Many people with psoriatic arthritis also benefit from physical and occupational therapy to strengthen muscles, protect joints from further damage, and increase flexibility.