Rheumatoid Arthritis

Rheumatoid Arthritis

Topic Overview

The skeletal system

Is this topic for you?

There are many types of
arthritis (disease of the joints). This topic is about
rheumatoid arthritis. If you are looking for information about how juvenile
idiopathic (rheumatoid) arthritis affects young children, see the topic
Juvenile Idiopathic Arthritis. If you are looking for
information on the most common form of arthritis in older adults, see the topic
Osteoarthritis.

What is rheumatoid arthritis?

Rheumatoid arthritis (RA) causes
the
joints to become
swollen, stiff, and painful (inflamed).

Over time, this
inflammation may destroy the joint tissues. This can limit your daily
activities and make it hard for you to walk and use your hands.

Rheumatoid arthritis is more common in women than in men. It often
begins between the ages of 40 and 60.

What causes rheumatoid arthritis?

The exact cause is not known. But rheumatoid arthritis is an
autoimmune disease. This means that the body's natural
defense system attacks the joints. The disease may run in some families.

What are the symptoms?

The main symptoms of rheumatoid arthritis are pain, stiffness, and
swelling in the joints of the hands, wrists, elbows, feet, ankles, knees, or
neck
. The disease usually affects both sides of the body at the same time. In
rare but severe cases, it may affect the eyes, lungs, heart, nerves, or blood
vessels.

Sometimes the disease
can cause bumps called nodules to form over the elbows, knuckles, spine, and
lower leg bones.

How is rheumatoid arthritis diagnosed?

There is no single test for rheumatoid
arthritis. Your doctor will do a physical exam and look at your joints for signs of swelling or
tenderness. He or she will also ask about your symptoms and past health.

You may have blood tests,
X-rays, and other tests to find out if another problem
is causing your joint pain.

How is it treated?

Treatment for rheumatoid arthritis continues throughout your life. It includes medicine,
exercise, and lifestyle changes. Getting treatment early may control the condition or keep it from getting worse.

Many of
the medicines used to treat rheumatoid arthritis have side effects. So it is
important to have regular checkups and talk with your doctor about any
problems. This will help your doctor find a treatment that works for you.

At home, there are things you can do to relieve your symptoms.

  • Rest when you are tired.
  • Protect
    your joints from injury by using devices like special kitchen tools or
    doorknobs.
  • Use splints, canes, or walkers to ease pain and take
    stress off your joints if your symptoms are severe.
  • Eat a
    balanced diet.
  • Exercise regularly.
  • Stay at a healthy
    weight.

If you try medicine, exercise, and lifestyle changes for at least a few years but pain and disability get much worse, surgery may be an option. Total joint replacement of the hip and knee are the most successful.

It can be hard to live with a long-term
illness that can limit your ability to do things. It is common for people with
rheumatoid arthritis to feel depressed. Your mood can affect how you feel and how well you cope with pain. Be sure to seek the help and
support you need from friends and family members. Professional counseling can also help.

Health Tools

Health Tools help you make wise health decisions or take action to improve your health.

Cause

The cause of
rheumatoid arthritis (RA) is not fully understood.
Genes play a role, but experts
don't know exactly what that role is. For most people with RA, the disease
doesn't run in their families and they don't pass it along to their children.
One or more genes may make it more likely that the body's
immune system will attack the tissues of the
joints. This immune response may also be triggered by
bacteria, a virus, or some other foreign substance.

Other causes of joint pain include osteoarthritis, lupus, and gout.

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 usually lasts at least 1 hour 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.

What Happens

The course of
rheumatoid arthritis is hard to predict. It usually progresses slowly, over months or years. In some people it doesn't get worse, and symptoms stay about the same. But in rare cases, symptoms come on rapidly, within days.

Symptoms can come and go. You may have times in your life when joint pain goes away on its own for a while. This is called remission.

If the disease progresses, joint pain can
restrict simple movements, such as your ability to grip, and daily activities,
such as climbing stairs. It is a common cause of permanent
disability. But early treatment may control the disease and keep it from getting worse.

Rheumatoid arthritis is more likely to get worse when:

  • A rheumatoid factor blood test is
    positive.
  • A blood test for the antibody CCP (cyclic citrullinated
    peptide) is positive.
  • The disease fails to respond to
    therapy.
  • Bumps (nodules) form rapidly.
  • Many
    joints are affected.
  • X-rays show early
    loss of bone or
    cartilage.

Joint damage

The ongoing inflammation caused by rheumatoid arthritis affects the tissues that line joints. It causes a breakdown in cartilage and loosens ligaments and tendons that support the joints. The resulting joint destruction can lead to deformed joints.

The pain, stiffness, fatigue, and
whole-body (systemic) symptoms of rheumatoid arthritis can be
disabling. Over time, the deformity caused by the disease can lead to difficulty with daily activities.
Specific joint problems may also occur later in the course of the
disease.

The hands and wrists and feet may be deformed. The hands are the most common location for
deformities.

Inflammation of the knees, if not controlled by
treatment, can cause erosion of cartilage and can later lead to the need
for knee replacement surgery.

Rheumatoid arthritis can also damage the cervical spine, or neck. This damage can limit how easily you can move your neck. In rare cases, the
damage can pinch a nerve or affect the spinal cord and cause numbness, pain, weakness, or paralysis in the arms or legs.

Other problems

In a small number of severe cases, the disease may damage other organs, such as the eyes and lungs.

People who have rheumatoid arthritis seem to develop plaque deposits in arteries (atherosclerosis) earlier than people who do not have rheumatoid arthritis. Inflammation may play a role in speeding up plaque development. When plaque develops in the arteries in the heart, it is called coronary artery disease (CAD) and it increases the risk of a heart attack. When plaque develops in the arteries in the neck, it increases the risk of stroke.

Rheumatoid arthritis and some of the medicines used to treat it can increase the risk of osteoporosis.

It is common for people with rheumatoid arthritis to feel depressed. These feelings may be caused by pain and
progressive disability.

Most women with rheumatoid arthritis can become pregnant and have a healthy baby.

What Increases Your Risk

Things that may increase
your risk for rheumatoid arthritis include:

  • Being female. Rheumatoid arthritis affects
    women 2 to 3 times as often as men.
  • Being
    middle-aged. Rheumatoid arthritis can begin at any age, but
    it most often begins in adulthood.
  • Smoking cigarettes.

When to Call a Doctor

Call your doctor immediately if you have:

  • Sudden, unexplained swelling and pain in any
    joint or joints.
  • Joint pain associated
    with a fever or rash.
  • Pain that is so severe that you cannot use
    the joint.
  • Back or neck pain along with weakness in your arms or legs.
  • Loss of bowel or bladder control.

Call your doctor within the next few days if
you have:

  • Joint pain that continues and
    has not improved for over 6 weeks.
  • Side effects that occur with
    large doses of
    nonsteroidal anti-inflammatory drugs (NSAIDs) or other
    medicine used to treat your arthritis. NSAIDs include ibuprofen (Advil) and naproxen (Aleve).

Watchful waiting

Watchful waiting is a wait-and-see approach. It is reasonable to try home
treatment for mild joint pain and stiffness. If there is no improvement after 6
weeks, or if any other symptoms are present, call your doctor.

Early treatment can slow and sometimes prevent significant joint damage.
So if you have symptoms similar to rheumatoid arthritis, see
your doctor to find out if you have rheumatoid arthritis.
Early diagnosis and treatment allows for possible reduction of joint pain,
slows joint destruction, and reduces the chance of permanent disability.

Who to see

Early arthritis symptoms can be
diagnosed by:

Rheumatoid arthritis can be treated by:

  • A rheumatologist.
  • A family medicine doctor or an internist who consults with a rheumatologist.

Supportive treatment can be provided by:

Exams and Tests

No single lab test can diagnose
rheumatoid arthritis. Instead, doctors look at symptoms and physical signs and then rule out other diseases that
can cause similar symptoms.

A
medical history and physical exam are usually
done to help find the cause of joint pain. The pattern and nature of
joint symptoms are the most important clues
to the diagnosis.

Diagnosis is based on a set of
classification criteria. The criteria include the results of these tests:

Other tests are used to help monitor and manage rheumatoid arthritis. These include:

Regular checkups

Because rheumatoid arthritis can lead to severe joint
destruction and disability over time, regular checkups are important to see if treatment is working or
needs to be adjusted.

Treatment Overview

Rheumatoid arthritis is most often treated with medicine, exercise, and lifestyle
changes. Treatment may help relieve symptoms and control the disease, but there
is no cure. Treatment for rheumatoid arthritis usually continues throughout
your life, but it will vary depending on:

  • The stage (active or in
    remission) and severity of your
    disease.
  • Your treatment history.
  • The benefits and risks
    of treatment options.
  • Your preferences for treatment options, such
    as cost, side effects, and daily schedules.

The goal of treatment is to help you maintain your
lifestyle, reduce joint pain, slow joint damage, and prevent disability.

Making a plan

Treatment
of
rheumatoid arthritis should start with education about
the disease, the possibility of joint damage and disability, and the risks and
benefits of potential treatments. A long-term treatment plan should be
developed by you and your team of doctors.

Treatment with medicines

Early and ongoing treatment of
RA with medicines called disease-modifying antirheumatic
drugs (DMARDs) can slow or sometimes prevent joint
destruction. Other medicines may be combined with DMARDs to relieve symptoms. These medicines include:

  • Medicines that reduce swelling, including ibuprofen (such as Advil or Motrin) and naproxen (such as Aleve or Naprosyn).
  • Medicines that relieve pain, such as acetaminophen, codeine, and hydrocodone.
  • Corticosteroids for early treatment, to control flare-ups, or to help manage the disease.

Be safe with medicines. Read and follow all instructions on the label.

For more information, see Medications.

Lifelong care

Treatment for
rheumatoid arthritis usually continues throughout your
life. Your doctor will want to closely monitor your condition. A
rheumatologist should evaluate you regularly. Depending on your symptoms and
treatment, this could be done as often as every 2 to 3 months or every 6 to 12 months. Testing, such as blood tests, may be done
more often.

During each follow-up visit, your doctor will assess:

  • The amount of joint pain.
  • How long
    morning stiffness lasts.
  • The number of actively inflamed
    joints.
  • How well you are functioning.
  • Results of lab tests.

In some cases, the disease does not respond to
the first several treatments. When this happens, the disease may be
treated with much higher doses of medicines or with different combinations of
medicines.

Surgery may be considered when the joints—especially the hips,
knees, or feet—are severely damaged or deformed and are causing extreme pain.
Surgery may include total joint replacement or other techniques to improve
joint function. For more information, see Surgery and Other Treatment.

Exercise and lifestyle changes

Exercise, physical therapy, and lifestyle
changes can help relieve joint pain. Many people with RA
benefit from self-care plans that balance rest and activity. You can take steps at home to relieve your symptoms and help control your disease. For more information, see Living With Rheumatoid Arthritis.

Living With Rheumatoid Arthritis

Living with
rheumatoid arthritis often means making changes to
your lifestyle. You can do things at home, such as staying active and taking
medicines, to help relieve your symptoms and prevent the disease from getting
worse.

You can also plan for those times when the disease symptoms
may be more severe. It is important to work closely with your health
professionals, who may include a
physical therapist or counselor, to find ways to
reduce pain.

Rest when you're tired

The disease itself causes fatigue. And the
strain of dealing with pain and limited activities also can make you tired. The
amount of rest you need depends on how bad your symptoms are.

  • With severe symptoms, you may need long periods
    of rest. You might need to rest a joint by lying down for 15 minutes several
    times a day to relax. Try to find a balance between daily
    activities that you must do or want to do and the amount of rest you need to do those activities.
  • Plan your day carefully, including
    rest periods. Pace your activities so that you don't get
    overtired.

Protect your joints

You may need to change the way you do certain activities so that you are not
overusing your joints. Try to find different ways to relieve your joint
pain.

  • Joint pain and stiffness may improve with heat
    therapy, such as:

    • Taking warm showers or baths after long
      periods of sitting or sleeping.
    • Soaking hand joints in warm wax
      baths.
    • Sleeping under a warm electric blanket.
  • Use
    assistive devices to reduce strain on your joints,
    such as special kitchen tools or doorknobs.
  • Choose the right shoes that fit well and will not cause joint problems.
  • Use splints, canes, or
    walkers to reduce pain and improve function.

Stay active

Keep moving to
keep your muscle strength, flexibility, and overall health.

  • Physical therapy may be recommended by
    your doctor.
  • Exercise for arthritis takes three forms—stretching,
    strengthening, and conditioning. Exercise can improve or maintain quality of life for people who have rheumatoid arthritis. Your specific joint problem may
    guide the type of activity that will help the most. For example:

    • Swimming is a good activity if
      you have joint problems in your knees, ankles, or
      feet.
    • Bicycling and walking are good activities if your
      joint problems are not in your legs or feet.

Avoid smoking

People with rheumatoid arthritis have an increased risk of plaque in the arteries (atherosclerosis). Smoking increases this risk even more. Smoking may also lower your response to treatment.footnote 1 So, if you're a smoker, quit. For more information on how to quit, see the topic Quitting Smoking.

Eat healthy foods

Try to eat a variety of healthy foods. Dietary needs are not the same for all people who have rheumatoid arthritis. To be sure you get the nutrients you need, you can ask a registered dietitian to help you make a plan.

  • Be sure to get enough
    calcium and
    vitamin D
    to protect your bones against osteoporosis.
    For more information, see the topic
    Osteoporosis.
  • Lose weight, if you are
    overweight. For more information, see the topic
    Weight Management.
  • People who have rheumatoid arthritis also have an increased
    risk of heart disease. But healthy lifestyle changes, such as exercise and a
    healthy diet, may reduce your risk.

For more information, see:

Take care of your teeth and gums

People who have rheumatoid arthritis tend to get gum disease. Some experts think that infection that enters the body through the mouth may make rheumatoid arthritis worse, although this has not been proved. You can help prevent gum disease through good basic dental care.

Medications

Medicines are the main treatment for
rheumatoid arthritis. The types of medicines used
depend on how severe your disease is, how fast it is progressing, and how it
affects your daily life.

If your symptoms ease, you and your
doctor will decide if you can take less medicine or stop taking medicine.
If your symptoms get worse, you will have to start taking medicine again.

Medicines are used to:

  • Relieve or reduce pain.
  • Improve
    daily function.
  • Reduce joint inflammation. Signs of joint
    inflammation include swelling, tenderness, and limited range of
    motion
    .
  • Prevent or delay significant
    joint damage and deformity.
  • Prevent
    permanent disability.
  • Improve quality of life.

Medicines called disease-modifying antirheumatic drugs
(DMARDs) can slow or sometimes prevent joint destruction. Starting treatment early with DMARDs can reduce the severity of the disease. DMARDs are also called immunosuppressive drugs or
slow-acting antirheumatic drugs (SAARDs). These medicines are usually taken over a long period to help control the disease.

DMARDs can be thought of as nonbiologic or biologic, depending on how they are made and how they act in the body. But they are all used to block harmful responses from the body's immune system. DMARDs are sometimes combined with one another or with other medicines. By combining medicines, you may be able to take lower doses of individual medicines. This may reduce your risk of side effects.

Some medicines for rheumatoid arthritis may cause birth defects. If you
are pregnant or are trying to become pregnant, talk with your doctor about your medicines.

Medicines to slow the disease

Disease-modifying antirheumatic drugs
(DMARDs)
are usually started within 3 months of your diagnosis. They are used to
control the progression of RA and to try to prevent joint
damage and disability. DMARDs are often given in combination with other
medicines.

Commonly used nonbiologic DMARDs

  • Antimalarials such as
    hydroxychloroquine or chloroquine
  • Leflunomide
  • Methotrexate
  • Sulfasalazine

Less commonly used nonbiologic DMARDs

  • Azathioprine
  • Cyclophosphamide
  • Cyclosporine
  • Gold salts
  • Minocycline
  • Penicillamine

Biologic DMARDs (biologics)

  • Abatacept
  • Adalimumab
  • Anakinra
  • Certolizumab
  • Etanercept
  • Golimumab
  • Infliximab
  • Rituximab
  • Tocilizumab

There is a newer biologic drug called tofacitinib (Xeljanz) for adults who have moderate to severe rheumatoid arthritis. This medicine is for people who have not responded well to methotrexate or who cannot take it. Tofacitinib is taken by mouth. It reduces the symptoms of rheumatoid arthritis and allows people to be more active. But the long-term safety of this medicine is still being studied.footnote 2, footnote 3

Medicines to relieve symptoms

  • Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen, and naproxen. NSAIDs are used to
    control pain and may help reduce inflammation. They don't control the disease
    or stop it from getting worse. NSAIDs may be combined with DMARDs.
  • Corticosteroids
    such as prednisone. These medicines are used to reduce disease
    activity and joint inflammation. But using only corticosteroids for an extended time is not considered the best treatment. Corticosteroids are
    often used to control symptoms and flares of joint inflammation until DMARDs
    reach their full effectiveness.
  • Analgesics (pain relievers). These don't reduce
    inflammation but may help with pain control. They include:

    • Nonprescription
      acetaminophen.
    • Acetaminophen with codeine (such as
      Tylenol with codeine).
    • Acetaminophen with hydrocodone (such as
      Vicodin).
    • Tramadol.

What to think about

  • Some DMARDs can take up to 6
    months to work.
  • In some people, a certain DMARD may not work at all. So a
    different DMARD will be used.
  • If you're taking DMARDs, it's a good idea to have a rheumatologist manage your care.
  • Many DMARDs have serious side effects. You will need regular blood and urine tests to check the drug's effects on
    blood-producing cells (bone marrow), the kidneys, and the liver.
  • If you have other conditions such as high blood pressure or high cholesterol, your doctor may recommend that you take medicine to control them.

Be safe with medicines. Read and follow all instructions on the label.

Surgery

Surgical treatment for
rheumatoid arthritis is used to relieve severe pain
and improve function of severely deformed joints that don't respond to
medicine and physical therapy.

Total joint replacement
(arthroplasty) can be done for many different joints in the body. Its success
varies depending on which
joint is replaced.

Surgery choices

Surgeries considered for people
who have severe rheumatoid arthritis include:

What to think about

Joint surgery often restores
near-normal movement in a person who has
osteoarthritis in just one or two joints. But this is
not the case for people affected by rheumatoid arthritis.

  • Rheumatoid arthritis usually affects multiple
    joints, particularly smaller joints, such as finger joints, which are needed
    for many daily activities. Surgical treatment may not be an option for all of
    the affected joints.
  • Joint surgery or replacement can relieve
    disabling pain and restore enough motion to allow you to do your daily
    activities. But it will seldom restore the joint to normal.

Before you decide to have surgery, consult with an
orthopedic surgeon who is experienced in joint surgery
for rheumatoid arthritis.

Other Treatment

Other types of treatment that may
help you control some of the symptoms of
rheumatoid arthritis include:

  • Physical therapy, to improve joint
    function. Physical therapy includes exercise, hot and cold therapy, and
    massage.
  • Occupational therapy. This helps you learn how to maintain
    movement in the joints while carrying out the activities of daily living.
  • Assistive devices such as household aids or mobility aids. For
    more information and a catalog, contact the Arthritis Foundation at www.arthritis.org.
  • Behavioral modification techniques to reduce pain and
    stress. These include
    biofeedback and relaxation therapy, such as
    breathing exercises and
    muscle relaxation.
  • Counseling. It can
    help you cope with long-term pain and disability.

Complementary medicine

Complementary medicine therapies are
used by many people to relieve symptoms and
improve their quality of life, even though there isn't strong scientific evidence that they help. These therapies include:

  • Acupuncture. This treatment is used to
    relieve pain and treat certain health conditions. It is done by inserting very
    thin needles into the skin at specific points on the body.
  • Herbs and dietary supplements. If you decide to
    use herbs or dietary supplements, be sure to tell your doctor.

    • Herbs such as the oil of evening primrose, borage seed, or blackcurrant seed may help relieve symptoms and improve function without significant side effects.
    • Essential fatty acids (such as fish oil) may provide some
      relief of symptoms.footnote 4
    • The dietary supplements glucosamine and chondroitin are sometimes used to
      try to relieve joint pain. But there is not evidence that they are effective for rheumatoid arthritis.
  • Massage. It can help relieve stress and reduce
    pain. But don't massage swollen or painful joints.

Find out about the safety of any complementary product or practice you want to try. Most mind and body practices—such as acupuncture and massage—are safe when used under the care of a well-trained professional. Choose an instructor or practitioner as carefully as you would choose a doctor.

Talk with your doctor about any complementary health practice that you would like to try or are already using. Your doctor can help you manage your health better if he or she knows about all of your health practices.

Other Places To Get Help

Organization

National Institute of Arthritis and Musculoskeletal and Skin Diseases (U.S.)
www.niams.nih.gov

References

Citations

  1. O'Dell JR (2013). Treatment of rheumatoid arthritis. In GS Firestein et al., eds., Kelley's Textbook of Rheumatology, 9th ed., vol. 2, pp. 1137–1160. Philadelphia: Saunders.
  2. Fleischmann R, et al. (2012). Placebo-controlled trial of tofacitinib monotherapy in rheumatoid arthritis. New England Journal of Medicine, 367(6): 495–507.
  3. Von Vollenhoven RF, et al. (2012). Tofacitinib or adalimumab versus placebo in rheumatoid arthritis. New England Journal of Medicine, 367(6): 508–519.
  4. Gomez FE, Kaufer-Horwitz M (2012). Medical nutrition therapy for rheumatic disease. In LK Mahan et al., eds., Krause's Food and the Nutrition Care Process, 13th ed., pp. 901–922. St Louis: Saunders.

Other Works Consulted

  • Combe B, et al. (2016). 2016 update of the EULAR recommendations for the management of early arthritis. Annals of the Rheumatic Diseases, published online December 15, 2016. DOI: 10.1136/annrheumdis-2016-210602. Accessed January 13, 2017.
  • O'Dell JR (2013). Treatment of rheumatoid arthritis. In GS Firestein et al., eds., Kelley's Textbook of Rheumatology, 9th ed., vol. 2, pp. 1137–1160. Philadelphia: Saunders.
  • Singh JA, et al. (2016). 2015 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care and Research, 68(1): 1–25. DOI: 10.1002/acr.22783. Accessed April 14, 2016.
  • Steultjens EEMJ, et al. (2009). Occupational therapy for rheumatoid arthritis. Cochrane Database of Systematic Reviews (1).
  • Sweeney SE, et al. (2013). Clinical features of rheumatoid arthritis. In GS Firestein et al., eds., Kelley's Textbook of Rheumatology, 9th ed., vol. 2, pp. 1109–1136. Philadelphia: Saunders.
  • Yasuda GT, et al. (2013). Rheumatoid arthritis. In JE Pizzorno, MT Murray, eds., Textbook of Natural Medicine, 4th ed., pp. 1769–1784. St. Louis: Elsevier.

Credits

ByHealthwise StaffPrimary Medical Reviewer Anne C. Poinier, MD - Internal Medicine E. Gregory Thompson, MD - Internal Medicine Adam Husney, MD - Family Medicine Martin J. Gabica, MD - Family Medicine Kathleen Romito, MD - Family Medicine Specialist Medical Reviewer Nancy Ann Shadick, MD, MPH - Internal Medicine, Rheumatology

Current as ofOctober 10, 2017

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