rheumatoid arthritis (redirected from Rheumatiod arthritis)

Rheumatoid Arthritis 

Definition

Rheumatoid arthritis (RA) is a chronic autoimmune disease that causes inflammation and deformity of the joints. Other problems throughout the body (systemic problems) may also develop, including inflammation of blood vessels (vasculitis), the development of bumps (called rheumatoid nodules) in various parts of the body, lung disease, blood disorders, and weakening of the bones (osteoporosis).

Description

The skeletal system of the body is made up of different types of strong, fibrous tissue called connective tissue. Bone, cartilage, ligaments, and tendons are all forms of connective tissue that have different compositions and different characteristics.

The joints are structures that hold two or more bones together. Some joints (synovial joints) allow for movement between the bones being joined (articulating bones). The simplest synovial joint involves two bones, separated by a slight gap called the joint cavity. The ends of each articular bone are covered by a layer of cartilage. Both articular bones and the joint cavity are surrounded by a tough tissue called the articular capsule. The articular capsule has two components, the fibrous membrane on the outside and the synovial membrane (or synovium) on the inside. The fibrous membrane may include tough bands of tissue called ligaments, which are responsible for providing support to the joints. The synovial membrane has special cells and many tiny blood vessels (capillaries). This membrane produces a supply of synovial fluid that fills the joint cavity, lubricates it, and helps the articular bones move smoothly about the joint.

In rheumatoid arthritis (RA), the synovial membrane becomes severely inflamed. Usually thin and delicate, the synovium becomes thick and stiff, with numerous infoldings on its surface. The membrane is invaded by white blood cells, which produce a variety of destructive chemicals. The cartilage along the articular surfaces of the bones may be attacked and destroyed, and the bone, articular capsule, and ligaments may begin to wear away (erode). These processes severely interfere with movement in the joint.

RA exists all over the world and affects men and women of all races. In the United States alone, about two million people suffer from the disease. Women are three times more likely than men to have RA. About 80% of people with RA are diagnosed between the ages of 35-50. RA appears to run in families, although certain factors in the environment may also influence the development of the disease.

Causes and symptoms

The underlying event that promotes RA in a person is unknown. Given the known genetic factors involved in RA, some researchers have suggested that an outside event occurs that triggers the disease cycle in a person with a particular genetic makeup.

Many researchers are examining the possibility that exposure to an organism (like a bacteria or virus) may be the first event in the development of RA. The body's normal response to such an organism is to produce cells that can attack and kill the organism, protecting the body from the foreign invader. In an autoimmune disease like RA, this immune cycle spins out of control. The body produces misdirected immune cells, which accidentally identify parts of the person's body as foreign. These immune cells then produce a variety of chemicals that injure and destroy parts of the body.

RA can begin very gradually, or it can strike quickly. The first symptoms are pain, swelling, and stiffness in the joints. The most commonly involved joints include hands, feet, wrists, elbows, and ankles, although other joints may also be involved. The joints are affected in a symmetrical fashion. This means that if the right wrist is involved, the left wrist is also involved. Patients frequently experience painful joint stiffness when they first get up in the morning, lasting for perhaps an hour. Over time, the joints become deformed. The joints may be difficult to straighten, and affected fingers and toes may be permanently bent (flexed). The hands and feet may curve outward in an abnormal way.

Many patients also notice increased fatigue, loss of appetite, weight loss, and sometimes fever. Rheumatoid nodules are bumps that appear under the skin around the joints and on the top of the arms and legs. These nodules can also occur in the tissue covering the outside of the lungs and lining the chest cavity (pleura), and in the tissue covering the brain and spinal cord (meninges). Lung involvement may cause shortness of breath and is seen more in men. Vasculitis (inflammation of the blood vessels) may interfere with blood circulation. This can result in irritated pits (ulcers) in the skin, tissue death (gangrene), and interference with nerve functioning that causes numbness and tingling.

Juvenile RA is a chronic inflammatory disease that affects the joints of children less than 16 years old. It is estimated to affect as many as 250,000 children in the United States alone. Most children with juvenile RA have arthritis when the illness starts, which affects multiple joints in 50% of these children, and only one joint in 30%. In all, 20% of the children affected by juvenile RA have the acute systemic form of the disease, which is characterized by fever, joint inflammation, rash, liver disease, and gastrointestinal disease.

Two periods of childhood are associated with an increased incidence of onset of juvenile RA. The first is from one to three years of age, and the second, from eight to 12 years. When more than four joints are affected, the disease is described as being polyarticular. If less than four joints are affected, the disease is known as pauciarticular. juvenile RA and this particular manifestation falls into two categories. The first occurs in girls aged one to four years old, and the onset of joint involvement is in the knees, ankles, or elbows. The second form occurs in boys aged eight years and older, and involves the larger joints, such as those of the hips and legs.

Diagnosis

There are no tests available that can absolutely diagnose RA. Instead, a number of tests exist that can suggest the diagnosis of RA. Blood tests include a special test of red blood cells (called erythrocyte sedimentation rate), which is positive in nearly 100% of patients with RA. However, this test is also positive in a variety of other diseases. Tests for anemia are usually positive in patients with RA, but can also be positive in many other unrelated diseases. Rheumatoid factor is another diagnostic test that measures the presence and amounts of rheumatoid factor in the blood. Rheumatoid factor is an autoantibody found in about 80% of patients with RA. It is often not very specific however, because it is found in about 5% of all healthy people and in 10-20% of healthy people over the age of 65. In addition, rheumatoid factor is also positive in a large number of other autoimmune diseases and other infectious diseases, including systemic lupus erythematosus, bacterial endocarditis, malaria, and syphilis. In addition, young people who have a process called juvenile rheumatoid arthritis often have no rheumatoid factor present in their blood.

Finally, the clinician may examine the synovial fluid, by inserting a thin needle into a synovial joint. In RA, this fluid has certain characteristics that indicate active inflammation. The fluid is cloudy, with increased protein and decreased or normal glucose. It also contains a higher than normal number of white blood cells. While these findings suggest inflammatory arthritis, they are not specific to RA.

Treatment

There is no cure available for RA. However, treatment is available to combat the inflammation in order to prevent destruction of the joints, and to prevent other complications of the disease. Efforts are also made to maintain flexibility and mobility of the joints.

The "first line" agents for the treatment of RA include nonsteroidal anti-inflammatory agents (NSAIDs) and aspirin, which are used to decrease inflammation and to treat pain. The NSAIDs include naproxen (Naprosyn), ibuprofen (Advil, Medipren, Motrin), and etodolac (Lodine). While these medications can be helpful, they do not interrupt the progress of the disease. Low-dose steroid medications can be helpful at both managing symptoms and slowing the progress of RA. Disease-modifying antirheumatic drugs, including gold compounds, D-penicillamine, certain antimalarial-like drugs, and sulfasalazine (Azulfadine) are also often the first agents clinicians use to treat RA, but in patients with the aggressive destructive type of RA, more slow-acting medications are needed. Methotrexate, azathioprine, and cyclophosphamide are all drugs that suppress the immune system and can decrease inflammation. All of the drugs listed have significant toxic side effects, which require healthcare professionals to carefully compare the risks associated with these medications versus the benefits.

Recently, several categories of drugs have been explored and developed for the treatment of RA. The first is a category of agents known as biological response modifiers. These work to reduce joint inflammation by blocking a substance called tumor necrosis factor (TNF). TNF is a protein that triggers inflammation during the body's normal immune responses. When TNF production is not regulated, the excess TNF can cause inflammation. Three agents in this class have become "second line" drugs for the treatment of RA. These are etanercept (Enbrel), leflunamide (Arava), and infliximab (Remicade), and they are recommended for patients in whom other medications have not been effective. Etanercept is approved by the FDA but is not recommended for patients with active infection. It is given twice weekly via subcutaneous injections by either the patient or a health care professional. Because this agent is so new, long-term side effects have not been fully studied. Infliximab is given intravenously once every eight weeks, and is approved for combined use with methotrexate to combat RA.

The cyclo-oxygenase-2 (COX-2) inhibitors are another category of drugs used to treat RA. Like the traditional NSAIDs, the COX-2 inhibitors work to block COX-2, which is an enzyme that stimulates inflammatory responses in the body. Unlike the NSAIDs, the COX-2 inhibitors do not carry a high risk of gastrointestinal ulcers and bleeding, because they do not inhibit COX-1, which is the enzyme that protects the stomach lining. These new agents include celecoxib (Celebrex) and rofecoxib (Vioxx). Celecoxib has been approved by the FDA for the treatment of RA and osteoarthritis, and is taken once or twice daily by mouth. Rofecoxib is approved for RA and osteoarthritis, and for acute pain caused by primary dysmenorrhea and surgery.

Total bed rest is sometimes prescribed during the very active, painful phases of RA. Splints may be used to support and rest painful joints. Later, after inflammation has somewhat subsided, physical therapists may provide a careful exercise regimen in an attempt to maintain the maximum degree of flexibility and mobility. Joint replacement surgery, particularly for the knee and the hip joints, is sometimes recommended when these joints have been severely damaged.

Alternative treatment

A variety of alternative therapies has been recommended for patients with RA. Meditation, hypnosis, guided imagery, and relaxation techniques have been used effectively to control pain. Acupressure and acupuncture have also been used for pain. Bodywork can be soothing, decreasing stress and tension, and is thought to improve/restore chemical balance within the body.

A multitude of nutritional supplements can be useful for RA. Fish oils, the enzymes bromelain and pancreatin, and the antioxidants (vitamins A, C, and E, selenium, and zinc) are the primary supplements to consider.

Many herbs also are useful in the treatment of RA. Anti-inflammatory herbs may be very helpful, including tumeric (Curcuma longa), ginger (Zingiber officinale), feverfew (Chrysanthemum parthenium), devil's claw (Harpagophytum procumbens), Chinese thoroughwax (Bupleuri falcatum), and licorice (Glycyrrhiza glabra). Lobelia (Lobelia inflata) and cramp bark (Vibernum opulus) can be applied topically to the affected joints.

Homeopathic practitioners recommended Rhus toxicondendron and Bryonia (Bryonia alba) for acute prescriptions, but constitutional treatment, generally used for chronic problems like RA, is more often recommended. Yoga has been used for RA patients to promote relaxation, relieve stress, and improve flexibility. Nutritionists suggest that a vegetarian diet low in animal products and sugar may help to decrease both inflammation and pain from RA. Beneficial foods for patients with RA include cold water fish (mackerel, herring, salmon, and sardines) and flavonoid-rich berries (cherries, blueberries, hawthorn berries, blackberries, etc.).

RA, considered an autoimmune disorder, is often connected with food allergies/intolerances. An elimination/challenge diet can help to decrease symptoms of RA as well as identify the foods that should be eliminated to prevent flare-ups and recurrences. Hydrotherapy can help to greatly reduce pain and inflammation. Moist heat is more effective than dry heat, and cold packs are useful during acute flare-ups.

Prognosis

About 15% of all RA patients will have symptoms for a short period of time and will ultimately get better, leaving them with no long-term problems. A number of factors are considered to suggest the likelihood of a worse prognosis. These include:

• race and gender (female and Caucasian).
• more than 20 joints involved.
• extremely high erythrocyte sedimentation rate.
• extremely high levels of rheumatoid factor.
• consistent, lasting inflammation.
• evidence of erosion of bone, joint, or cartilage on x rays.
• poverty.
• older age at diagnosis.
• rheumatoid nodules.
• other coexisting diseases.
• certain genetic characteristics, diagnosable through testing.

Patients with RA have a shorter life span, averaging a decrease of three to seven years of life. Patients sometimes die when very severe disease, infection, and gastrointestinal bleeding occur. Complications due to the side effects of some of the more potent drugs used to treat RA are also factors in these deaths.

Prevention

There is no known way to prevent the development of RA. The most that can be hoped for is to prevent or slow its progress.

Key terms

Articular bones — Two or more bones connected to each other via a joint.

Joint — Structures holding two or more bones together.

Pauciarticular juvenile RA — Rheumatoid arthritis found in children that affects less than four joints.

Polyarticular juvenile RA — Rheumatoid arthritis found in children that affects more than four joints.

Synovial joint — A type of joint that allows articular bones to move.

Synovial membrane — The membrane that lines the inside of the articular capsule of a joint and produces a lubricating fluid called synovial fluid.

Resources

Books

Arthritis Foundation. The Good Living with Rheumatoid Arthritis. New York: Longstreet Press Inc., 2000.

Periodicals

Case, J. P. "Old and New Drugs Used in Rheumatoid Arthritis: A Historical Perspective. Part 2: The Newer Drugs and Drug Strategies." American Journal of Therapeutics May-June 2001: 163-79.

Goekoop, Y. P., et al. "Combination Therapy in Rheumatoid Arthritis." Current Opinions in Rheumatology May 2001: 177-83.

Koivuniemi, R., and M. Leirisalo-Repo. "Juvenile Chronic Arthritis in Adult Life: A Study of Long-term Outcome in Patients with Juvenile Chronic Arthritis or Adult Rhuematoid Arthritis." Clinical Rheumatology 1999: 220-6.

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arthritis /ar·thri·tis/ (ahr-thri´tis) pl. arthri´tides   inflammation of a joint.

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acute arthritis  arthritis marked by pain, heat, redness, and swelling.

chronic inflammatory arthritis  inflammation of joints in chronic disorders such as rheumatoid arthritis.

arthritis defor´mans  severe destruction of joints, seen in disorders such as rheumatoid arthritis.

degenerative arthritis  osteoarthritis.

enteropathic arthritis  arthritis associated with inflammatory bowel disease or following bacterial infection of the bowel.

hypertrophic arthritis  osteoarthritis.

infectious arthritis  arthritis caused by bacteria, rickettsiae, mycoplasmas, viruses, fungi, or parasites.

juvenile rheumatoid arthritis  rheumatoid arthritis in children, with swelling, tenderness, and pain involving one or more joints, sometimes leading to impaired growth and development, limitation of movement, and ankylosis and flexion contractures of the joints; often accompanied by systemic manifestations.

Lyme arthritis  see under disease.

menopausal arthritis  that seen in some menopausal women, due to ovarian hormonal deficiency, and marked by pain in the small joints, shoulders, elbows, or knees.

arthritis mu´tilans  severe deforming polyarthritis with gross bone and cartilage destruction, an atypical variant of rheumatoid arthritis.

rheumatoid arthritis  a chronic systemic disease primarily of the joints, usually polyarticular, marked by inflammatory changes in the synovial membranes and articular structures and by atrophy and rarefaction of the bones. In late stages, deformity and ankylosis develop.

septic arthritis , suppurative arthritis a form marked by purulent joint infiltration, chiefly due to bacterial infection but also seen in Reiter's disease.

tuberculous arthritis  that secondary to tuberculosis, usually affecting a single joint, marked by chronic inflammation with effusion and destruction of contiguous bone.

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rheumatoid arthritis

n. Abbr. RA

A chronic, inflammatory arthritis, commonly involving the hands and feet, characterized by joint pain, stiffness, and weakness that can lead to deformity and disability. Also called arthritis deformans.

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rheumatoid arthritis (RA)

Etymology: Gk, rheuma, flux, eidos, form, arthron, joint, itis, inflammation

a chronic, inflammatory, destructive, and sometimes deforming collagen disease that has an autoimmune component. It is characterized by symmetric inflammation of synovial membranes and increased synovial exudate, leading to thickening of the membranes and swelling of the joints. Rheumatoid arthritis usually first appears when patients, most often women, are between 36 and 50 years of age. The course of the disease is variable but is most frequently marked by alternating periods of remission and exacerbation. Also called arthritis deformans, atrophic arthritis. See also ankylosing spondylitis, juvenile rheumatoid arthritis.

observations The medical diagnosis and prognosis of rheumatoid arthritis are based on a variety of clinical and laboratory findings. Clinical data, mainly from radiographic studies and physical examination, classify the progress of the disease into four stages. Stage I, representing early effects, is based on x-ray films showing the onset of bone changes. Stage II, moderate rheumatoid arthritis, incorporates cases in which there is evidence of some muscle atrophy and loss of mobility, in addition to x-ray findings. Stage III, severe rheumatoid arthritis, is marked by joint deformity, extensive muscle atrophy, soft tissue lesions, and definite bone and cartilage destruction. Stage IV includes all the stage III clinical signs plus fibrous or bony ankylosis. Rheumatoid arthritis may also be classified on the basis of functional capacity: class I, no loss of function; class II, minor impairment of functional capacity with some pain and immobility; class III, capacity limited to a few tasks; and class IV, confinement to bed or a wheelchair. The disease may first be present with fatigue, weakness, poor appetite, low-grade fever, anemia, and an increased erythrocyte sedimentation rate. The diagnostic criteria listed by the American Rheumatism Association include morning stiffness, joint pain or tenderness, swelling of at least two joints, subcutaneous nodules (called arthritic nodules and usually found at pressure points such as the elbows), structural changes in joints seen on x-ray film, a positive rheumatoid factor agglutination test, decreased precipitation of mucin from synovial fluid, and characteristic histologic changes on pathologic examination of the fluid. Higher titers of rheumatoid factor are correlated with more severe forms of the disease, especially forms with extraarticular manifestations, such as cardiac involvement, vasculitis, pulmonary disease, and proteinuria. There may also be a thickening of synovial membranes, called pannus formation. In long-term, severe, chronic rheumatoid arthritis, Felty's syndrome may be present. Rheumatoid arthritis is not always progressive, deforming, or debilitating; most patients may continue in their jobs.

interventions Treatment includes sufficient rest, range-of-motion exercises to maintain joint function, medication for the relief of pain and reduction of inflammation, orthopedic intervention to prevent or correct deformities, proper nutrition, and weight loss, if necessary. Salicylates are usually given. If improvement is not achieved, other antiinflammatory agents may be used, such as indomethacin, phenylbutazone, antimalarials, gold salts, or some antineoplastic drugs. Corticosteroids are prescribed with caution because of their side effects, including gastric ulcer, adrenal suppression, and osteoporosis. Other treatments, including diathermy, ultrasound, warm paraffin applications, exercise under water, and applications of heat, are occasionally used.

nursing considerations The nurse monitors drug treatment and notes its effects; encourages the patient to get sufficient sleep and to rest both small and weight-bearing joints; suggests the most effective use of heat or cold; instructs the patient in muscle-strengthening exercises and methods for easing pain and preventing deformities, such as the proper use of pillows, splints, or molds; and offers emotional support. Because stress often precedes exacerbation of the condition, the patient is counseled to avoid situations known to cause anxiety, worry, fatigue, or infection.

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rheumatoid arthritis (rōōˑ·m·toid är·thīˑ·tis),

n an autoimmune, inflam-matory form of arthritis marked by periods of progression and remission; results in joint destruction and deformity; often strikes women between the ages of 36 and 50. Also called
arthritis deformans, atrophic arthritis.

Rheumatoid arthritis.

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rheumatoid arthritis,

n a chronic, destructive, sometimes deforming collagen disease that has an autoimmune component. Rheumatoid arthritis usually first appears in early middle age, between 36 and 50 years of age, and most commonly in women.

rheumatoid arthritis, juvenile,

n a chronic disease affecting the immune system that occurs in children younger than age 16. Symptoms include joint inflammation in the spine, knees, and wrists and a limited ability to open the oral cavity.

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rheumatoid

resembling rheumatism.

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rheumatoid arthritis

see rheumatoid arthritis.

rheumatoid factor

antibodies, particularly IgM but also IgG, that are directed against antigenic determinants on the Fc region of other immunoglobulins. When the immunoglobulin binds to antigen, changes occur in the folding of the protein of the Fc region such that new, 'non-self' antigenic determinants are exposed and it is to these that rheumatoid factors, i.e. other antibodies, are directed.

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arthritis, rheumatoid 

An autoimmune systemic inflammatory disease characterized by swelling of the joints causing pain and sometimes deformity. It is often accompanied by ocular inflammations, which include keratoconjunctivitis sicca, episcleritis, scleritis and uveitis, as well as corneal ulceration and scleral thinning (scleromalacia). See Reiter's disease; marginal furrow; keratoconjunctivitis sicca; keratolysis; peripheral ulcerative keratitis; Brown's superior oblique tendon sheath syndrome; Sjögren's syndrome.

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rheumatoid arthritis

Rheumatology A multisystem autoimmune disease characterized by chronic inflammation of multiple joints; RA is defined by the 1987 revised criteria, which requires that criteria 1-4 be present for > 6 wks Lab IgG autoantibodies, aka rheumatoid factors Management Etanercept ↓ disease activity in therapeutically refractive RA

Rheumatoid arthritis–Revised criteria

1. Periarticular morning stiffness lasting ≥ one hour before maximum improvement

2. Soft tissue swelling ('arthritis') of ≥ 3 joints observed by a physician

3. Swelling ('arthritis') of proximal interphalangeal, metacarpophalangeal or wrist joints

4. Symmetric swelling ('arthritis')

5. Rheumatoid nodules

6. Presence of rheumatoid factor

7. Roentgenographic erosions and/or periarticular osteopenia

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Patient discussion about Rheumatiod arthritis.

Q. My wife suffers from rheumatoid arthritis. what is the best drug therapy? My wife suffers from rheumatoid arthritis. she was diagnosed last week and our physician told us a lot about the optional drug therapies. we understand that there are disease modifying drugs and pain killers. What is a good combination between them? are there any risk factors that we should know?

A. If your car shows you with a warning lamp that there is not enough motor oil around, it helps not that you cover the warning lamp with a sticker to have not this disturbing light in your sight. As long you don't fill up your car with the necessary quantity of motor oil, there will be sooner or later a big problem. The same is with our body. If we don't drink enough water daily, our body will send a sign of alarm in form of pain.

To read about water and what it can cure, follow this link:

http://www.amazon.com/s/ref=nb_ss_b?url=search-alias%3Dstripbooks&field-keywords=batmanghelidj&x=0&y=0

Q. My GP told me I suffer from osteo-arthritis. What does it mean? I am a 67 year old female that is in retirement. I went to my GP because I suffer from osteo-arthritis. What does it mean? I always thought that arthritis is a systemic disease and that it is called Rheumatoid arthritis. Are there really two different arthritis diseases or is it two names for the same situation?

A. Those are two distinct medical situation, and you can actually have both of them (as I have). Osteo-arthritis is a joint disease of the cartilage, and it is not a systemic disease. The best treatment is weight loss and pain killers. In severe case you can inject steroids to the join. It helped me, but you need an injection every 2 months or so.

Q. Is it for life? I was recently diagnosed with rheumatoid arthritis, and started taking meds (MTX and others). How long will I have to take these medications?

A. sadly, i can't give you better news then mrfoot56 and brwnis65. these medication are for life. but there are all sort of new treatments that are now researched, using biological ways to reduce the immunoglobolins complexes that accumulates in your joints, here is an article about top 10 advances of 2007:
http://www.arthritis.org/media/newsroom/news-releases/Top_10_Arthritis_Advances_of_2007.pdf