rheumatoid 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.

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

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.

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.

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.

arthritis [ahr-thri´tis] (pl. arthri´tides)

inflammation of a joint. adj., adj arthrit´ic. The term is often used by the public to indicate any disease involving pain or stiffness of the musculoskeletal system. Arthritis is not a single disease, but a group of over 100 diseases that cause pain and limit movement. The most common types are osteoarthritis and rheumatoid arthritis.

Arthritis of the fingers. Left, normal hand and finger. Right, arthritic hand and finger, with ankylosis, or “locking” of the joint by bone and scar tissue. Courtesy of Bergman Associates.

rheumatoid arthritis a chronic systemic disease characterized by inflammatory changes occurring throughout the body's connective tissues. As such, it is classified as a collagen disease. This form of arthritis strikes during the most productive years of adulthood, with onset in the majority of cases between the ages of 20 and 40. No age is spared, however, and the disease may affect infants as well as the very old. The disease affects men and women about equally in number, but three times as many women as men develop symptoms severe enough to require medical attention.

Etiology. The cause of rheumatoid arthritis is unknown and it is doubtful that there is one specific cause. It is regarded by some researchers as an autoimmune disease, in which the body produces abnormal antibodies against its own cells and tissues. Evidence to support this theory is found in the fact that there is an abnormally high level of certain types of immunoglobulins in the blood of patients suffering from rheumatoid arthritis. Other researchers contend that the disease may be due to infection, perhaps from an undefined virus or some other microorganism (e.g., Mycoplasma). There also is the possibility that rheumatoid arthritis is a genetic disorder in which one inherits a predisposition to the disease. Physical and emotional stress also play some part in the onset of acute attacks; however, psychological stress is implicated as a causative factor in the onset of many illnesses.

Symptoms and Pathology. In about 75 per cent of patients the onset of rheumatoid arthritis is gradual, with only mild symptoms at the beginning. Early symptoms include malaise, fever, weight loss, and morning stiffness of the joints. One or more joints may become swollen, painful, and inflamed. Some patients may experience only mild episodes of acute symptoms with lengthy remissions. The more typical patient, however, experiences increasingly severe and frequent attacks with subsequent joint damage and deformity. The pattern of remissions and exacerbations continues throughout the course of the disease.

If untreated, and sometimes in spite of treatment, the joint pathology goes through four stages: (1) proliferative inflammation of the synovium with increased exudate, which eventually leads to thickening of the synovium; (2) formation of a layer of granulation tissue (pannus) that erodes and destroys the cartilage and eventually spreads to contiguous areas, causing destruction of the bone capsule and parts of the muscles that control the joint; (3) fibrous ankylosis resulting from invasion of the pannus by tough fibrous tissue; and (4) bony ankylosis as the fibrous tissue becomes calcified.

In addition to the joint changes there is atrophy of muscles, bones, and skin adjacent to the affected joint. The most characteristic lesions of rheumatoid arthritis are subcutaneous nodules, which may be present for weeks or months and are most commonly found over bony prominences, especially near the elbow.

Because rheumatoid arthritis is a systemic disease, there is involvement of connective tissues other than those in the musculoskeletal system. Degenerative lesions may be found in the collagen in the lungs, heart, blood vessels, and pleura.

Patients with rheumatoid arthritis appear undernourished and chronically ill. Most are anemic because of the effect of the disease on blood-forming organs. The erythrocyte sedimentation rate is elevated and the WBC may be slightly elevated.

Treatment and Patient Care. Management of rheumatoid arthritis is aimed at providing rest and freedom from pain, minimizing emotional stress, preventing or correcting deformities, and maintaining or restoring function so that the patient can enjoy as much independence and mobility as possible. Occupational therapy is needed to teach patients effective ways to carry out such activities of daily living as grooming and self-care, preparing meals, and light housekeeping. This often involves using specially designed utensils and tools that allow deformed joints to perform these tasks.

Rest and Exercise. It is recommended that the patient with rheumatoid arthritis plan for 10 to 12 hours of sleep out of each 24. The patient should be careful to maintain good posture while lying in bed and avoid pillows or other devices that support the joints in a flexed position. A firm mattress is recommended, with only one pillow under the head. During periods of severe attacks, the patient may require continuous bed rest.

The purpose of rest is to allow the body's natural defenses against inflammation to work at optimal level. It is necessary, however, even in the acute phase to balance rest with prescribed exercises which take into account the severity of the case, the joints affected, and the patient's individual needs and tolerance.

Physical Therapy. The goals of physical therapy for the patient with rheumatoid arthritis are to prevent and correct deformities, control pain, strengthen weakened muscles, and improve function.

Therapeutic exercise is of major importance in the physical therapy program established for the patient. It is necessary to enlist the patient's cooperation, and this can be done most effectively by explaining the purposes of the exercises and teaching ways to exercise that will not increase pain. In many instances proper exercise can actually diminish pain. The patient's tolerance for exercise must be carefully monitored. While it is expected that some discomfort may be present during exercise, there should not be persistent pain that continues for hours after the exercises have been done. If such pain and fatigue do occur, the exercise program should be reviewed and revised so that a good balance of rest and exercise is obtained. It should be remembered that overactivity can contribute to the inflammatory process.

Applications of heat or cold may be used in the management of rheumatoid arthritis. Heat applications improve circulation, promote relaxation, and relieve pain. When used in conjunction with exercise, heat can allow more freedom of joint movement. Various forms of heat therapy may be used, including dry heat, moist heat, diathermy, and ultrasound. For dry heat a therapeutic infrared heat lamp may be most convenient during home care. Hot water bottles or electric heating pads also may be used. For treatment of the hands, paraffin baths are effective. Wet heat can be applied by hot tub baths with the water temperature not exceeding 39°C (102°F) or by means of a towel dipped in hot water, wrung out, and applied to the joint. Whirlpool baths are effective, especially when prolonged treatment is indicated. Relief from pain and stiffness can be provided for some patients by applications of cold packs to the affected joints. This can be done by placing ice packs directly over the joint. When either heat or cold is used, care must be taken to protect the patient's skin. It should be remembered that rheumatoid arthritis affects the skin as well as other tissues.

Whenever it is necessary to handle the joints and limbs of a patient with rheumatoid arthritis, it is extremely important to move slowly and gently, avoiding sudden, jarring movements which stimulate muscle contraction and produce pain. The affected joints should be supported so that there is no excessive motion.

Medication. There is no drug that will cure arthritis. The health care provider does have a variety of medications that may be prescribed, depending on the needs and tolerance of the patient. It is important that the patient be advised of the expected results and possible undesirable side effects that may accompany ingestion of certain drugs. He or she should also be advised that therapeutic trials of several different drugs may be necessary. With this information at hand, he or she can work cooperatively with the physician in determining which drug or drugs can be most beneficial for treatment of the condition.

Aspirin was among the first drugs used to treat rheumatoid arthritis and remains a low-cost treatment option. It is a potent antiinflammatory agent when given at dosages that achieve a serum level of 20–30 mg/100 ml. For those prone to stomach upset or other gastrointestinal side effects from aspirin, enteric-coated tablets or antacid mixtures of aspirin are available.

Other nonaspirin, nonsteroidal antiinflammatory drugs (NSAIDs) include the indole derivatives indomethacin, sulindac, and tolmetin and the phenylalkanoic acid derivatives fenoprofen, ibuprofen, and naproxen. Nowadays NSAIDs are the most used group of medications for treatment of arthritis. They may provide more relief than aspirin for certain patients, but they also may have side effects related to the gastrointestinal and nervous systems. COX-2 (cyclooxygenase-2) inhibitors are the latest class of NSAIDs. They have fewer gastrointestinal side effects than other NSAIDs.

Cytotoxic agents may also be used; these drugs act as immunosuppressants and block the inflammatory process of the disease. methotrexate is the most common of these. The dosage for the management of rheumatoid arthritis is much lower than the dosages for malignancies; thus the associated side effects are fewer. gold compounds or penicillamine may be prescribed for selected patients who cannot tolerate or are not responding well to more conservative methods of treatment.

The corticosteroids may be used in treating rheumatoid arthritis, but they are not a substitute for other forms of treatment. In some cases these drugs produce side effects that are more difficult to treat than arthritis. They also may worsen certain features of the disease rather than relieve them. Drugs included in this group are cortisone, hydrocortisone, prednisone, prednisolone, and dexamethasone.

Another group of medications that reduce inflammation are the biological response modifiers. Members of this group used to treat arthritis include etanercept and infliximab.

Surgical Intervention and Orthopedic Devices. In the past, surgical intervention was reserved for patients who had already suffered severe joint deformity. There is presently a trend toward the use of surgery in the early stages of the disease so that deformities and serious mechanical abnormalities can be prevented or at least modified.

One surgical procedure employed is synovectomy (excision of the synovial membrane of a joint). The goal of this treatment is to interrupt the destructive inflammatory processes that eventually lead to ankylosis and invasion of surrounding cartilage and bone tissues.

Surgical repair of a hip joint (arthroplasty) may be performed when there is extensive damage and ambulation is not possible. The purpose of this procedure is to restore, improve, or maintain joint function. In cases in which it is not possible to restore the damaged hip joint there is a surgical procedure in which the diseased joint is completely replaced with a total hip prosthesis. The procedure is called a total hip replacement. A similar procedure involving total replacement of the knee can be done when there is extensive damage to the knee joint.

Braces, casts, or splints are sometimes used to immobilize the affected part so that it can rest during an active stage of the disease. Devices that immobilize the affected joint also may allow for motion of adjacent muscle, thereby improving muscle strength and permitting more independence on the part of the patient. Braces also may be used to prevent deformities by maintaining good position of the joints.

Patient Education. Unfortunately, arthritis is so widespread and such a crippling disease that its victims may be easy prey for charlatans and promoters of “miraculous cures.” The nature of the disease, with its unexplained remissions and relief of symptoms, makes it easy for unscrupulous individuals to convince the arthritic patient that some bizarre treatment they have used has indeed “cured” the arthritis. It is important that members of the health team recognize the need for patient education and work diligently with the patient and family so that they can cooperatively participate in a program of care that is most effective for the individual patient.

Home care is an essential part of the management of arthritis. To help in education of the public The Arthritis Foundation provides a number of pamphlets and other educational materials, supports a broad program of research and education, and helps finance improvement of local facilities for treatment of arthritis. The address of the foundation is The Arthritis Foundation, 1330 W. Peachtree St., Atlanta, GA 30309, telephone 404-872-7100.

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