Many people tend to think of arthritis as a disease that affects older people. While it's true that most Americans living with arthritis are over age 50, arthritis is an equal-opportunity disease. Anybody can have arthritis. One of the most common types of arthritis is rheumatoid arthritis (RA). Like some other forms of arthritis, RA occurs more frequently in women than men. It often begins in middle age, with increased frequency in older people. Children and young adults also develop it.

  Unlike osteoarthritis, the "wear and tear" arthritis that results from the mechanical breakdown of joint cartilage, rheumatoid arthritis is an inflammatory disease that causes pain, swelling, stiffness and loss of joint function. It has several special features that separate it from other forms of arthritis. First, RA generally occurs in a symmetrical pattern (both knees, both hands, etc.). It affects the finger joints closest to the hand and the wrist rather than the ends of the fingers. People with RA can experience fatigue, occasional fever and general sense of not feeling well. Joints affected are tender, warm and swollen.

  RA affects different people in different ways. In one person it may last a few months or a year or two and go away without causing noticeable damage. Other people can experience mild or moderate disease with flares and remissions. Still others have severe disease that is active most of the time, which can lead to serious joint damage and disability.

  A normal joint is surrounded by a joint capsule that protects and supports it. Cartilage covers and cushions the ends of the two bones. The joint capsule is lined with a type of tissue called synovium, which produces synovial fluid. This clear fluid lubricates and nourishes the cartilage and bones inside the joint capsule. Since cartilage has no blood supply, if the cartilage becomes damaged it cannot heal itself.

Understanding the Inflammatory Process
  In progressive RA, destruction to the cartilage accelerates when the fluid and inflammatory cells accumulate in the synovium to produce a pannus -- a growth composed of thickened synovial tissue. The pannus produces more enzymes that destroy nearby cartilage, aggravating the area and attracting more inflammatory white cells, thereby perpetuating the process. This inflammatory process not only affects cartilage and bones but can also harm organs in other parts of the body.

  The inflammatory process is a byproduct of the body's immune system, which normally fights infection and heals wounds and injuries. When an injury or infection occurs, white blood cells are mobilized to rid the body of any foreign proteins, such as a virus. The masses of blood cells that gather at the injured or infected site cause the area to become inflamed. Under normal conditions, the inflammatory process is controlled and self-limited, but in people with chronic rheumatoid arthritis, this process keeps going.

  The primary infection-fighting units are two types of white blood cells - lymphocytes and leukocytes. Lymphocytes include two subtypes known as T-cells and B-cells. Normally, when a foreign agent infects the body, helper T-cells recognize that the invader, known as an antigen, is an alien and trigger a series of immune responses to destroy it. In RA, however, a process called autoimmunity occurs. The T-cells mistake the body's own collagen cells as foreign antigens and set off a series of events to rid the body of the perceived threat. Initial events include stimulation of lymphocyte B cells to produce antibodies -- molecules designed for attack on a specific antigen. When these antibodies attack the body's own tissue, they are called auto-antibodies.

  The leukocytes are the other major white blood cells that are spurred into action by the overactive T-cells. Leukocytes stimulate the production of two key players in the inflammatory process: leukotrienes, which attract even more white blood cells to the area, and prostaglandins, which open blood vessels and increase blood flow. As part of their activity, leukocytes also produce cytokines -- small proteins that many researchers believe are critical in the process that leads to joint damage and may even be responsible for inflammation that occurs in parts of the body beyond the joints. In small amounts, these powerful chemicals are important for healing. If overproduced, cytokines can cause serious damage, including fever, shock, and even damage to organs, such as the liver. Important cytokines in the process of rheumatoid arthritis are those known as tumor necrosis factor (TNF) and interleukins. Some cytokines play a role in releasing specific enzymes. One of the most important cytokines currently targeted in rheumatoid arthritis research is tumor necrosis factor. Levels of this cytokine soar in the synovial fluid during arthritic flare-ups.

  If this process continues, the abnormal synovial cells begin to destroy the cartilage and bone within the joint. The surrounding muscles, ligaments and tendons that support and stabilize the joint become weak and unable to work normally. This leads to the pain and deformity often seen with RA.

  Scientists who study RA now believe this damage begins during the first year or two that a person has the disease. That's why early diagnosis and aggressive treatment is so very important in the effective management of RA.

Diagnosing Rheumatoid Arthritis
  Diagnosing and treating rheumatoid arthritis is a team effort involving the patient and a variety of healthcare professionals. Patients can begin seeking help through your family doctor or a rheumatologist. A rheumatologist is a doctor who specializes in arthritis and other diseases of the joints, bones and muscles.

  RA can be difficult to diagnose in its early stages for several reasons. First, there is no single test for the disease. Second, symptoms differ in different people. Symptoms can mock other conditions. Finally, the full range of symptoms develops over time. As a result, doctors use a variety of tools to diagnose the disease and to rule out other conditions.

  You can help by describing your symptoms, when and how they began. Describe the pain, swelling and joint changes you are experiencing. The doctor will want to perform a physical examination of your joints, skin, reflexes and muscle strength. Your blood may be tested for rheumatoid factor (RF), an antibody that is eventually present in the blood of most RA patients. Not all people with RA test positive for RF, especially in the early stages of the disease.

  Other common blood tests done include two that indicate the presence of inflammation in the body, called erythrocyte sedimentation rate (sed rate or ESR) and C-reactive protein; a white blood cell count; and a blood test for anemia. X-rays can be used to determine the degree of joint destruction and monitor the disease on an ongoing basis.

Treatment Options
  Doctors use a variety of approaches to treat rheumatoid arthritis. These are used in different combinations and at different times during the course of the disease and are chosen according to the patient's individual situation. While it is important to control the pain and associated symptoms, it is critical that the disease itself be monitored and managed so long-term damage is kept to a minimum

  No matter what treatment plan the doctor and patient choose, the goals are the same: relieve pain, reduce inflammation, slow down or stop joint damage and improve the person's sense of well-being and ability to function.

Elements of a successful RA treatment plan

General Guidelines
  The treatment of rheumatoid arthritis involves medications and lifestyle changes. Many drugs are used for managing the pain and slowing the progression of rheumatoid arthritis, but no medical program has been found to cure the disease. The object of most drug therapies is to reduce inflammation, prevent damage to the bones and ligaments of the joint, preserve movement, and as free from side effects as possible over the long term.

  Until recently, physicians had recommended a "pyramidal approach" for treating people diagnosed with rheumatoid arthritis, using the least powerful drugs first to avoid toxic effects, then building up to stronger and stronger drugs until the disease was under control. The first drugs used against rheumatoid arthritis were usually nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDS have not been shown to slow or halt the course of the disease. These drugs relieve pain by reducing inflammation, but do not contain steroids. In the past, if NSAIDs were still not effective after about four to six weeks, more potent drugs, disease modifying anti-rheumatic drugs (DMARDs) were added to the regimen. Such drugs are more effective than NSAIDs and may even improve long-term function. Some DMARDS have been shown to slow and halt the progression of the disease.

  However, the problem with this pyramidal approach is its failure to prevent the progression of joint destruction in the majority of people with RA. Working through the pyramid, drug by drug, generally takes 5 to 8 years. Much of the damage in rheumatoid arthritis occurs in the first two years when only the drugs used are those that control symptoms or no drugs are used at all.

  Many experts are now recommending that patients with moderate to severe RA should start out immediately with DMARDs, with or without NSAIDs, or start DMARDs after three months if NSAIDs have not relieved symptoms. Indicators for prompt and aggressive treatment with DMARDs include slow progression, involvement in parts of the body other than joints, high levels of rheumatoid factor, and genetic markers. All of these drugs have potentially toxic side effects. Certain factors that might warrant against the aggressive approach include male gender, older age, lack of genetic markers, and an acute onset of the disease.

  Now, let's look at medications and specific areas of lifestyle change-

  Medications-As already stated, the use of medication is aimed at reducing pain and slowing or halting the disease process.

  Non-steroidal anti-inflammatories. Two-thirds of people with RA seek professional help for pain. The most common pain relievers are non-steroidal anti-inflammatory medications. There are dozens of NSAIDS and some are safer than others. NSAIDS do not alter the course of the disease but are designed to reduce inflammation and pain. These drugs block prostaglandins, the substances that dilate blood vessels resulting in inflammation and pain. Pain and stiffness from RA increase gradually during the night, reach their greatest severity at the time of awakening. It's important to take your dose, if singular, in the evening or, if twice daily, morning and evening. All NSAIDS are capable of damaging the mucous layer and causing ulcers and gastrointestinal (GI) bleeding when taken for long periods. Other side effects include dizziness, ringing in the ears, headache and skin rash. If you experience new swelling and rapid gain when using an NSAID, report it immediately to your doctor. People with hypertension, severe vascular disease, kidney or liver problems and those taking diuretics must be closely monitored if they need to take NSAIDS.

  The newer Cox-2 inhibitor medications, celecoxib (Celebrex) and rofecoxib (Vioxx) are generally safer and easier on the stomach. However, these two medications are no more effective than other NSAIDS.

  Disease-Modifying Anti-Rheumatic Drugs (DMARDs) are designed to slow down the progression of rheumatoid arthritis. Studies show that these drugs significantly delay the long-term damage and joint deformities associated with RA. Methotrexate has the best record for long-term use. Leflunomide (Arava) is the first new DMARD approved in over 10 years. Studies indicate that it reduces symptoms, possibly better than methotrexate, and may even slow progression of RA.

  Biologic Response Modifiers are drugs that interfere with the autoimmune response in RA. These drugs are genetically engineered to target the immune factors, particularly tumor necrosis factor (TNF) and certain interleukins, which play a major role in the destructive RA process.

  Etanercept. Recent studies show etanercept (Enbrel) neutralizes TNF and has reduced joint pain in more than 80% of patients, many of whom could not tolerate or were unresponsive to standard medications. Enbrel inhibits joint destruction/erosions. Enbrel also has an FDA indication for juvenile rheumatoid arthritis and psoriatic arthritis. Route of administration is self-administered by subcutaneous injection, similar to a diabetic patient giving insulin.

  Other Biologic Response Modifiers are also showing promise. Infliximab (Remicade) approved for Crohn's disease can also reduce symptoms of RA and inhibits joint erosions. Prior to receiving Remicade, patients are tested for people who could be exposed to tuberculosis. Route of administration is an in-office intravenous infusion.

  Although some people with RA would prefer to stay off these types of medications, it is critical to understand that these drugs are the mainstay of a long-term quality lifestyle.
  Rest and Exercise-Both are important. Rest more when the disease is active, and exercise more when you are feeling well. Rest helps reduce active joint inflammation and pain, and fights fatigue. The need for rest varies from person to person, but in general shorter rest breaks every now and then are more helpful than long periods of best rest.

  The goal of exercise is to maintain a wide range of motion, increase strength, endurance, and mobility, improve general health, and promote well-being. A patient should begin with the easiest exercises -- stretching and tensing of the joints without movement -- and then slowly progress to more difficult kinds. The patient can next attempt mild strength training. Aerobic exercises (walking, dancing or swimming-particularly in heated pools). T'ai chi, which uses graceful slow sweeping movements, is an excellent method for combining stretching and range-of-motion exercises with relaxation techniques. People with RA should avoid heavy impact exercises such as running, downhill skiing, and jumping. Common sense is your guide; if exercise is causing sharp pain, stop immediately. If lesser aches and pains continue for more than a hour or two, then a lighter exercise program should be tried for awhile.

  Exercise is important for maintaining healthy and strong muscles, preserving joint mobility and maintaining flexibility. To simply reduce pain will not return function.

  Joint Protection-You can reduce stress to joints by discovering new ways of doing old tasks. Zipper pullers, long-handled shoe horns, thick-handled brushes, and devices to help with getting on and off chairs, toilet seats and beds are examples of things that help protect joints. Sometimes people find that using a splint for a short time for a painful joint reduces pain and swelling as well.

  Healthful Diet-A nutritious diet with the proper amount of calories, protein and calcium is important.

  Surgery-Several surgical procedures are available to people who have severely damaged joint(s). They can reduce or eliminate pain, improve joint function and appearance, and improve lifestyle. Joint replacement surgery is the most frequently performed for RA. Tendon reconstruction is done when RA causes damage to tendons. This procedure is most often done on the hands. Synovectomy is another procedure sometimes done when its necessary to reduce inflamed synovial tissue around a joint. Synovectomy is commonly performed as part of a reconstructive procedure, especially tendon reconstruction. Total joint replacement is performed when a particular joint is damaged so severely that the joint needs to be reconstructed with artificial parts to restore normal joint movement without pain.

Keeping a Positive Attitude
  People with RA often have a hard time coming to grips with the fact that their lifestyle must be rearranged to accommodate their disease, that they can't always do the things they used to. It can be a difficult adjustment, particularly for people in the prime of life, with children and jobs to manage. Lifting your child or tying your shoes suddenly becomes difficult or impossible.

  Fear, anger and frustration combined with pain and physical limitations can increase stress, and make living with RA more difficult. Regular rest, relaxation and visualization exercises do help. Exercise, warm baths, music, support groups, taking time for yourself and good communication with your healthcare team will also reduce stress. Learn to let little things go, and don't feel you have to do everything.

  Studies continue to show that people who learn about living with RA and participate actively in their own care experience less pain and make fewer visits to the doctors than do other people with RA. People who are actively involved understand more about the disease process, utilize many methods to reduce pain, learn coping skills and have a greater sense of control over their disease.

  While there is no cure for rheumatoid arthritis, we do know that people with a certain gene are susceptible to the disease, and researchers are honing in on what triggers it. For now, we can take charge of RA and take comfort in the knowledge that medicine has made great strides in its ability to effectively treat RA before it causes serious damage.

About the author:
Jan Revella, R.N., arthritis nurse specialist, is founder and director of Arthritis Education by Professionals, Inc., based in Phoenix, Arizona. She is among the most prominent speakers and educators on the subject of arthritis in the United States. Her mission is to empower people with arthritis to use knowledge as power when making decisions about their personal healthcare. Arthritis Education by Professionals, Inc. provides educational programs and services to people with arthritis.

© Copyright 2005. Arthritis Education by Professionals, Inc.