RHEUMATOID ARTHRITIS (RA)
WHAT
The language of medicine can be complicated and at times confusing. This section lays out in plain and simple English the basics of these conditions. As far as possible, technical terms and medical language is minimised or explained. What is the basic starting point for each of the conditions. What is the literal translation of the diagnostic label? What does this mean and what are the key symptoms of the disease?
Rheumatoid Arthritis (RA) is the name given to one of the most common forms of inflammatory arthritis. This is a disorder of the immune system that leads to inflammation “itis” of the joints “arth”. The disease mainly attacks synovial tissue – this is the lining encircling joints. If left untreated, this has the risk of damaging the joint structure because of the immune systems attack on the joint structures. The immune system is a very capable defence mechanism capable of clearing harmful foreign substances like viruses and bacteria. In “auto-immune” conditions like rheumatoid arthritis, your immune system mistakenly targets your own body, thus inflicting damage on otherwise healthy cellular structures.
WHO
The next section is who, the scientific word for this is the epidemiology of the condition. Epidemiology refers to the study of patterns and trends associated with diseases or injuries within a population. In other words, how common is the condition, what age range is affected? Are men and women affected equally? Does the frequency of the illness depend on what part of the world I live in? In other words, who is more likely to suffer from this condition.
Rheumatoid arthritis can affect anyone from the age of 16 onward. Inflammation of the joints in childhood is called Juvenile Idiopathic Arthritis (JIA), although some subtypes of this are remarkably similar to rheumatoid arthritis and may even share common antibody abnormalities. It affects around 1% of the UK population, this means around half a million people are living with rheumatoid arthritis. The condition is more common in women, who are two to three times more likely to develop the condition than men. Although you can be diagnosed with rheumatoid arthritis at any age, the most common age is between 40 and 60, a second peak is noted in older adults.
WHY
Why has this condition affected me, and what is happening in my body that is causing it? We can break this down into two parts: aetiology (which is the study of what might be causing the condition) and pathophysiology (which is about what is happening in the body as the disease progresses). Scientists are still studying these areas, and we don’t have all the answers yet. This section will provide a simple summary of what we do know, without all the complex medical terms.
A great deal of work has been done to try and unlock the secrets behind why people develop rheumatoid arthritis. A good number of questions have been answered in this area; however the exact cause is still not fully understood. We each have a unique genetic makeup. Even identical twins, who share the same DNA, experience some changes in their genetics (epigenetics) that can lead to differences. Multiple areas of genetics have been studies in auto-immune disease, especially the genes that underpin some of the functions of the immune system, one of these areas is called the “HLA” gene. Because the risk of rheumatoid arthritis is higher in women, hormones and how these affect the immune system may have a role in developing rheumatoid arthritis. Being overweight or obese also increases the risk of developing rheumatoid arthritis. Lifestyle can also have an important influence, this can include the diet we eat (from foods believed to be “pro-inflammatory” to deficiencies in vitamins like vitamin C) to our habits, in particular toxins like smoking. Other factors that might trigger our underlying genetic vulnerability include infections or even environmental factors like air pollution. Once one of these triggers has activated the underlying vulnerability for rheumatoid arthritis, a whole series of changes take place within the immune system.
HOW
The how section answers more practical questions. This discusses what the next steps are in getting towards a diagnosis. If you have been suffering from the symptoms of a rheumatic condition, you will ultimately need to be reviewed by an appropriate specialist and will likely require some form of further investigation to help confirm or refute a particular diagnosis. This section lays out the typical medical work up you can expect for any given condition.
If you think you may be suffering from rheumatoid arthritis, it is important to seek medical attention without delay. In the UK the diagnosis is usually confirmed by a specialist rheumatologist, but you will usually need a referral from your local General Practitioner (GP) unless you choose to be seen privately. If your GP feels the overall clinical picture is suggestive of rheumatoid arthritis, they will likely make an urgent referral to be reviewed. If your GP feels an inflammatory arthritis is possible but not evident (or they would like reassurance in ruling our rheumatoid arthritis) they are likely to refer you routinely for an assessment. Making a diagnosis of RA involves a combination of a patient’s history, physical examination, and laboratory tests. When meeting with a rheumatologist, obtaining the history involves asking questions about the symptoms, such as joint pain, stiffness, swelling, and fatigue, and how long they have been going on. Other areas explored include any family history of medical conditions, past medical problems and any medication use.
The next stage is a physical examination. Although particular focus will be paid to look for joint inflammation, deformities, and other signs, it is common to have a broad assessment of other organ systems as well. In some cases, the rheumatologist may use bedside tests such as an ultrasound to look into the joints. Once you have been assessed in the clinic, further investigations are likely to be requested (if these have not already been performed when the GP made the initial referral). These include blood tests such as rheumatoid factor (RF) (positive in about 70-80% of patients with RA) and anti-cyclic citrullinated peptide (anti-CCP) antibodies with is more specific for RA. Markers of inflammation are also tested for often including an elevated erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP).
Imaging studies such as X-rays, ultrasound, or MRI may be ordered to detect joint damage and inflammation. X-rays may show joint erosions or holes, which are a sign of damage more commonly seen in long-standing RA. The benefit of ultrasound and MRI imaging is that they can detect early joint inflammation and swelling. In rare instances, or if participating in some research studies, novel technologies may be used to aid the diagnosis, or you may be offered a synovial biopsy. This involves taking a small sample of the joint lining for further examination under a microscope.
The combination of these together helps not only to confirm if you are suffering from rheumatoid arthritis but also to get an idea of your outlook or prognosis. For example, if you present with very high antibodies, both antibodies and damage in the bones on X-ray at an early stage of your RA, you are likely to have a more aggressive variant that requires more rapid escalation of your treatment.
WHAT NOW
Having now gained some better understanding of the condition; you now hopefully have a number of crucial questions on the background of the disease answered. The “What now” section outlines the road ahead. This includes an overview of the most common interventions that are likely to be considered for this including common medications and non-drug therapies. The list is not exhaustive and not all options listed are appropriate for every patient. What now also seeks to provide you a list of valuable additional resources where you can learn even more and get local and online support for your condition.
The first thing that should happen at the initial rheumatology appointment is a brief explanation. This may include information on whether the diagnosis is definite or being considered a possibility at this stage (in which case the clinician will usually outline what additional steps and tests are needed to confirm this). If this diagnosis is clear, it is important to obtain some disease education. Unfortunately, there is rarely enough time with the rheumatologist to cover this stage in sufficient detail, however supporting material (leaflets and web resources) is often given and you may be referred to a specific education programme to better understand rheumatoid arthritis. This can help explain in more detail the nature of the disease, its potential complications, and the importance of compliance with treatment to control the symptoms.
Treatment with medications is required in most cases unless your arthritis happens to enter remission. You may well have already trialled over the counter medication such as nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen. Corticosteroids (often referred to as just “steroids”) are a rapid acting treatment. They can be given as tablets or as an injection and sometimes as an infusion. The injection may be given into a joint when only one or two areas are affected, however if you have multiple inflamed joints then this might be given into the muscle – typically into a big muscle in the buttocks (bum).
Although steroids are rapidly effective, they have numerous long-term consequences. A better and more tailored treatment for rheumatoid arthritis is disease-modifying antirheumatic drugs (DMARDs) like methotrexate. DMARDs can be given as single agents or in combinations of several drugs. If your arthritis is still not well controlled with DMARDs, you may require so called “targeted therapies”. These include targeted biologic DMARDs (such as TNF inhibitors) and targeted small-molecule medications (like JAK inhibitors). While the rheumatologist will lead on your care, additional support may be required from a number of different medical specialties or from different disciplines within the specialty of rheumatology. You may need a referral to an occupational therapist or a physical therapist or require support from other areas from clinical psychology to orthopaedic surgery. Therapy services like occupational therapy and physical therapy may be helpful in managing symptoms, maintaining joint function, and improving quality of life. These therapies may include exercise programs, joint protection techniques, and assistive devices such as splints or braces.
Although you may be offered a wide variety of support from different departments after being diagnosed with rheumatoid arthritis, the hard work is ultimately born by the patients with rheumatoid arthritis themselves. It is very important to consider lifestyle modifications and what you can do to assist your clinical team in managing your health. Lifestyle changes, such as adopting a healthy diet and exercise routine, are important but quitting smoking is especially critical as this is likely to make your arthritis more aggressive and challenging to manage. Although being newly diagnosed with a chronic condition can feel like being caught up in a storm at times, it is important to realise you are not alone. A number of supporting agencies and societies exist that can provide invaluable support wherever you are based. Some links are provided below.
FURTHER LINKS
