Spotlight on rheumatoid arthritis

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There are over 100 different types of arthritis affecting more than 4 million Canadians. While some types of arthritis are very rare, others are quite common; while several forms of arthritis have fairly mild symptoms, many can be painful, disabling, and even deadly.

Rheumatoid arthritis is an autoimmune disease with hallmark symptoms of inflammation and resulting pain. It is a disease process (like cancer or diabetes) where the body's immune system mistakenly attacks its own healthy joints. It is a relatively common disease-approximately 300,000 or 1 in 100 Canadians get it-and is often devastating to a person's body if not treated properly. The disease process causes swelling and pain in and around joints and can affect the body's organs, including the eyes, lungs, and heart. Rheumatoid arthritis most commonly affects the hands and feet. Other joints often affected include the elbows, shoulders, neck, jaw, ankles, knees, and hips. When moderate to severe, the disease reduces a person's life span by as much as a dozen years.

Interestingly, rheumatoid arthritis affects women two out of three times more often than men, and like many forms of inflammatory arthritis, it tends to strike people in the prime of their lives; most commonly, people are diagnosed between the ages of 20 and 50, though rheumatoid arthritis can strike at any time-people of every age from toddlers to senior citizens have been diagnosed with the disease.

Diagnosis of rheumatoid arthritis

Rheumatoid arthritis has several "hallmark" symptoms when the disease first presents itself. These include:
  • Morning stiffness, lasting longer than 30 minutes
  • Pain and/or inflammation in the same joints on both sides of your body
  • Pain in three or more joints at the same time
  • Loss of motion in affected joints
  • Severe fatigue

If you experience two or more of these symptoms you should speak with your family physician. Be sure to tell your doctor about any history of rheumatoid arthritis in your family. While there is no known cause of rheumatoid arthritis, research indicates that heredity likely plays a role in that a susceptibility to the disease may be inherited.

If your doctor believes you may have rheumatoid arthritis, you will usually be referred to a rheumatologist-a specialist in the treatment of arthritis. Rheumatologists have many years of extra training on top of their regular medical schooling, and are experts at diagnosing and treating all forms of arthritis, including rheumatoid arthritis.

To confirm a diagnosis of rheumatoid arthritis, a doctor may run a number of tests. These may include:
  • blood tests, including those to look for abnormal blood antibodies and to get baseline liver and blood counts
  • x-ray imaging, to check for joint damage or deterioration
  • bone scans are infrequently used but sometimes can help to check for joint inflammation
  • joint fluid tests, or arthrocentesis, in which a small amount of joint fluid is extracted using a needle and then analyzed in the laboratory

Treatment of rheumatoid arthritis

Once a rheumatologist has diagnosed rheumatoid arthritis, there are effective treatments available to help a person manage the symptoms and minimize joint damage. While there is no known cure for rheumatoid arthritis, good treatments now exist and rheumatologists are the best people to discuss these with and formulate a treatment plan to address all aspects of the disease.

Treating rheumatoid arthritis early and aggressively is vitally important and can help to prevent crippling joint damage. Today specialists recommend a treatment plan that includes education, medication-often a combination of several different types of medication will be used in a person's treatment plan-social support, appropriate amounts of range-of-motion, cardiovascular and muscle strengthening exercises, rest, vitamins and mineral supplements and a well-balanced diet.

Along with educating oneself about rheumatoid arthritis, medications are a cornerstone of a rheumatoid arthritis treatment plan. There are five major medication groups used to treat the disease. These are:
  • Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (for example Advil® or Motrin IB®), naproxen (or Naprosyn®), diclofenac (or Voltaren® and Arthrotec®)
  • COX-2 inhibitors, such as celecoxib (Celebrex®)
  • Corticosteroids, such as prednisone
  • Disease-modifying anti-rheumatic drugs (DMARDs) such as methotrexate, sulfasalazine, hydroxychloroquine, leflunomide and azathioprine
  • Biologic response modifiers (or "biologics"), including abatecpt (Orencia®), adalimumab (Humira®), anakinra (Kineret®), etanercept (Enbrel®), infliximab (Remicade ®), and rituximab (Rituxan®), all of which have been approved in Canada for use in treating rheumatoid arthritis.

These medications can work alone or in combination with one another. Today's "gold standard" of treatment looks like this:

Step 1:
A person with newly or recently diagnosed with moderate to severe rheumatoid arthritis is typically started on methotrexate, and possibly one or two other DMARDs in combination with methotrexate such as sulfasalazine and hydroxychloroquine (triple therapy). While waiting for the drugs to take effect, an NSAID or cox 2 inhibitor or in some cases prednisone, can be used to reduce inflammation quickly.

Step 2:
If a person does not respond, or does not respond well enough to the above combination therapy (which is to say their inflammation is not well controlled), then they would be considered a good candidate for a biologic response modifier medication (only one is used at any given time). They are usually used in combination with methotrexate.

This medication approach is very similar to that used to treat cancer. In cancer, aggressive medication therapy is used to stop or reduce the size of tumours or lesions. In rheumatoid arthritis, early and aggressive medication therapy is used to stop or markedly reduce inflammation-inflammation is the equivalent of a tumour.

Because people with active, moderate to severe rheumatoid arthritis are at high risk for irreparable joint damage caused by the disease's symptoms it is very important for them to closely follow their treatment regimen. It is this regimen that helps to prevent or reduce joint damage and disability and delivers the highest quality of life possible.

Exercise is also a very important component of a successful treatment plan in rheumatoid arthritis. Appropriate stretching and strengthening of muscles and tendons surrounding affected joints can help to keep them stronger and healthier and is effective at reducing pain and maintaining mobility. In addition, moderate forms of aerobic exercise can help to maintain a healthy body weight and lessens unnecessary strain on joints. Swimming, walking, and cycling are often recommended but they must be done at a level which safely "challenges" a person's aerobic capacity. A physiotherapist trained in rheumatoid arthritis is the ideal person to recommend a safe and effective exercise program for people living with the disease.

Heat and cold can be used to decrease pain and stiffness. Hot showers can often relax aching muscles and reduce pain; applying cold compresses-like ice packs-to swollen joints can help to reduce heat, pain and inflammation and allow a person to exercise more freely, or to recover from exercise more quickly.

Finally, maintaining a healthy lifestyle is also a critical part of a rheumatoid arthritis treatment plan. A nutritionally sound diet that includes appropriate levels of calcium, vitamin D and folic acid is important. Managing stress levels, getting appropriate amounts of rest, and good old-fashioned relaxation lead to a higher quality of life.