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Treating rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic degenerative inflammatory disease of the joints. More than two million Americans have the condition; about 70% of them are women. The causes of RA are unknown, and no cure is in sight. However, medical science has made striking progress in treating the condition.

Rheumatoid arthritis causes the affected joints to feel warm, swollen, and tender. They may be stiff after waking in the morning and ache after periods of rest. Rheumatoid arthritis often strikes the wrists and the upper part of the fingers. The neck, shoulders, hips, knees, ankles, and feet may also be affected.

Rheumatoid arthritis can also attack tissues beyond the joints, causing further symptoms. Fatigue and fever are common. Lymph nodes may swell. Some people develop nodules (lumps of tissue) beneath the skin near the joints, or in bony areas often exposed to pressure, such as the elbow and the forearm. In about 40% of RA cases, the pericardium — the tissue sac that encircles the heart — becomes inflamed. Inflammation may also occur in the lining of the lungs (pleuritis) or in the tear ducts and salivary glands, resulting in dry eyes and mouth. Some people develop anemia (a low red blood cell count).

The course of the disease is varied and unpredictable. For some women, symptoms come and go over a few months and then disappear without noticeable damage. Others have moderate symptoms for a lifetime, with phases where severe symptoms, called flares, alternate with remissions. Still others have severe disease that continues for decades and causes debilitating joint damage. Mounting evidence suggests that infectious agents, such as viruses or bacteria, may unleash the disease in genetically susceptible people.

The diagnostic process may involve a variety of blood tests, including erythrocyte sedimentation rate (a general measure of inflammation), a complete blood count, and a test for rheumatoid factor — an antibody found in the blood of most people who have rheumatoid arthritis.

Anatomy of rheumatoid arthritis

Joints are surrounded by a capsule lined with a membrane called synovium. Synovium produces a fluid that fills the capsule, lubricating the joint and nourishing the cartilage and bones inside the capsule. In rheumatoid arthritis, the immune system, which normally protects the body from infection and disease, attacks tissues within the joint capsule.

White blood cells migrate to the synovium and cause inflammation. Inflamed joints become warm, swollen, red, and painful. The synovium thickens, and enzymes released by inflammatory cells destroy cartilage and bone. The joints become enlarged and lose their normal range of motion.

Treating rheumatoid arthritis

A combination of medications and nondrug therapies is used to relieve pain, control inflammation, slow or stop joint damage, and improve overall function.

In the past, physicians prescribed medications conservatively. But many experts are taking a more aggressive approach, treating RA early with powerful drugs and using drug combinations rather than a single medication. There are several reasons for this. Studies have shown a link between ongoing RA inflammation and an increased rate of death and illness. Also, more effective therapeutic drugs have become available, and it has been shown that drug combinations can improve long-term outcomes. For women whose joint damage is severe and a source of constant pain, surgery may be the best option. Artificial joints and procedures to reconstruct tendons can restore function and dramatically improve quality of life.

Treating pain and inflammation

Three classes of drugs help relieve RA symptoms, though they cannot alter the course of the disease.

Analgesics. Acetaminophen (Tylenol, others) and prescription analgesics relieve pain but have little or no effect on inflammation. They may help during a flare.

Anti-inflammatory drugs. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Motrin), naproxen (Aleve), and aspirin reduce inflammation and relieve pain, but they all can have side effects on the stomach. The NSAIDs known as COX-2 inhibitors appear to have fewer such side effects for some. But COX-2 inhibitors, as a group, are undergoing review after Vioxx was withdrawn from the market for increasing stroke and heart attack risk.

Steroids. Prednisone and related steroids reduce inflammation by suppressing the immune system. They provide rapid, dramatic relief, but don’t change the course of the disease. Over time, they may produce many adverse effects, so they’re usually prescribed at the lowest dose possible for the shortest period of time.

Heading off joint damage

Drugs that actually alter the course of rheumatoid arthritis show promise in reducing long-term disability.

Disease-modifying antirheumatic drugs (DMARDs). Most people with rheumatoid arthritis will take a DMARD, usually methotrexate, as early as possible to reduce or prevent joint damage. These drugs take weeks or months to begin working and must be carefully monitored to prevent serious side effects. A DMARD may be given along with a steroid. The steroid is then gradually withdrawn when the DMARD begins to take effect.

Biological response modifiers (BRMs). This group of injected drugs works by interfering with substances that trigger inflammation as part of the body’s normal immune response. Biological response modifiers include etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira), and anakinra (Kineret). These drugs can interfere with the ability to fight infection and long-term effects are not fully known.

Protein-A immunoadsorption. This treatment filters the blood, trapping immune substances and removing them. The FDA has approved it for treating people with RA who don’t respond to or can’t tolerate other therapies.

Nondrug approaches

To live successfully with rheumatoid arthritis, learning to manage symptoms is essential — especially when and how to exercise and rest. Resting an inflamed joint reduces the inflammation, but prolonged inactivity can result in muscle weakness and loss of joint motion. Exercise also helps to prevent osteoporosis — a condition that’s more likely to occur in women who have rheumatoid arthritis.

Some complementary approaches, such as certain fish and plant oils and certain supplements, have shown promise in expanding nondrug treatment options. However, their safety and effectiveness are not proven. It's best to consult a clinician before trying any of these complementary therapies.

Other nondrug approaches can help. An occupational therapist can be very helpful in helping those with rheumatoid arthritis protect joints during daily activities and in recommending devices that make it easier to eat, write, lift objects, and do other chores.

March 2005 Update

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