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
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
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
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.
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
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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