Like many autoimmune diseases, the precise causes of rheumatoid arthritis (RA) are still not fully understood, although existing research points to a combination of genetic and environmental factors.
The first traces of rheumatoid arthritis in archaeological records date back to at least 4,500BC, although the disease was extremely rare in Europe prior to the 17th Century.
RA primarily affects the joints – in particular the hands and fingers – and causes swelling in the synovial membrane, and pain which can develop slowly over a period of weeks or months. Inflammation and swelling can also occur around the lungs and heart, and the condition may lead to fever and low energy levels.
There are other autoimmune conditions which may present similar symptoms, such as systemic lupus erythematosus,psoriatic arthritis, and fibromyalgia – and so whilst diagnosis is usually based on a patient’s symptoms, further tests and x-rays may be used to rule out these other possibilities.
Also in common with other autoimmune diseases, rheumatoid arthritis is classified as being incurable. For this reason, treatments are focused on reducing pain and discomfort and improving the patient’s general quality of life.
Signs and Symptoms
Rheumatoid arthritis is a condition which primarily affects the joints. However, 20-25% of patients may also experience symptoms in other organs.
Swelling and painful inflammation of the joints occurs more often in the morning and last for more than an hour, and can also occur after periods of rest or inactivity. The time and duration of the discomfort can help to differentiate rheumatoid arthritis from other forms such as osteoarthritis.
Typically, the symptoms occur symmetrically (affecting both sides of the body equally) although this is not always the case and symptoms may develop asymmetrically. As the condition advances, the inflammation can lead to damage to both cartilage and bone in the joints, resulting in a loss of mobility and movement, as well as further pain and discomfort. This damage to the cartilage and bone may also result in deformity of the joints, particularly in the fingers.
As well as issues with joints, around 30% of patients experience what is known as the ‘rheumatoid node’. the most common non-joint symptom. It is a kind of inflammatory reaction which occurs in the skin, usually over bony areas such as the elbow, heel and knuckles. Other, less common, skin associated symptoms include pyoderma gangrenosum, Sweet’s syndrome, drug reactions, erythema nodosum, lobe panniculitis, atrophy of finger skin, palmar erythema, diffuse thinning (rice paper skin), and skin fragility.
Fibrosis of the lungs is commonly associated with rheumatoid arthritis. In studies in the USA, approximately 25% of RA patients also developed rheumatoid lung disease.
In addition, rheumatoid arthritis can cause complications in the kidneys (such as renal amyloidosis) and in the heart and blood vessels. In some cases these associated conditions are a result not of the arthritis itself but a reaction to treatment. Anti-inflammatory drugs in particular can have an impact on blood vessels and doctors need to consider this when prescribing treatments.
Current research suggests that genetics account for approximately half of the known causes of rheumatoid arthritis (although as mentioned earlier, the causes are not yet fully understood).
Of the known non-genetic causes, smoking is believed to be the most significant, with rheumatoid arthritis being up to three times more common in smokers.
It has also been observed that a deficiency in Vitamin D is more common among rheumatoid arthritis patients than the general population – although it is unclear whether this deficiency is a cause or result of the disease.
There is no evidence as yet to suggest that rheumatoid arthritis is hereditary.
Treatment and Management
As yet, there is no cure for rheumatoid arthritis, and so treatment is based on managing and alleviating symptoms.
The primary treatment is known as Disease Modifying Anti Rheumatic Drugs (DMARDs). This collection of drugs has been shown to cause remission of rheumatoid arthritis in up to 50% of patients when started early and they are generally found to reduce symptoms, decrease joint damage and reduce pain and discomfort. DMARDs include methotrexate,hydroxychloroquine, sulfasalazine, leflunomide, TNF-alpha inhibitors (certolizumab, infliximab and etanercept), abatacept, and anakinra.
Other anti-inflammatory agents can also be prescribed to rheumatoid arthritis patients, although these must be used with caution in the presence of other conditions such as gastrointestinal, cardiovascular or kidney problems.
In the early stages of rheumatoid arthritis surgery can be an option, removing the inflamed synovia. In later stages, joint replacement surgery may become necessary.
In addition to medical treatment, lifestyle measures such as taking regular gentle exercise and receiving occupational therapy have been demonstrated to reduce the symptoms and advancement of rheumatoid arthritis. There is as yet no evidence that dietary measures have an impact although research is continuing in this area.
Facts and Figures
● Named in 1859 by English rheumatologist Dr Alfred Baring Garrod
● Affects between 0.5 – 1% of adults in the developed world
● Approximately 25 new cases per 100,000 population per year
● Rarely seen in those under 15 years of age
● Most commonly begins between 40 – 50 years of age
Like many other autoimmune diseases there is no known cure for rheumatoid arthritis. However, advances in medicine and continuing research are uncovering ways to manage and treat the symptoms. In addition, it is possible to ‘self-manage’ to a good degree by making appropriate lifestyle choices.