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Rheumatoid Arthritis (RA)

Overview

Rheumatoid arthritis is an autoimmune disease in which your body’s immune system reacts abnormally against the synovial membrane lining your joints resulting in inflammation on both sides of your body. Most commonly, the wrist and small joints of the body are affected and appear red, swollen, tender, stiff, and deformed if not treated. The disease is lifelong and can affect other body organs like the skin, heart, lungs, and eyes.
The actual cause of the disease is still unknown, but a combination of genetic and environmental factors is thought to play a role. Environmental factors such as smoking, infection, and trauma can trigger a reaction in genetically susceptible patients.
The treatment aims to reduce pain and inflammation by giving analgesics, NSAIDs, etc., and slowing down the progression of the disease by giving disease-modifying agents like hydroxychloroquine and methotrexate.

Causes

The exact cause of the disease is unknown; however, it is thought to result from a combination of genetic and environmental factors. Your immune system is programmed to attack the bacteria, viruses foreign cells; however, in some people, triggers such as infection, smoking, trauma can disturb the immune system, which starts a series of inflammatory reactions and cause damage to the synovial lining of the joints. Once the damage is done, it cannot be reversed.

Epidemiology

Rheumatoid arthritis is the most common autoimmune inflammatory disorder. It is more common in Native Americans rather than Caribbean Americans. The peak age group is between 35- 50 years, affecting females more than males.

Risk Factors

Certain factors put you at high risk of inflammation.

  • Family history
  • Female gender
  • Being overweight
  • Smoking
  • Excessive use of caffeine, red meat, salts, and sugars

Signs And Symptoms

You may experience the following symptoms if you are suffering from the disease;

  • Red swollen, painful joints
  • Small joints of both hands are affected first, followed by wrists and larger joints( knees, elbows)
  • Stiffness of the joints that is severe in the morning and after rest
  • Movement limitation of the joints
  • Fever, fatigue, loss of appetite

These symptoms vary in severity and can sometimes remit or, at other times can flare up due to triggers. Other organs of the body can also be affected like

  • Skin: redness, rashes, nodules
  • Lungs: nodules, fibrosis
  • Heart: endocarditis (inflammation), fibrosis, increased risk of heart attacks, stroke
  • Eye: scleritis, episcleritis (inflammation of eyeball layers)
  • Nerves: neuropathy

Diagnosis

The diagnosis is made on clinical symptoms and physical examination. Other tests can be advised to complement the diagnosis.
The important features that support the diagnosis of RA are the symmetric involvement of small joints of hands and morning stiffness of more than one hour. Upon physical examination, your doctor may find swelling, tenderness (pain on the touch), nodules, some deformities of fingers, and the limitation of movement of the joints.
Blood tests: ESR and CRP tests may be advised, the increase of which points towards inflammation. Rheumatoid factor (inflammatory proteins) and CCP antibody test may also be performed.
Imaging tests: x-rays can show disease activity in the joints. MRI may be advised to check the severity of the disease.

Differential Diagnosis

Some other disorders can mimic the presentation of RA;

  • Osteoarthritis
  • Psoriatic arthritis
  • Sjogren's disease
  • Sarcoidosis
  • Systemic lupus erythematosus (SLE)

Treatment

Rheumatoid arthritis is managed by prescribing pain medicines that abolish the pain, anti-inflammatory medicines that stop the inflammation, disease-modifying agents that stop the progression of the disease. Along with these, you would be asked to adopt some lifestyle changes that will help you tackle the disease, like doing simple exercises, consuming anti-oxidant and omega 3 fatty-acids-rich food. Certain support groups and occupational therapy are also available.
Pain-relieving medicines: paracetamol, NSAIDs, celecoxib can be prescribed
Anti-inflammatory medicines: NSAIDs also reduce inflammation but have side effects. Steroids are used in low doses to control inflammation before the commencement of disease-modifying agents.
Disease-modifying agents (DMARDs): these are the group of agents that slows the progression of the disease, improve pain, prevent damage, and are now considered as the primary treatment which should be started as early as possible. They include methotrexate, sulfasalazine, hydroxychloroquine, TNF alpha inhibitors (infliximab, etanercept), monoclonal antibodies (rituximab)

Surgery

Depending upon your symptoms and joint destruction, your doctor may suggest some surgical therapies, especially if the joint is deformed or if other medical treatments are insufficient.
These surgeries include the following;

  • Synovectomy: the inflamed synovial lining around your joint is removed to reduce pain and improve joint movement.
  • Tenosynovectomy: the inflammation damages your tendons and synovium, which are removed in this surgery.
  • Tendon realignment: surgery can be done to realign your damaged tendons and lose their position and attachment with the joint to improve movement and flexibility.
  • Reconstructive surgery or arthroplasty: the whole joint can be reconstructed to improve function.
  • Arthrodesis: in this procedure, your joints may be fused to align them or relieve pain.

Prognosis

Rheumatoid arthritis is a lifelong disease. You may have remissions, but ultimately the disease will progress to disability. Early diagnosis and commencement of medicines favor an excellent outcome. Effects of the disease on the other organs like the heart also results in increased morbidity and mortality.
Lifestyle Changes
The disease progression and severity can be controlled by adopting some changes in lifestyle;

  • Gentle exercises can have a good impact on your joint mobility
  • Consuming foods rich in omega 3 fatty acids (walnuts, chia seeds, fish), anti-oxidants (berries, kidney beans, spinach)
  • Taking rest and applying cold/hot patches on inflamed joints
  • Splints and braces can be used to support the disabled joint

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