Rheumatoid Arthritis

Rheumatoid arthritis is a long-term condition where the immune system attacks the body’s own joints, causing pain, swelling and stiffness that can affect daily activities and quality of life.

Table of contents

• What is rheumatoid arthritis?
• What causes rheumatoid arthritis?
• Who is more likely to develop rheumatoid arthritis?
• Signs and symptoms
• The stages of rheumatoid arthritis
• How is rheumatoid arthritis diagnosed?
• Treatment options
• Living with rheumatoid arthritis
• Complications

What is rheumatoid arthritis?

Rheumatoid arthritis is an ongoing condition that causes pain, swelling and irritation in the joints^[1]. It is an autoimmune disease, which means the immune system, which normally fights infections, attacks the body’s own tissues by mistake^[4]. In rheumatoid arthritis, the immune system attacks the tissue lining the joints, called the synovium, causing inflammation and swelling^[2].

This condition most commonly affects the joints in the fingers, hands, wrists, knees, ankles, feet and toes^[3]. Unlike some other types of arthritis, rheumatoid arthritis usually occurs in the same joints on both sides of the body, such as both hands or both knees^[2].

Rheumatoid arthritis differs from osteoarthritis, which is a more common form of arthritis caused by wear and tear on joints over time. Osteoarthritis results from damage to joints from overuse, while rheumatoid arthritis affects the lining of the joints and eats away at the bone beneath them^[1].

When inflammation is not controlled, it can damage the cartilage, which normally acts as a shock absorber in the joints. Over time, this can cause joints to bend out of shape, and eventually the bone itself erodes. This can lead to permanent joint deformity^[1][3].

The inflammation from rheumatoid arthritis can also damage other parts of the body beyond the joints. These may include the skin, eyes, lungs, heart and blood vessels^[1][2].

• Joints (fingers, hands, wrists, knees, ankles, feet, toes)
• Synovium (joint lining)
• Cartilage
• Skin
• Eyes
• Lungs
• Heart
• Blood vessels

What causes rheumatoid arthritis?

The exact cause of rheumatoid arthritis is not known. In a healthy person, the immune system protects against illness by fighting off germs and other foreign substances. In rheumatoid arthritis, the immune system mistakes the body’s cells for foreign invaders and releases inflammatory chemicals that attack those cells^[2][6].

Researchers believe that people who develop rheumatoid arthritis may have certain genes that are activated by a trigger in the environment, such as a virus or bacteria, physical or emotional stress, or some other external factor^[2][8].

While the specific cause remains unclear, it is understood that rheumatoid arthritis is often caused by the interaction between genes and environmental factors, including tobacco use^[8].

Who is more likely to develop rheumatoid arthritis?

Rheumatoid arthritis can happen at any age, but it usually starts to develop between the ages of 30 and 60^[3][5]. Your chance of developing rheumatoid arthritis can increase based on several factors.

Women are two to three times more likely to develop rheumatoid arthritis than men. For unknown reasons, more women than men get the condition, and it usually develops in middle age^[2][5]. Women who have not given birth may have a greater risk^[6].

Having a family member with rheumatoid arthritis increases your odds of developing it. If a close relative, such as a parent, sibling or child, has the condition, you are more likely to develop it yourself^[2][6]. Certain genes can increase the risk, such as the human leukocyte antigen (HLA) class II gene^[6].

Smoking over a long period of time increases your risk of getting rheumatoid arthritis and can make the disease more serious^[4][6]. Smoking can also make arthritis worse and make it harder to be physically active, which is important for managing symptoms^[6].

Other factors that may be linked to rheumatoid arthritis include early life exposures. Children whose parents smoked were more likely to develop rheumatoid arthritis as adults. Adults from lower-income families may also have a higher risk^[6].

Signs and symptoms

Symptoms of rheumatoid arthritis may include painful, warm, swollen joints and joint stiffness that is most often worse in the mornings and after periods of rest^[1]. This morning stiffness can last for 45 minutes or longer, and sometimes more than 60 minutes^[1][3].

Many people also experience tiredness, fever and loss of appetite^[1][3]. Weakness is another common symptom. The joints may feel tender, swollen and warm, and moving them may be difficult^[2].

In the early stages, people with rheumatoid arthritis may not see redness or swelling in the joints, but they may experience tenderness and pain^[2]. Early signs include joint pain, tenderness, swelling or stiffness that lasts for six weeks or longer, and morning stiffness that lasts for 30 minutes or longer^[2].

More than one joint is typically affected, and small joints in the wrists, hands and feet are often affected first. The same joints on both sides of the body are usually involved^[2].

Rheumatoid arthritis affects everyone differently. In some people, symptoms develop over several years. In other people, symptoms progress rapidly. Many people have periods with symptoms, called flares, and then periods without any symptoms, called remission^[3][4]. A flare can be difficult to predict and may last for days or months^[2][4].

Rheumatoid arthritis can also cause problems in other parts of the body beyond the joints. These health effects may include dryness, pain, inflammation, redness and sensitivity to light in the eyes. The mouth may become dry with gum inflammation, irritation or infection. Small lumps called rheumatoid nodules may appear under the skin over bony areas^[2].

The lungs can be affected by inflammation and scarring that lead to shortness of breath and lung disease. Blood vessels may become inflamed, leading to damage in the nerves, skin and other organs^[2].

The stages of rheumatoid arthritis

Rheumatoid arthritis progresses through four stages. It may take many years to go through all stages, and some people do not progress through all of them^[3].

Stage 1: In early-stage rheumatoid arthritis, there is inflammation in the tissue around the joints. You may have some joint pain and stiffness. If X-rays are taken, they will not show destructive changes in the bones^[3].

Stage 2: The inflammation has begun to damage the cartilage in the joints. You might notice stiffness and a decreased range of motion^[3].

Stage 3: The inflammation is so severe that it damages the bones. You will have more pain, stiffness and even less range of motion than in stage 2. You may start to see physical changes^[3].

Stage 4: In this stage, the inflammation stops but the joints keep getting worse. You will have severe pain, swelling, stiffness and loss of mobility^[3].

How is rheumatoid arthritis diagnosed?

There is no single test to detect rheumatoid arthritis. The disease can be hard to diagnose in its early stages because early symptoms can be similar to those of other common conditions^[9]. Diagnosing rheumatoid arthritis requires a combination of approaches^[7].

During the physical exam, the healthcare professional checks the joints for swelling, redness and warmth. They may also check reflexes and muscle strength^[9].

Blood tests are used to look for signs of rheumatoid arthritis. People with the condition often have an elevated erythrocyte sedimentation rate (ESR), also called sed rate, or C-reactive protein (CRP) level. These tests may show a higher level of inflammation in the body^[9].

Other blood tests look for rheumatoid factor and anti-cyclic citrullinated peptide (anti-CCP) antibodies. Anti-CCP antibody elevation is more specific for rheumatoid arthritis^[9][14].

Imaging tests such as X-rays can help track rheumatoid arthritis in the joints over time. MRI scans and ultrasound tests may help with diagnosis and can show how severe the condition is^[9]. The first change on X-ray is often joint space narrowing, but bone erosions near the joint may develop early in the course of the disease^[14].

It is important to get diagnosed with rheumatoid arthritis as soon as possible so treatment can start. Healthcare professionals who specialize in arthritis, called rheumatologists, should diagnose and treat the condition^[6]. Early treatment helps prevent symptoms from getting worse and reduces damage to the joints^[6][14].

Treatment options

There is no cure for rheumatoid arthritis. However, early diagnosis and appropriate treatment enable many people with the condition to have periods of months or even years between flares^[4]. The goal of treatment is to reduce pain and swelling, slow or stop the progression of the disease, prevent joint damage, and improve physical function^[5][15].

Treatment of rheumatoid arthritis involves regular follow-up with the healthcare team to watch for joint damage, see whether treatment is working, and look for possible side effects^[9].

Medications

Medications are an essential part of treatment for most people with rheumatoid arthritis. The healthcare professional will suggest medicines based on how severe the symptoms are and how long the person has had the condition^[9][15].

Disease-modifying antirheumatic drugs (DMARDs) are usually the first treatment prescribed for rheumatoid arthritis. These medicines help slow the disease from getting worse and control joint swelling. Common DMARDs include methotrexate, leflunomide, hydroxychloroquine and sulfasalazine^[5][6]. Methotrexate is usually the first medicine given, often combined with another DMARD and a short course of steroids to relieve pain^[13].

Biologic drugs are genetically engineered proteins that target specific parts of the immune system that fuel inflammation. They are typically used if the disease does not respond to conventional DMARDs. Different biologics work in different ways in the body. Examples include abatacept, adalimumab, etanercept and tocilizumab. All are given by injection or infusion^[5][6][15].

JAK inhibitors are a newer class of drugs that work by blocking enzymes called Janus kinase, which play a role in the inflammatory and immune responses. These include tofacitinib, baricitinib and upadacitinib. They are taken orally^[5][13][15].

Nonsteroidal anti-inflammatory drugs (NSAIDs) can help relieve pain at low doses. At higher, prescription doses they can also help control inflammation^[9][15]. However, these drugs alone do not change the course of the disease or prevent joint destruction^[10].

Corticosteroids are potent anti-inflammatory medicines similar to cortisone that the body makes naturally. The doctor may prescribe oral corticosteroids to reduce inflammation that can damage joints and organs, usually while waiting for slower-acting disease-modifying drugs to take effect^[13][15].

Pain relievers such as acetaminophen can ease pain if a person is not able to take NSAIDs, but they will not reduce inflammation^[15].

Every medication comes with risks and possible side effects. It is important to ask the doctor about medication risks and what to do if side effects occur. No single treatment works for all patients, and many people may change their treatment at least once during their lifetime^[5][15].

Physical therapy and occupational therapy

Physical therapists can help keep people moving and show them exercises to do at home safely. They help build strength while avoiding overdoing it and triggering a flare^[17]. Occupational therapists show people ways to do specific tasks at home or at work, helping them adapt everyday activities to protect their joints^[17].

Surgery

Surgery may be needed to correct joint problems that develop, particularly if other treatments have not been effective^[9].

Living with rheumatoid arthritis

Rheumatoid arthritis is a long-term condition, but there are many things people can do on their own to manage it and improve their quality of life.

Take medications as prescribed

It is important to take medicine as instructed, even when starting to feel better. Medicine can help prevent flares and reduce the risk of further problems, such as joint damage^[18]. If medicines cause any side effects or problems, notify the doctor^[18].

Stay physically active

Regular exercise can help relieve pain and stiffness, boost muscle strength, keep joints mobile, and improve overall health^[17][18]. Exercise also reduces inflammation, strengthens bones, is good for the heart and lungs, improves mood and sleep, and helps with weight loss^[20].

Low-impact exercises such as walking, swimming, cycling and aqua-aerobics put less strain on joints^[18][22]. Slow, gentle exercises like Pilates, tai chi and yoga help boost balance and flexibility and may even ease pain^[17].

Most people should aim for at least 30 minutes of exercise a day on most days of the week. This can be broken up into shorter periods^[22]. If there is a lot of pain when exercising, stop and talk with the doctor or therapist before starting again^[17].

Maintain a healthy weight

Losing weight can be difficult, but fat cells release proteins that cause inflammation. This not only makes joint pain worse but also makes it less likely that medicine will work^[20]. Even a little weight loss can make a difference. Keeping a healthy weight reduces the load on joints and helps ease some of the pain^[24].

Eat a healthy diet

Although there is no specific diet for rheumatoid arthritis, eating healthy, well-balanced meals can be beneficial. A diet low in saturated fat and high in greens will help keep the heart healthy^[24]. An anti-inflammatory diet may also help improve pain^[17].

Stop smoking

Smoking can make symptoms of rheumatoid arthritis worse and remission less likely. It also makes it tough to stay active and increases the risk of other health problems that are common with the condition, especially heart disease^[20].

Get enough rest and sleep

Inflammation associated with rheumatoid arthritis can cause significant fatigue. If the disease is active, intermittent periods of rest during the day may be needed^[24]. Good sleep is also important, as poor sleep makes people more sensitive to pain^[20]. Avoid caffeine late in the day, limit screen time before bed, and exercise during the day to help improve sleep^[20].

Protect joints

Learning how to protect joints from further damage is an important part of living with rheumatoid arthritis. Respect pain and inflammation, as these are signals that the body needs to take it easier^[19][24].

Use larger joints when possible. For instance, push open a door with the shoulder instead of the hands. Avoid stressful positions, such as sitting in low chairs that can be hard to exit^[19]. Wrapping a joint with splints or braces can provide more stability and ease pain. If there is arthritis in the hip or knee, using a cane or walker can help unload some of the weight^[24].

Many assistive devices can make daily tasks easier. These include electrical appliances like can openers, padded handles for pots, pens and keys, larger door handles, and elevated seats^[19][24].

Manage stress

Stress can trigger flares and make symptoms worse. Finding ways to manage stress, such as through mindfulness, relaxation techniques or talking with a counselor, can help improve overall well-being^[20].

Attend regular checkups

Regular follow-up appointments with the healthcare team are important to monitor the disease, adjust medications, and prevent complications^[18][24].

Complications

Having rheumatoid arthritis can lead to several other conditions that may cause additional symptoms and can sometimes be life threatening^[4].

Possible complications include carpal tunnel syndrome and inflammation of other areas of the body, such as the lungs, heart and eyes. There is also an increased risk of heart attack and stroke^[4].

Making sure that rheumatoid arthritis is well controlled can help reduce the risk of these complications^[4]. New medicines have improved treatment choices greatly, but rheumatoid arthritis can still cause long-term damage and increase the risk of heart disease if left unaddressed^[1].