Rheumatoid Arthritis (RA)

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Rheumatoid Arthritis (RA)

What is rheumatoid arthritis?

Rheumatoid arthritis is a serious autoimmune and inflammatory arthritis that, if treated early, is quite manageable for those impacted by the disease. Rheumatoid arthritis is a complex, chronic condition that mostly affects smaller joints in the body. RA inflammation causes pain, stiffness, and swelling to the affected joints and can also involve other organs such as the eyes, heart, lungs, blood and nerves.

Who can develop rheumatoid arthritis?

Rheumatoid arthritis is the most common autoimmune arthritis affecting over 1.5 million Americans.Women tend to develop the illness more than men, representing 3 out of 4 people suffering from this illness. This type of arthritis can occur at any age but is more commonly seen in middle-aged (30 - 50) adults.

Where does rheumatoid arthritis occur?

This symmetric, autoimmune arthritis mostly affects smaller joints initially: the hands, wrists, feet, ankles, and if severe can also involve larger joints like the elbows and knees.

Causes

What is the cause of rheumatoid arthritis?

The exact cause of rheumatoid arthritis is not well understood at this time. Research shows that it develops due to your body’s immune system accidentally sending messages to your body to produce inflammation in healthy tissues, instead of to bacteria or viruses, that it normally does. This is why it is called an autoimmune disease because the body’s immune system is attacking itself. The inflammation made by your body affects the synovial lining of joints causing swelling, permanent joint damage and chronic pain. The chronic inflammation also increases a person’s risk for heart disease, infections and certain types of cancer (lymphoma) as the immune system is not doing what it should be, protecting the body. 

What risk factors are there for developing rheumatoid arthritis?

There are many risk factors associated with developing rheumatoid arthritis. They include:

  • Gender - Women are affected (3-4) times more commonly than men.
  • Genetics- People with a family history of rheumatoid arthritis may also develop this condition. Research is also detecting if certain genes place people at higher risk of developing this disease, particularly after certain triggers in the environment. Some triggers of concern include:
  1. Bacteria
  2. Viruses
  3. Stress
  • Age- Rheumatoid arthritis can occur at any time, however most develop RA in their 30s - 50s, the most “productive” time in one’s life. 
  • Smoking- There is STRONG evidence that smoking increases someone’s chances of developing this autoimmune arthritis and may make symptoms worse.
  • Motherhood-  People who have never birthed a child have been linked to having a higher chance of developing rheumatoid arthritis. 
  • Weight gain- Obesity has also been shown to increase a person’s chance of developing rheumatoid arthritis.

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Symptoms

What are the symptoms of rheumatoid arthritis?

One of the more specific signs and symptoms for rheumatoid arthritis is morning stiffness that can last for more than 30 minutes. In fact, morning stiffness is one of the hallmark indicators that someone may have rheumatoid arthritis. Extended morning stiffness is rarely seen in other arthritic conditions such as osteoarthritis. Other examples of rheumatoid arthritis symptoms include:

  • Firm masses, known as rheumatoid nodules, near the elbows
  • Low-grade fevers
  • Loss of appetite
  • Fatigue
  • Swelling of joints (hands & feet) which makes shaking hands uncomfortable
  • Dry mucous membranes (eyes and mouth) known as Sjorgen’s syndrome
  • Restriction of joint movement (usually in smaller joints)
  • Pain
  • Redness
  • Multiple joints affected on both sides
  • Joint deformity
  • Weakness
  • Warmth

Can serious health problems arise from rheumatoid arthritis?

Rheumatoid arthritis may cause serious complications to organs such as the lungs, heart, and blood vessels. This chronic inflammation may cause the lungs to scar resulting in shortness of breath and damage of the muscles in the heart. Other medical conditions can arise, such as diabetes, high cholesterol, and heart disease due to the inability to exercise from the chronic pain impacting joints. Unemployment is also an issue with rheumatoid arthritis regarding highly physical jobs as the disease may progress, causing limitations in activity level.

Are there any tools to help me track my symptoms? 

YES - there are various tools to help you keep track of your symptoms. For example, an application called Arthritis Power can track your health information to help you better understand any changes in your health. The application can also be customized to your needs.

Diagnosis

Who usually diagnoses rheumatoid arthritis?  

Proper diagnosis of rheumatoid arthritis is made by a licensed medical professional. It can be tricky to diagnose this autoimmune arthritis, especially during the initial development. A rheumatologist may be the most qualified specialist for the diagnosis and treatment of this condition. 

How is rheumatoid arthritis diagnosed?

A thorough medical history is performed to determine if there are any family members also suffering from rheumatoid arthritis or other autoimmune conditions. The symptoms one may be experiencing will also be reviewed. Next, a physical exam will then be performed. This evaluation includes an examination of joints for tenderness, swelling and warmth, and the detection for rheumatoid nodules. Usually, a diagnosis for rheumatoid arthritis does not occur unless typical symptoms persist for more than six weeks.

Are there any diagnostic tests that can be performed to confirm rheumatoid arthritis?

Currently, there is no one test that can be used to confirm rheumatoid arthritis. A variety of blood tests and diagnostic images (X-rays) are usually performed that may be commonly seen in this autoimmune disease. They include:

  • CBC test (complete blood count) - used to determine if there is a low red blood cell count, also known as anemia
  • Erythrocyte sedimentation rate - if elevated, usually confirms increased inflammation which is seen in rheumatoid arthritis
  • C-reactive protein - also an indicator for inflammation and can help rule in rheumatoid arthritis.
  • Anti-CCP test (Antibodies to cyclic citrullinated peptides) - seen in more than 60% of rheumatoid arthritis patients helping with its confirmation of the disease.
  • Rheumatoid factor -  an antibody test and the hallmark blood test used to confirm the diagnosis. It’s not as helpful in the early stages of rheumatoid arthritis, but usually seen in 80% of rheumatoid patients.
  • X Rays - may not be definitive in the early diagnosis of rheumatoid arthritis but can be used to show the progression of the disease when used for comparison purposes.
  • MRI - may be helpful in detecting early disease if x-rays are negative.
  • Ultrasound - a cheaper imaging modality than MRI to detect RA joint involvement.

Treatment

What are treatment options for rheumatoid arthritis?

There is no cure for rheumatoid arthritis; however, early intervention has been shown to be greatly beneficial for those suffering from rheumatoid arthritis to function almost to normal levels and remain in remission. The goal of treatment includes reducing inflammation, pain, and preventing permanent joint and other organ damage (eye, lung, nerves). Treatment options have evolved over the years. Although medications appear to be the most common method for the management of rheumatoid arthritis, TeleMed2U rheumatologists offer integrative, holistic treatment approaches as well, based upon a “S.E.N.S.E.” - ible approach: Stress management, Exercise, Nutrition, Sleep & positive social Engagements. 

Here are the different types of medications currently available for rheumatoid arthritis: 

  • Disease-modifying antirheumatic drugs (DMARDs) - are the first-line treatments for rheumatoid arthritis as they positively influence the natural history of RA (makes RA less damaging to your joints and body). They are successful with treating symptoms and slowing the progression of joint damage from the disease. Examples include:
  1. methotrexate* (Rheumatrex, Trexall, Otrexup, Rasuvo)
  2. leflunomide (Arava)
  3. hydroxychloroquine (Plaquenil)
  4. sulfasalazine (Azulfidine)

*If you are taking methotrexate, make sure you are also taking a folic acid supplement like MTX Advanced Support: https://theralogix.com/products/mtx-support-folic-acid-b12-supplement 

  • Nonsteroidal anti-inflammatory drugs (NSAIDs)- usually used in conjunction with DMARDs to help reduce pain and swelling from chronic inflammation. NSAIDS do NOT improve the natural history (outcome) of RA, but do help reduce pain.
  • Corticosteroids- a stronger anti-inflammatory used alongside DMARDs as well that may help relieve symptoms. Usually used in a low dose form, and the goal of physicians is to eventually discontinue its use once symptoms have resolved. Cortisone does NOT improve the natural history (outcome) of RA, but does help to reduce pain, swelling and inflammation. 
  • Biologic response modifiers (biologic agents)- used for more advanced rheumatoid arthritis symptoms. These agents work by blocking the immune system’s signals to cause inflammation. They are usually combined with methotrexate to give a better treatment response, as only 20-25% of patients with moderate to severe RA are successfully managed with methotrexate alone. Examples of biologics include:
  1. abatacept (Orencia)
  2. adalimumab (Humira)
  3. anakinra (Kineret)
  4. certolizumab (Cimzia)
  5. etanercept (Enbrel)
  6. golimumab (Simponi) 
  7. infliximab (Remicade)
  8. rituximab (Rituxan, MabThera)
  9. sarilumab (Kevzara)
  10. tocilizumab (Actemra)
  • Targeted synthetic DMARDs-  the newest class of medication for RA, usually used when traditional DMARDs and biologic agents have failed. Examples include:
  1. tofacitinib (Xeljanz) 
  2. baracitinib (Olumiant)
  3. upadacitinib (Rinvoq) 

If you have questions about RA treatments & pregnancy, please visit the Mother To Baby website at: https://mothertobaby.org/ 

If medications fail, what are other treatment options available?

Surgery may be considered for managing rheumatoid arthritis symptoms when medications fail to provide relief of symptoms or the joint has become severely damaged. The goal of surgery is to restore the function of the damaged joint and reduce pain. Some surgical procedures that may be considered include:

  • Joint replacement- a prosthetic is usually inserted after damaged tissue and bone is removed from the joint.
  • Joint fusion- a fusion of the joint is usually chosen when restoration of joint position is needed. It also provides pain relief and is performed if joint replacement surgery is not an option.
  • Tendon repair- performed due to the chronic inflammation around the joint also affecting the tendons resulting in tears or ruptures.
  • Synovectomy- involves removal of the inflamed synovium, which improves pain and flexibility of the joint.

Fortunately, since the development and proper use of biologic agents in the late 1990s, the need for joint surgery in RA patients have steadily declined.

Are there other treatment options available for rheumatoid arthritis other than medications or surgery?

Yes. It is believed that medication alone cannot tackle rheumatoid arthritis, and various self-management techniques may be helpful. Patient education and support is vital for understanding how to manage this condition. Therefore, a multidisciplinary approach with several different healthcare providers will be needed. A healthy diet, cessation of smoking, exercise, and even physical therapy may all be used as tactics to help reduce the symptoms that occur from rheumatoid arthritis.

Rheumatoid arthritis can be debilitating, however when an individualized, integrative treatment program is created with our physicians at TeleMed2U, you will be able to live your best life, managing your RA while taking the least amount of medications.

References

American College of Rheumatology. (2019, March). Rheumatoid arthritishttps://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Rheumatoid-Arthritis   
Arthritis Foundation. (n.d.).  Rheumatoid arthritis. https://www.arthritis.org/diseases/rheumatoid-arthritis 
Centers for Disease Prevention and Control. (2020, July).  Rheumatoid Arthritishttps://www.cdc.gov/arthritis/basics/rheumatoid-arthritis.html 
Mayo Clinic. (2021, May).Rheumatoid arthritis.https://www.mayoclinic.org/diseases-conditions/rheumatoid-arthritis/symptoms-causes/syc-20353648

Information

Medically reviewed by:

Dr Roy Kedem, MD

Dr Roy Kedem started his premedical studies at Harvard, and research in genetics and gene sequencing at Harvard, Beth Israel. He attended medical school in the UK at the Cambridge Overseas Medical Program in 1998.  Dr Kedem then completed his residency in Internal Medicine at Columbia College of Physicians and Surgeons in Stamford, Connecticut and his fellowship in Hospital Medicine at the Cleveland Clinic in Cleveland, Ohio.

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Rheumatology

Your copay
Depending on insurance

Without Insurance

Rheumatology

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Initial Visit

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Follow Up