Rheumatoid arthritis (RA) facts

Rheumatoid arthritis is an autoimmune disease that can cause chronic inflammation of the
joints and other areas of the body.

Rheumatoid arthritis symptomsand signs include

o

joint pain in the feet, hands, and knees,

swollen joints,

fever,

tender joints,

loss of joint function,

stiff joints,

fatigue,

joint redness,

rheumatoid nodules,

joint warmth,

joint deformity.
Rheumatoid arthritis is a chronic disease characterized by periods of disease flares

and remissions.

In rheumatoid arthritis, multiple joints are usually, but not always, affected in a
symmetrical pattern.

Chronic inflammation of rheumatoid arthritis can cause permanent joint destruction

and deformity.

Damage to joints can occur early and does not always correlate with the severity
of RA symptoms.

The "rheumatoid factor" is an antibody that can be found in the blood of 80% of
people with rheumatoid arthritis. Rheumatoid factor is detected in a simple blood test. Possible
risk factors for developing rheumatoid arthritis include genetic background, smoking,
silica inhalation, periodontal disease, and microbes in the bowels (gut bacteria).
There is no cure for RA. The treatment of rheumatoid arthritis optimally involves a
combination of patient education, rest andexercise, joint protection, medications, and
occasionally surgery.

Medications used in the treatment of rheumatoid arthritis includeNSAIDs, DMARDs,

TNF alpha inhibitors, IL-6 inhibitors, T-cell activation inhibitors, B-cell depletors, JAK inhibitors,
immunosuppressants, and steroids.

Early RA treatment results in a better prognosis.

Rheumatoid arthritis can affect people of all ages. The cause of rheumatoid arthritis
is not known.

Picture of hands affected by rheumatoid arthritis. Notice the joint deformity in the fingers; Image
provided by Getty Images

What is rheumatoid arthritis (RA)?

Rheumatoid arthritis (RA) is an autoimmune disease that causes chronic inflammation of the joints.
Autoimmune diseases are illnesses that occur when the body's tissues are mistakenly attacked by
their own immune system. The immune system contains a complex organization of cells and
antibodies designed normally to "seek and destroy" invaders of the body, particularly infections.
Patients with autoimmune diseases have antibodies and immune cells in their blood that target their
own body tissues, where they can be associated with inflammation. While inflammation of the tissue
around the joints and inflammatory arthritis are characteristic features of rheumatoid arthritis, the
disease can also cause inflammation and injury in other organs in the body. Because it can affect
multiple other organs of the body, rheumatoid arthritis is referred to as a systemic illness and is
sometimes called rheumatoid disease. Rheumatoid arthritis that begins in people under 16 years of
age is referred to as juvenile idiopathic arthritis(formerly juvenile rheumatoid arthritis).

Picture of a joint with rheumatoid arthritis

While rheumatoid arthritis is a chronic illness, meaning it can last for years, patients may experience
long periods without symptoms. However, rheumatoid arthritis is typically a progressive illness that
has the potential to cause significant joint destruction and functional disability.
A joint is where two bones meet to allow movement of body parts. Arthritis means joint inflammation.
The joint inflammation of rheumatoid arthritis causes swelling, pain, stiffness, and redness in the
joints. The inflammation of rheumatoid disease can also occur in tissues around the joints, such as
the tendons, ligaments, and muscles.
In some people with rheumatoid arthritis, chronic inflammation leads to the destruction of the
cartilage, bone, and ligaments, causing deformity of the joints. Damage to the joints can occur early
in the disease and be progressive. Moreover, studies have shown that the progressive damage to
the joints does not necessarily correlate with the degree of pain, stiffness, or swelling present in the
joints.

Picture of rheumatoid arthritis joint deformity in the feet; Image provided by Getty Images
Rheumatoid arthritis is a common rheumatic disease, affecting approximately 1.3 million people in
the United States, according to current census data. The disease is three times more common in
women as in men. It afflicts people of all races equally. The disease can begin at any age and even
affects children (juvenile idiopathic arthritis), but it most often starts after 40 years of age and before
60 years of age. Though uncommon, in some families, multiple members can be affected,
suggesting a genetic basis for the disorder.

What are causes and risk factors of rheumatoid arthritis?

The cause of rheumatoid arthritis is unknown. Even though infectious agents such as viruses,
bacteria, and fungi have long been suspected, none has been proven as the cause. The cause of
rheumatoid arthritis is a very active area of worldwide research. It is believed that the tendency to
develop rheumatoid arthritis may be genetically inherited (hereditary). Certain genes have been
identified that increase the risk for rheumatoid arthritis. It is also suspected that certain infections or
factors in the environment might trigger the activation of the immune system in susceptible
individuals. This misdirected immune system then attacks the body's own tissues. This leads to
inflammation in the joints and sometimes in various organs of the body, such as the lungs or eyes.
It is not known what triggers the onset of rheumatoid arthritis. Regardless of the exact trigger, the
result is an immune system that is geared up to promote inflammation in the joints and occasionally
other tissues of the body. Immune cells, called lymphocytes, are activated and chemical messengers
(cytokines, such as tumor necrosis factor/TNF, interleukin-1/IL-1, and interleukin-6/IL-6) are
expressed in the inflamed areas.

Gut Bacteria, Smoking, and Gum Disease

Environmental factors also seem to play some role in causing rheumatoid arthritis. For example,
scientists have reported thatsmoking tobacco, exposure to silica mineral, and chronic periodontal
disease all increase the risk of developing rheumatoid arthritis. There are theories about different gut
bacteria (microbes that inhabit the lining of the bowels) that might trigger the onset of rheumatoid
arthritis in genetically susceptible individuals. No specific microbes have been identified as definite
causes.

What are complications of rheumatoid arthritis?

Since rheumatoid arthritis is a systemic disease, its inflammation can affect organs and areas of the
body other than the joints. Inflammation of the glands of the eyes and mouth can cause dryness of
these areas and is referred to as Sjgren's syndrome. Dryness of the eyes can lead to corneal
abrasion. Inflammation of the white parts of the eyes (the sclerae) is referred to asscleritis and can
be very dangerous to the eye. Rheumatoid inflammation of the lung lining (pleuritis) causes chest
pain with deepbreathing, shortness of breath, or coughing. The lung tissue itself can also become
inflamed and scarred, and sometimes nodules of inflammation (rheumatoid nodules) develop within
the lungs. Inflammation of the tissue (pericardium) surrounding the heart, called pericarditis, can
cause a chest pain that typically changes in intensity when lying down or leaning forward.
Rheumatoid arthritis is associated with an increased risk for heart attack. Rheumatoid disease can
reduce the number of red blood cells (anemia) and white blood cells. Decreased white cells can be
associated with an enlarged spleen (referred to as Felty's syndrome) and can increase the risk of
infections. The risk of lymph gland cancer(lymphoma) is higher in patients with rheumatoid arthritis,
especially in those with sustained active joint inflammation. Firm lumps or firm bumpsunder the skin
(subcutaneous nodules called rheumatoid nodules) can occur around the elbows and fingers where
there is frequent pressure. Even though these nodules usually do not cause symptoms, occasionally
they can become infected. Nerves can become pinched in the wrists to causecarpal tunnel
syndrome. A rare, serious complication, usually with longstanding rheumatoid disease, is blood
vessel inflammation (vasculitis). Vasculitis can impair blood supply to tissues and lead to tissue
death (necrosis). This is most often initially visible as tiny black areas around the nail beds or as leg
ulcers.

What are rheumatoid arthritis symptoms and signs?

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RA symptoms come and go, depending on the degree of tissue inflammation. When body tissues
are inflamed, the disease is active. When tissue inflammation subsides, the disease is inactive (in
remission). Remissions can occur spontaneously or with treatment and can last weeks, months, or

years. During remissions, symptoms of the disease disappear, and people generally feel well. When
the disease becomes active again (relapse), symptoms return. The return of disease activity and
symptoms is called a flare. The course of rheumatoid arthritis varies among affected individuals, and
periods of flares and remissions are typical.
When the disease is active, RA symptoms can include fatigue, loss of energy, lack of appetite, lowgrade fever, muscle and joint aches, and stiffness. Muscle and joint stiffness are usually most
notable in the morning and after periods of inactivity. This is referred to as morning stiffness and
post-sedentary stiffness. Arthritis is common during disease flares. Also during flares, joints
frequently become warm, red, swollen, painful, and tender. This occurs because the lining tissue of
the joint (synovium) becomes inflamed, resulting in the production of excessive joint fluid (synovial
fluid). The synovium also thickens with inflammation (synovitis).
Rheumatoid arthritis usually inflames multiple joints and affects both sides of the body. In its most
common form, therefore, it is referred to as a symmetric polyarthritis. Early RA symptoms may be
subtle. The small joints of both the hands and wrists are often involved. Early symptoms of
rheumatoid arthritis can be pain and prolonged stiffness of joints, particularly in the morning.
Symptoms in the hands with rheumatoid arthritis include difficulty with simple tasks of daily living,
such as turning door knobs and opening jars. The small joints of the feet are also commonly
involved, which can lead to painful walking, especially in the morning after arising from bed.
Occasionally, only one joint is inflamed. When only one joint is involved, the arthritis can mimic the
joint inflammation caused by other forms of arthritis, such as gout or joint infection. Chronic
inflammation can cause damage to body tissues, including cartilage and bone. This leads to a loss
of cartilage and erosion and weakness of the bones as well as the muscles, resulting in joint
deformity, destruction, and loss of function. Rarely, rheumatoid arthritis can even affect the joint that
is responsible for the tightening of our vocal cords to change the tone of our voice, the cricoarytenoid
joint. When this joint is inflamed, it can cause hoarseness of the voice. Symptoms in children with
rheumatoid arthritis include limping, irritability, crying, and poor appetite.

What tests do physicians use to diagnose rheumatoid arthritis?

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There is no singular test for diagnosing rheumatoid arthritis. The diagnosis is based on the clinical
presentation. Ultimately, rheumatoid arthritis is diagnosed based on a combination of the
presentation of the joints involved, characteristic joint swelling and stiffness in the morning, the
presence of blood rheumatoid factor and citrulline antibody, as well as findings of rheumatoid
nodules and radiographic changes (X-ray testing). It is important to understand that there are many
forms of joint disease that can mimic rheumatoid arthritis.
The first step in the diagnosis of rheumatoid arthritis is a meeting between the doctor and the
patient. The doctor reviews the history of symptoms, examines the joints for inflammation,

tenderness, swelling, and deformity, the skin for rheumatoid nodules (firm bumps under the skin,
most commonly over the elbows or fingers), and other parts of the body for inflammation. Certain
blood and X-ray tests are often obtained. The diagnosis will be based on the pattern of symptoms,
the distribution of the inflamed joints, and the blood and X-ray findings. Several visits may be
necessary before the doctor can be certain of the diagnosis. A doctor with special training in arthritis
and related diseases is called a rheumatologist.
It is the inflammation in the joint that helps to distinguish rheumatoid arthritis from common types of
arthritis that are not inflammatory, such as osteoarthritis ordegenerative arthritis. The distribution of
joint inflammation is also important to the doctor in making a diagnosis. In rheumatoid arthritis, the
small joints of the hands and fingers, wrists, feet, and knees are typically inflamed in a symmetrical
distribution (affecting both sides of the body). When only one or two joints are inflamed, the
diagnosis of rheumatoid arthritis becomes more difficult. The doctor may then perform other tests to
exclude arthritis due to infection or gout. The detection of rheumatoid nodules (described above),
most often around the elbows and fingers, can suggest the diagnosis.
Abnormal antibodies can be found in the blood of people with rheumatoid arthritis with simple blood
testing. An antibody called "rheumatoid factor" (RF) can be found in 80% of patients with rheumatoid
arthritis. Patients who are felt to have rheumatoid arthritis and do not have positive rheumatoid factor
testing are referred to as having "seronegative rheumatoid arthritis." Citrulline antibody (also referred
to as anticitrulline antibody, anticyclic citrullinated peptide antibody, and anti-CCP antibody) is
present in 50%-75% people with rheumatoid arthritis. It is useful in the diagnosis of rheumatoid
arthritis when evaluating cases of unexplained joint inflammation. A test for citrulline antibodies is
especially helpful in looking for the cause of previously undiagnosed inflammatory arthritis when the
traditional blood test for rheumatoid arthritis, rheumatoid factor, is not present. Citrulline antibodies
have been felt to represent the earlier stages of rheumatoid arthritis in this setting. Citrulline
antibodies also have been associated with more aggressive forms of rheumatoid arthritis. Another
antibody called the "antinuclear antibody" (ANA) is also frequently found in people with rheumatoid
arthritis.
It should be noted that many forms of arthritis in childhood (juvenile inflammatory arthritis) are not
associated with blood test positivity for rheumatoid factors. In this setting, juvenile rheumatoid
arthritis must be distinguished from other types of joint inflammation, including plant thorn arthritis,
joint injury, arthritis of inflammatory bowel disease, and rarely joint tumors.
A blood test called the sedimentation rate (sed rate) is a crude measure of the inflammation of the
joints. The sed rate actually measures how fast red blood cells fall to the bottom of a test tube. The
sed rate is usually faster (high) during disease flares and slower (low) during remissions. Another
blood test that is used to measure the degree of inflammation present in the body is the C-reactive
protein. Blood testing may also reveal anemia, since anemia is common in rheumatoid arthritis,
particularly because of the chronic inflammation.

The rheumatoid factor, ANA, sed rate, and C-reactive protein tests can also be abnormal in other
systemic autoimmune and inflammatory conditions. Therefore, abnormalities in these blood tests
alone are not sufficient for a firm diagnosis of rheumatoid arthritis.
Joint X-rays may be normal or only demonstrate swelling of soft tissues early in the disease. As the
disease progresses, X-rays can reveal bony erosions typical of rheumatoid arthritis in the joints.
Joint X-rays can also be helpful in monitoring the progression of disease and joint damage over time.
Bone scanning, a procedure using a small amount of a radioactive substance, can also be used to
demonstrate the inflamed joints. MRIscanning can also be used to demonstrate joint damage.
The American College of Rheumatology has developed a system for classifying rheumatoid arthritis
that is primarily based upon the X-ray appearance of the joints. This system helps medical
professionals classify the severity of your rheumatoid arthritis with respect to cartilage, ligaments,
and bone.
Stage I

No damage seen on X-rays, although there may be signs of bone thinning

Stage II

On X-ray, evidence of bone thinning around a joint with or without slight bone damage

Slight cartilage damage possible

Joint mobility may be limited; no joint deformities observed

Atrophy of adjacent muscle

Abnormalities of soft tissue around joint possible

Stage III

On X-ray, evidence of cartilage and bone damage and bone thinning around the joint

Joint deformity without permanent stiffening or fixation of the joint

Extensive muscle atrophy

Abnormalities of soft tissue around joint possible

Stage IV

On X-ray, evidence of cartilage and bone damage and osteoporosisaround joint

Joint deformity with permanent fixation of the joint (referred to asankylosis)

Extensive muscle atrophy

Abnormalities of soft tissue around joint possible

Rheumatologists also classify the functional status of people with rheumatoid arthritis as follows:

Class I: completely able to perform usual activities of daily living

Class II: able to perform usual self-care and work activities but limited in activities outside of
work (such as playing sports, household chores)

Class III: able to perform usual self-care activities but limited in work and other activities

Class IV: limited in ability to perform usual self-care, work, and other activities

The doctor may elect to perform an office procedure called arthrocentesis. In this procedure, a sterile
needle and syringe are used to drain joint fluid out of the joint for study in the laboratory. Analysis of
the joint fluid in the laboratory can help to exclude other causes of arthritis, such as infection
and gout. Arthrocentesis can also be helpful in relieving joint swelling and pain. Occasionally,
cortisone medications are injected into the joint during the arthrocentesis in order to rapidly relieve
joint inflammation and further reduce symptoms.

What is the treatment for rheumatoid arthritis? What types

of medications treat RA?
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There is no known cure for rheumatoid arthritis. To date, the goal of treatment in rheumatoid arthritis
is to reduce joint inflammation and pain, maximize joint function, and prevent joint destruction and
deformity. Early medical intervention has been shown to be important in improving outcomes.
Aggressive management can improve function, stop damage to joints as monitored on X-rays, and
prevent work disability. Optimal RA treatment involves a combination of medications, rest, jointstrengthening exercises, joint protection, and patient (and family) education. Treatment is
customized according to many factors such as disease activity, types of joints involved, general
health, age, and patient occupation. RA treatment is most successful when there is close
cooperation between the doctor, patient, and family members.
Two classes of medications are used in treating rheumatoid arthritis: fast-acting "first-line drugs" and
slow-acting "second-line drugs" (also referred to as disease-modifying antirheumatic drugs or
DMARDs). The first-line drugs, such as aspirin and cortisone (corticosteroids), are used to reduce

pain and inflammation. The slow-acting second-line drugs, such

asmethotrexate (Rheumatrex, Trexall, Otrexup) and hydroxychloroquine(Plaquenil), promote disease
remission and prevent progressive joint destruction.
The degree of destructiveness of rheumatoid arthritis varies among affected individuals. Those with
uncommon, less destructive forms of the disease or disease that has quieted after many years of
activity ("burned out" rheumatoid arthritis) can be managed with rest plus pain control and antiinflammatory medications alone. In general, however, function is improved and disability and joint
destruction are minimized when the condition is treated earlier with second-line drugs (diseasemodifying antirheumatic drugs), even within months of the diagnosis. Most people require more
aggressive second-line drugs, such as methotrexate, in addition to anti-inflammatory agents.
Sometimes these second-line drugs are used in combination. In some cases with severe joint
deformity, surgery may be necessary.

"First-line" rheumatoid arthritis medications

Acetylsalicylate (aspirin), naproxen(Naprosyn), ibuprofen (Advil, Medipren,Motrin),
and etodolac (Lodine) are examples of nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs are
medications that can reduce tissue inflammation, pain, and swelling. NSAIDs are not cortisone.
Aspirin, in doses higher than those used in treating headaches and fever, is an effective antiinflammatory medication for rheumatoid arthritis. Aspirin has been used for joint problems since the
ancient Egyptian era. The newer NSAIDs are just as effective as aspirin in reducing inflammation
and pain and require fewer dosages per day. Patients' responses to different NSAID medications
vary. Therefore, it is not unusual for a doctor to try several NSAID drugs in order to identify the most
effective agent with the fewest side effects. The most common side effects of aspirin and other
NSAIDs include stomach upset, abdominal pain, ulcers, and even gastrointestinal bleeding. In order
to reduce gastrointestinal side effects, NSAIDs are usually taken with food. Additional medications
are frequently recommended to protect the stomach from the ulcer effects of NSAIDs. These
medications include antacids, sucralfate (Carafate), proton-pump inhibitors (Prevacidand others),
and misoprostol (Cytotec). Newer NSAIDs include selectiveCox-2 inhibitors, such
as celecoxib (Celebrex), which offer anti-inflammatory effects with less risk of stomach irritation and
bleeding risk.
Corticosteroid medications can be given orally or injected directly into tissues and joints. They are
more potent than NSAIDs in reducing inflammation and in restoring joint mobility and function.
Corticosteroids are useful for short periods during severe flares of disease activity or when the
disease is not responding to NSAIDs. However, corticosteroids can have serious side effects,
especially when given in high doses for long periods of time. These side effects include weight gain,
facial puffiness, thinning of the skin and bone, easy bruising, cataracts, risk of infection, muscle
wasting, and destruction of large joints, such as the hips. Corticosteroids also carry some increased
risk of contracting infections. These side effects can be partially avoided by gradually tapering the
doses of corticosteroids as the individual achieves improvement in symptoms. Abruptly discontinuing
corticosteroids can lead to flares of the disease or other symptoms of corticosteroid withdrawal and

is discouraged. Thinning of the bones due toosteoporosis may be prevented by calcium and vitamin
Dsupplements.

What are newer rheumatoid arthritis treatments?

Newer "second-line" drugs (DMARDs) for the treatment of rheumatoid arthritis
includeleflunomide (Arava) and the "biologic"
medications etanercept (Enbrel), infliximab(Remicade), anakinra (Kineret),adalimumab (Humira), ritu
ximab (Rituxan),abatacept (Orencia), golimumab (Simponi),certolizumab pegol
(Cimzia), tocilizumab(Actemra), and JAK inhibitors represented by tofacitinib (Xeljanz). Each of
these medications can increase the risk for infections, and the development of any infections should
be reported to the health-care professional when taking these newer second-line drugs.
Leflunomide (Arava) is available to relieve the symptoms and halt the progression of the disease. It
seems to work by blocking the action of an important enzyme that has a role in immune activation.
Leflunomide can cause liver disease, diarrhea, hair loss, and/or rash in some people. It should not
be taken just before or duringpregnancy because of possible birth defectsand is generally avoided in
women who might become pregnant.
Biologic DMARDs represent a novel approach to the treatment of rheumatoid arthritis and are
products of modern biotechnology. These are referred to as the biologic medications or biological
response modifiers. In comparison with traditional DMARDs, the biologic medications have a much
more rapid onset of action and can have powerful effects on stopping progressive joint damage. In
general, their methods of action are also more directed, defined, and targeted.
Etanercept, infliximab, adalimumab, golimumab, and certolizumab pegol are biologic medications
that intercept a messenger protein in the joints (tumor necrosis factor or TNF) that promotes
inflammation of the joints in rheumatoid arthritis. These TNF-blockers intercept TNF before it can act
on its natural receptor to "switch on" the process of inflammation. This effectively blocks the TNF
inflammation messenger from recruiting the cells of inflammation. Symptoms can be significantly,
and often rapidly, improved in those using these drugs. Etanercept must be injected subcutaneously
once or twice a week. Infliximab is given by infusion directly into a vein (intravenously). Adalimumab
is injected subcutaneously either every other week or weekly. Golimumab is injected subcutaneously
on a monthly basis. Certolizumab pegol is injected subcutaneously every two to four weeks. Each of
these medications is being evaluated by doctors in practice to determine what role they may have in
treating patients in various stages of rheumatoid arthritis. Research has shown that biological
response modifiers also prevent the progressive joint destruction of rheumatoid arthritis. They are
currently recommended for use after other second-line medications have not been effective. The
biological response modifiers (TNF-inhibitors) are expensive treatments. They are also frequently
used in combination with methotrexate and other DMARDs. Furthermore, it should be noted that the
TNF-blocking biologics all are more effective when combined with methotrexate. These medications
should be avoided by people with significant congestive heart failure or demyelinating diseases
(such asmultiple sclerosis) because they can worsen these conditions.

Anakinra (Kineret) is another biologic DMARD treatment that is used to treat moderate to severe
rheumatoid arthritis. Anakinra works by binding to a cell messenger protein (IL-1, a proinflammatory
cytokine). Anakinra is injected under the skin daily. Anakinra can be used alone or with other
DMARDs. The response rate of anakinra does not seem to be as high as with other biologic
medications.
Rituximab (Rituxan) is an antibody that was first used to treat lymphoma, acancer of the lymph
nodes. Rituximab can be effective in treating autoimmune diseases like rheumatoid arthritis because
it depletes B-cells, which are important cells of inflammation and in the production of abnormal
antibodies that are common in these conditions. Rituximab is used to treat moderate to severely
active rheumatoid arthritis in patients who have failed treatment with the TNF-blocking biologics.
Preliminary studies have shown that Rituximab was also found to be beneficial in treating severe
rheumatoid arthritis complicated by blood vessel inflammation (vasculitis) andcryoglobulinemia.
Rituximab is an intravenous infusion given in two doses, two weeks apart, approximately every six
months.
Abatacept (Orencia) is a biologic medication that blocks T-cell activation. Abatacept is used to treat
adult patients who have failed treatment with a traditional DMARD medication. Abatacept is an
intravenous infusion given monthly or a weekly subcutaneous injection.
Tocilizumab (Actemra) is approved for the treatment of adult patients with moderately to severely
active rheumatoid arthritis (RA) who have had an inadequate response to one or more tumor
necrosis factor (TNF) antagonist therapies. Tocilizumab is the first approved biologic medication that
blocks interleukin-6 (IL-6), which is a chemical messenger of the inflammation of rheumatoid
arthritis. Tocilizumab is an intravenous infusion given monthly or a weekly subcutaneous injection.
Tofacitinib (Xeljanz) is the first in a new class of medications used to treat rheumatoid arthritis called
JAK inhibitors. Tofacitinib is used to treat adults with moderately to severely active rheumatoid
arthritis in which methotrexate did not work well. Tofacitinib can be used with or without
methotrexate. This prescription medicine is taken by mouth twice daily. Tofacitinib is considered a
"targeted" medication that specifically blocks special enzymes of inflammation called Janus kinase
within cells. It is, therefore, referred to as a JAK inhibitor.
While biologic medications are often combined with traditional DMARDs in the treatment of
rheumatoid arthritis, they are generally not used with other biologic medications because of the
unacceptable risk for serious infections. Similarly, JAK inhibitor medication is not used with traditional
biologic medications.

Rheumatoid arthritis diet, exercise, home remedies, and alternative

medicine
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There is no special RAdiet or diet "cure" for rheumatoid arthritis. One hundred years ago, it was
touted that "night-shade" foods, such as tomatoes, would aggravate rheumatoid arthritis. This is no
longer accepted as true. There are no specific foods or food groups that should be universally
avoided by individuals with rheumatoid arthritis.
Nevertheless, there are some home remedies that may be helpful, although these are not
considered as potent or effective as disease-modifying drugs. Fish oils, such as in salmon,
and omega-3 fatty acids supplements have been shown to be beneficial in some short-term studies
in rheumatoid arthritis. This suggests that there may be benefits by adding more fish to the diet, such
as in the popularMediterranean diet. The anti-inflammatory effects of curcumin in dietary turmeric, an
ingredient in curry, may be beneficial in reducing symptoms of rheumatoid arthritis. Supplements
such as calcium and vitamin D are used to prevent osteoporosis in patients with rheumatoid arthritis.
Folic acid is used as a supplement to prevent side effects of methotrexate treatment of rheumatoid
arthritis. Alcohol is minimized or avoided in rheumatoid arthritis patients taking methotrexate.
There is no evidence that gluten bothers rheumatoid arthritis. Nevertheless, for those who are
definitely sensitive to gluten (wheat, barley, and rye), the gluten-free diet can prevent poor intestinal
absorption of important nutrients because the smallintestines can become inflamed in these
individuals. Bowel inflammation can be detrimental for those also affected by rheumatoid arthritis if
they become deficient in nutrients, such as vitamin D and folate.
The benefits of cartilage preparations such as glucosamine and chondroitin for rheumatoid arthritis
remain unproven. Symptomatic pain relief can often be achieved with oral acetaminophen (Tylenol)
or over-the-counter topical preparations, which are rubbed into the skin. Antibiotics, in particular
the tetracycline drug minocycline(Minocin), have been tried for rheumatoid arthritis recently in clinical
trials. Early results have demonstrated mild to moderate improvement in the symptoms of arthritis.
Minocycline has been shown to impede important mediator enzymes of tissue destruction, called
metalloproteinases, in the laboratory as well as in humans.
The areas of the body other than the joints that are affected by rheumatoid inflammation are treated
individually. Sjgren's syndrome (described above, see symptoms) can be helped by artificial tears
and humidifying rooms in the home or office. Medicated eyedrops, cyclosporine ophthalmic drops
(Restasis), are also available to help the dry eyes in those affected. Regular eye checkups and early
antibiotic treatment for infection of the eyes are important. Inflammation of the tendons (tendinitis),
bursae (bursitis), and rheumatoid nodules can be injected with cortisone. Inflammation of the lining
of the heart and/or lungs may require high doses of oral cortisone.
Because impact loading the joints can aggravate inflamed, active rheumatoid arthritis and also be
difficult when joints have been injured in the past by the disease, it is important to customize
activities and exerciseprograms according to each individual's capacity. Movement exercises that

are less traumatic for the joints, including yoga and tai chi, can be beneficial in maintaining flexibility
and strength as well as lead to an improved general sense of well-being.
Proper regular exercise is important in maintaining joint mobility and in strengthening the muscles
around the joints. Swimming is particularly helpful because it allows exercise with minimal stress on
the joints. Physical and occupational therapists are trained to provide specific exercise instructions
and can offer splinting supports. For example, wrist and finger splints can be helpful in reducing
inflammation and maintaining joint alignment. Devices such as canes, toilet seat raisers, and jar
grippers can assist in the activities of daily living. Heat and cold applications are modalities that can
ease symptoms before and after exercise.
Surgery may be recommended to restore joint mobility or repair damaged joints. Doctors who
specialize in joint surgery are orthopedic surgeons. The types of joint surgery range
from arthroscopy to partial and complete replacement of the joint. Arthroscopy is a surgical
technique whereby a doctor inserts a tube-like instrument into the joint to see and repair abnormal
tissues.
Total joint replacement is a surgical procedure whereby a destroyed joint is replaced with artificial
materials. For example, the small joints of the hand can be replaced with plastic material. Large
joints, such as the hips or knees, are replaced with metals.
Finally, minimizing emotional stress can help improve the overall health in people with rheumatoid
arthritis. Support and extracurricular groups provide those with rheumatoid arthritis time to discuss
their problems with others and learn more about their illness.

What about rheumatoid arthritis and pregnancy?

In general, rheumatoid arthritis often improves during pregnancy. It is commonplace for the
rheumatoid joint inflammation to decrease and be minimized during pregnancy. Unfortunately, this
reduction of joint inflammation during pregnancy is not usually sustained after delivery.
Medications that are commonly used to treat inflammation, such as nonsteroidal anti-inflammatory
drugs including ibuprofen (Motrin, Advil), naproxen (Aleve), and others, are not used during
pregnancy. Drugs that are used to stop the progression of rheumatoid disease, such as
methotrexate (Rheumatrex, Trexall) and cyclosporine (Neoral, Sandimmune), are not used during
pregnancy and also must be discontinued well in advance of conceptionbecause of potential risks to
the fetus. Biologic medications are avoided during pregnancy when possible.
When rheumatoid arthritis is active during pregnancy, steroid medications such
asprednisone and prednisolone are often used to quiet the joint inflammation. These medications do
not adversely affect the fetus.

What is the prognosis (outlook) for patients with rheumatoid arthritis?

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With early, aggressive treatment, the outlook for those affected by rheumatoid arthritis can be very
good. The overall attitude regarding ability to control the disease has changed tremendously since
the turn of the century. Doctors now strive to eradicate any signs of active disease while preventing
flare-ups. The disease can be controlled and a cooperative effort by the doctor and patient can lead
to optimal health.
Rheumatoid arthritis causes disability and can increase mortality and decrease life expectancy to
lead to an early death. Patients have a less favorable outlook when they have deformity, disability,
ongoing uncontrolled joint inflammation, and/or rheumatoid disease affecting other organs of the
body. Overall, rheumatoid arthritis tends to be potentially more damaging when rheumatoid factor or
citrulline antibody is demonstrated by blood testing. Life expectancy improves with earlier treatment
and monitoring.

What Is Rheumatoid Arthritis?

Rheumatoid arthritis (RA) is an autoimmune disease where the body attacks

itself, causing chronic joint inflammation. While it primarily affects joints, it can
also cause inflammation of organs as the disease progresses. People with RA
may experience an increase in symptoms called flares that can last for
days or weeks. They may also have periods of remission where they have few
or no symptoms. There is no cure for rheumatoid arthritis, but medications can
slow the progression of the disease and ease symptoms.

A Picture Guide to Rheumatoid Arthritis

What Is Rheumatoid Arthritis?

Rheumatoid arthritis (RA) is an autoimmune disease where the body attacks itself, causing
chronic joint inflammation. While it primarily affects joints, it can also cause inflammation of
organs as the disease progresses. People with RA may experience an increase in symptoms
called flares that can last for days or weeks. They may also have periods of remission where
they have few or no symptoms. There is no cure for rheumatoid arthritis, but medications can
slow the progression of the disease and ease symptoms.

Who Is at Risk for Rheumatoid Arthritis?

According to the Arthritis Foundation, rheumatoid arthritis affects about 1.5 million people in the
U.S. Women develop RA two to three times more often than men, and symptoms in women tend
to appear between the ages of 30 and 60, while symptoms usually develop later in life for men.
There may also be a genetic basis for the disease. Cigarette smoking is also a risk factor, as are
certain infections.

What Is Juvenile Rheumatoid Arthritis?

Juvenile rheumatoid arthritis (JRA), also called juvenile idiopathic arthritis (JIA), is a type of
arthritis that occurs in children age 1 to 16. Symptoms include stiff, sowllen, painful joints, and
sometimes fever and rash. To be diagnosed with JRA the child's symptoms must last at least six
weeks.

What Is the Difference Between Normal, Healthy Joints and Arthritic Joints?

Arthritis refers to more than 100 conditions that affect the musculoskeletal system, specifically,
the joints. The joints are the parts of the body where bones connect. When arthritis is present, the
joints may become inflamed, stiff, red, and painful. Rheumatoid arthritis is one type of arthritis
classified as 'systemic,' meaning it can affect the entire body. Damage from RA may occur in
tissues surrounding the joints including the tendons, ligaments, and muscles. In some patients,
symptoms may extend to the skin and eyes, and internal organs including the liver, kidneys,
heart, and lungs.

What Causes Rheumatoid Arthritis?

The exact cause of rheumatoid arthritis remains unknown, but several risk factors have been
identified. Women are diagnosed with RA more often, and it is suspected estrogen may play a
role. Several studies have shown there is a genetic component to developing RA. Cigarette
smoking appears to increase the risk of developing the disease. Occupational exposure to certain
dusts such as silica, wood, or asbestos can also lead to a higher risk for developing the illness. It
is thought there may be a viral or bacterial infectious cause of RA but that is still being studied.

Remission, Relapse, and Flares

When a person with rheumatoid arthritis has symptoms including joint inflammation and pain,
this is called a flare. Flares may last from weeks to months. This can alternate with periods of
remission, when symptoms are minimal to nonexistent. Periods of remission can last weeks,
months, or even years. After a period of remission, if the symptoms return this is called a relapse.
It is common for RA patients to have periods of flares, remissions, and relapses, and the course
of the illness varies with each patient.

What Are the Symptoms of Rheumatoid Arthritis?

In addition to the hallmark symptoms of swollen, painful, and stiff joints and muscles,
rheumatoid arthritis patients may also experience symptoms such as fatigue, low-grade fever,
lack of energy, and loss of appetite. The muscle and joint stiffness is usually worst in the
morning or after extended periods of inactivity.
Other symptoms include bumps under the skin (rheumatoid nodules), shortness of breath due to
inflammation or damage to the lungs, hoarseness, and eye problems.
8. What Are the Symptoms of Rheumatoid Arthritis? (continued)

With rheumatoid arthritis hands are almost always affected. However, RA can affect any joint in
the body, including wrists, elbows, knees, feet, hips, and even the jaw. In most cases joints are
affected symmetrically, meaning the same joints on both sides of the body are affected.
Rheumatoid arthritis can be very painful, and chronic inflammation can lead to debilitating loss
of cartilage, bone weakness, and joint deformity.
9. Rheumatoid Arthritis and Inflammation of Organs

Rheumatoid arthritis is a systemic disease, meaning it can affect the entire body. In addition to
the joints and muscles, RA can cause problems in many other areas of the body:

Eyes and mouth: inflammation of the glands in the eyes and mouth causes
dryness, and a condition called Sjgren's syndrome. It can also lead to
inflammation of the white part of the eye (scleritis).

Lungs: inflammation of the lung lining (pleuritis) or the lungs themselves can
cause shortness of breath and chest pain.

Heart: inflammation of the tissue surrounding the heart (pericarditis) can

cause chest pain, which tends to be worse when lying down. RA patients are
also at greater risk for heart attacks.

Spleen: inflammation of the spleen (Felty's syndrome) can cause a decrease

in white blood cells, which raises the risk of infections.

Skin: firm lumps under the skin (rheumatoid nodules), typically located
around affected joints, often on pressure points such as elbows, fingers, and
knuckles.

Blood vessels: inflammation of the blood vessels (vasculitis) can limit blood
supply to surrounding tissues, causing tissue death (necrosis).

0. What is a Rheumatologist?

A rheumatologist is a physician who specializes in treatment of arthritis, and other disorders of

the joints, muscles, and bones, autoimmune diseases, and soft tissue diseases.
A rheumatologist is usually an internal medicine specialist or pediatrician, with additional
specialized rheumatology training to identify and treat the more than 100 different types of
arthritis in addition to other autoimmune disorders such as lupus, gout, and osteoporosis.
11 How Is Rheumatoid Arthritis Diagnosed?

There is not a singular test to diagnose rheumatoid arthritis. First, the patient will meet with a
rheumatologist who will perform a physical and take a history of symptoms. The joints will be
examined to determine if there is inflammation and tenderness, and the skin may be examined to
look for rheumatoid nodules. The doctor may order blood tests or X-rays to help diagnose the
condition.
Many other diseases such as gout, fibromyalgia, and lupus may resemble rheumatoid arthritis, so
the doctor will rule out these conditions before making a diagnosis of RA.
12 RA Diagnostic Test: Citrulline Antibody Test

Blood tests are usually run to help make a diagnosis of rheumatoid arthritis. These tests check for
certain antibodies including anti-cyclic citrullinated peptide antibodies (ACPA), rheumatoid
factor (RF), and antinuclear antibodies (ANA), which are present in a majority of RA patients.
Rheumatoid factor (RF) is present in about 75% to 80% of RA patients, and a high RF may
indicate a more aggressive for of the disease. An advantage of anti-cyclic citrullinated peptide
antibody (ACPA) tests is that they can often detect the disease earlier on, and the sooner
treatment begins the better patients can manage the disease. The presence of antinuclear
antibodies (ANA) is not a definitive diagnosis for RA, but their presence can indicate to the
doctor that an autoimmune disorder may be present.
13 RA Diagnostic Test: Sedimentation Rate (Sed Rate)

Other blood tests that may be run can help the doctor determine the extent of the inflammation in
the joints and elsewhere in the body. The erythrocyte sedimentation rate (ESR, or "sed rate")
measures how quickly red blood cells fall to the bottom of a test tube. Usually, the higher the sed
rate, the more inflammation there is in the body.
Another blood test that measures inflammation is the C-reactive protein (CRP) test. If the CRP is
high, inflammation levels are usually high as well, such as during a flare.
14 RA Diagnostic Test: Joint X-rays

Another test used to diagnose rheumatoid arthritis is X-ray. Early in the disease X-rays are not as
helpful because they do not show soft tissue damage, but they can be useful in later stages to
monitor how the disease progresses over time because they show bone erosion. Other imaging
tests used may include bone density scans (DXA or DEXA scans), ultrasound, and magnetic
resonance imaging (MRI).
15 RA Diagnostic Test: Arthrocentesis

A joint aspiration procedure (arthrocentesis) may be performed to obtain joint fluid to test in the
laboratory. A sterile needle and syringe drain fluid from the joint, which is then analyzed to
detect causes of joint swelling such as arthritis. Removing this joint fluid can also help relieve
joint pain. In some cases, cortisone may be injected into the joint during the aspiration procedure
for more immediate pain relief.
16 How Is Rheumatoid Arthritis Treated?

Currently, there is no cure for rheumatoid arthritis, but there are a number of medications that
can ease symptoms. Most treatments are aimed at remission, where the patient has few to no
symptoms of RA. When treatment is started early on in the disease process, this can help
minimize or slow damage to the joints and improve quality of life for patients. Treatment usually

involves a combination of medication, exercise, rest, and protecting the joints. In some cases,
surgery may be needed.
17 What Medications Are Used to Treat Rheumatoid Arthritis?

If you are diagnosed with rheumatoid arthritis, the sooner the treatment begins, the better your
outcome is likely to be. There are many different medications used to help alleviate symptoms of
RA and with the goal of bringing a patient into remission. The main types of RA drugs include:

Disease-modifying antirheumatic drugs (DMARDs) such as methotrexate,

hydroxycholorquine (Plaquenil), sulfasalazine (Azulfidine, Azulfidine EN-Tabs),
leflunomide (Arava), and azathioprine (Imuran)

Biologic response modifiers (another type of DMARD) such as abatacept

(Orencia), adalimumab (Humira), anakinra (Kineret), certolizumab and pegol
(Cimzia) etanercept (Enbrel), infliximab (Remicade), golimumab (Simponi),
and rituximab (Rituxan)

Nonsteroidal anti-inflammatories (NSAIDs) such as ibuprofen (Advil, Motrin),

ketoprofen (Actron, Orudis KT), naproxen sodium (Aleve), and celecoxib
(Celebrex)

Janus kinase (JAK) Inhibitor a new drug called tofacitinib (Xeljanz)

Corticosteroids

Analgesics (painkillers)

Drugs used to reduce pain (analgesics) and inflammation (NSAIDs) are often considered "firstline" drugs as they are fast-acting and can relieve symptoms quickly. Medications such as
DMARDs and biologic drugs take longer to have an effect, but they can help prevent
inflammation and joint damage.
18 Other Treatments for Rheumatoid Arthritis

While there is no special diet people with rheumatoid arthritis should follow, eating a healthy,
balanced diet is always recommended, and some foods may help ease inflammation.

Omega-3 fatty acids found in fish oil may offer anti-inflammatory benefits, so
fish such as herring, mackerel, trout, salmon, and tuna may be a part of a
healthy diet. If you choose to take fish oil supplements, check with your
doctor for the proper dosage.

Extra fiber from fruits, vegetables, and whole grains can result in a lower Creactive protein (CRP) in the blood. High levels of CRP indicate inflammation.

Many people with RA have low levels of the mineral selenium. This can be
found in whole-grain wheat products and shellfish. Consult your doctor before
taking selenium supplements for the proper dosage as it can increase your
risk for developing diabetes.

Vitamin D may help lower the risk for RA in women. Eggs, fortified breads and
cereals, and low-fat milk contain Vitamin D.

While some foods can ease inflammation, others may trigger it. Fried foods, grilled meats,
margarine, egg yolks, and certain oils may contribute to inflammation and should be eaten in
moderation or avoided if possible.
19 Other Treatments for Rheumatoid Arthritis (cont.)

Rheumatoid arthritis can also affect other areas of the body, and these symptoms may be treated
individually.

Sjgren's syndrome can cause eye dryness and may be treated with eye
drops to moisturize, and also drops to increase tear production such as
cyclosporine (Restasis). Dry mouth related to Sjgren's may be treated with
prescription mouthwashes and toothpastes.

Inflammation of the lung lining (pleuritis) or the lungs themselves may

require treatment with corticosteroids.

Inflammation of the tissue surrounding the heart (pericarditis) usually

requires keeping the overall inflammation levels down and many RA drugs
can help.

Inflammation of the spleen (Felty's syndrome) can cause a decrease in white

blood cells, which raises the risk of infections and may be treated with a
stimulating factor (granulocyte stimulating factor/GSF) used to increase the
amount of white blood cells.

Rheumatoid nodules may require injections of steroids, or surgery to remove

them if they are severe.

Inflammation of the blood vessels (vasculitis) may be treated with painkillers,

antibiotics, and protecting the areas affected.

20 Why Are Rest and Exercise Important?

A balance of physical activity and rest periods are important in managing rheumatoid arthritis.
Exercise more when your symptoms are minimal, rest more when your symptoms are worse.

Exercise helps maintain joint flexibility and motion. There are therapeutic exercises, such as
physical therapy that is prescribed, that can help with strength, flexibility, and range of motion of
specific joints or body parts affected by your RA. Many recreational activities such as walking
swimming are helpful because allow movement with little to no impact on the joints. Consult
your rheumatologist or physical therapist to find out what exercises are right for you.
Just as physical activity is important, so is rest. When you have an RA flare and your symptoms
are worse, it is best to rest to help reduce joint inflammation and pain, and to cope with the
fatigue that may accompany it.
21 Is Surgery an Option for Rheumatoid Arthritis?

In severe cases of rheumatoid arthritis, surgery may be needed to reduce pain and improve joint
function. Some surgeries include joint replacement, fusion of joints (arthrodesis), tendon
reconstruction, and removal of inflamed tissues (synovectomy). Discuss your treatment options
with your doctor to find out what is right for you.