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Rheumatoid arthritis (RA) is an autoimmune disease that causes chronic inflammation of the joints. Rheumatoid arthritis can also cause inflammation of the tissue around the joints, as well as in other organs in the body. 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 in their blood that target their own body tissues, where they can be associated with inflammation. 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. 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 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. 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, but it most often starts after 40 years of age and before 60 years of age. In some families, multiple members can be affected, suggesting a genetic basis for the disorder.
depending on the degree of tissue inflammation. destruction. Immune cells. and sometimes nodules of inflammation . and interleukin-6/IL-6) are expressed in the inflamed areas. none has been proven as the cause. symptoms return. Environmental factors also seem to play some role in causing rheumatoid arthritis. Since rheumatoid arthritis is a systemic disease. symptoms can include fatigue. the disease is active. such as tumor necrosis factor/TNF. it can cause hoarseness of the voice. and loss of function. can become difficult during flares. This leads to a loss of cartilage and erosion and weakness of the bones as well as the muscles. In rheumatoid arthritis. only one joint is inflamed.What causes rheumatoid arthritis? The cause of rheumatoid arthritis is unknown. joints frequently become red. loss of energy. the arthritis can mimic the joint inflammation caused by other forms of arthritis. The small joints of the feet are also commonly involved. and people generally feel well. lack of appetite. The course of rheumatoid arthritis varies among affected individuals. Simple tasks of daily living. the result is an immune system that is geared up to promote inflammation in the joints and occasionally other tissues of the body. or years. and fungi have long been suspected. Regardless of the exact trigger. or coughing. the disease is inactive (in remission). It is also suspected that certain infections or factors in the environment might trigger the activation of the immune system in susceptible individuals. are activated and chemical messengers (cytokines. When the disease becomes active again (relapse). This occurs because the lining tissue of the joint (synovium) becomes inflamed. This leads to inflammation in the joints and sometimes in various organs of the body. scientists have reported that smoking tobacco increases the risk of developing rheumatoid arthritis. swollen. shortness of breath. Arthritis is common during disease flares. When the disease is active. The return of disease activity and symptoms is called a flare. such as the lungs or eyes. Chronic inflammation can cause damage to body tissues. For example. Occasionally. Also during flares. its inflammation can affect organs and areas of the body other than the joints. resulting in the production of excessive joint fluid (synovial fluid). When only one joint is involved. When this joint is inflamed. Rarely. low-grade fever. Remissions can occur spontaneously or with treatment and can last weeks. and stiffness. rheumatoid arthritis can even affect the joint that is responsible for the tightening of our vocal cords to change the tone of our voice. scarred. This misdirected immune system then attacks the body's own tissues. months. It is believed that the tendency to develop rheumatoid arthritis may be genetically inherited. muscle and joint aches. When tissue inflammation subsides. and tender. When body tissues are inflamed. such as gout or joint infection. resulting in joint deformity. painful. The cause of rheumatoid arthritis is a very active area of worldwide research. and periods of flares and remissions are typical. Even though infectious agents such as viruses. including cartilage and bone. interleukin-1/IL-1. the cricoarytenoid joint. Rheumatoid inflammation of the lung lining (pleuritis) causes chest pain with deep breathing. During remissions. called lymphocytes. What are the symptoms and signs of rheumatoid arthritis? The symptoms of rheumatoid arthritis come and go. such as turning door knobs and opening jars. Inflammation of the glands of the eyes and mouth can cause dryness of these areas and is referred to as . multiple joints are usually inflamed in a symmetrical pattern (both sides of the body affected). symptoms of the disease disappear. The synovium also thickens with inflammation (synovitis). bacteria. The small joints of both the hands and wrists are often involved. The lung tissue itself can also become inflamed. Muscle and joint stiffness are usually most notable in the morning and after periods of inactivity.
The doctor may then perform other tests to exclude arthritis due to infection or gout. ANA. can cause a chest pain that typically changes in intensity when lying down or leaning forward. Citrulline antibody(also referred to as anticitrulline antibody. The distribution of joint inflammation is important to the doctor in making a diagnosis. In rheumatoid arthritis. When only one or two joints are inflamed. and knees are typically inflamed in a symmetrical distribution (affecting both sides of the body). The doctor reviews the history of symptoms. Another antibody called the "antinuclear antibody" (ANA) is also frequently found in people with rheumatoid arthritis. and C-reactive protein tests can also be abnormal in other systemic autoimmune and inflammatory conditions. It is useful in the diagnosis of rheumatoid arthritis when evaluating cases of unexplained joint inflammation. Citrulline antibodies have been felt to represent the earlier stages of rheumatoid arthritis in this setting. examines the joints for inflammation and deformity. Decreased white cells can be associated with anenlarged spleen (referred to as Felty's syndrome) and can increase the risk of infections. anticyclic citrullinated peptide antibody. Abnormal antibodies can be found in the blood of people with rheumatoid arthritis. occasionally they can become infected. is blood vessel inflammation (vasculitis). Several visits may be necessary before the doctor can be certain of the diagnosis. since anemia is common in rheumatoid arthritis. the distribution of the inflamed joints. usually with long-standing rheumatoid disease. the small joints of the hands. This is most often initially visible as tiny black areas around the nail beds or as leg ulcers. A blood test called the sedimentation rate (sed rate) is a measure of how fast red blood cells fall to the bottom of a test tube. Vasculitis can impair blood supply to tissues and lead to tissue death (necrosis). and the blood and X-ray findings. called pericarditis. serious complication. Certain blood and X-ray tests are often obtained. The rheumatoid factor. particularly because of the chronic inflammation. Therefore. the skin for rheumatoid nodules. Firm lumps under the skin (rheumatoid nodules) can occur around the elbows and fingers where there is frequent pressure. Joint X-rays may be normal or only show swelling of soft tissues early in the disease. Blood testing may also reveal anemia. Nerves can become pinched in the wrists to cause carpal tunnel syndrome. abnormalities in these blood tests alone are not sufficient for a firm diagnosis of rheumatoid arthritis. As the disease progresses. Xrays can show bony erosions typical of rheumatoid arthritis in the joints. A rare. Another blood test that is used to measure the degree of inflammation present in the body is the C-reactive protein. wrists. is not present. The sed rate is usually faster during disease flares and slower during remissions. sed rate. most often around the elbows and fingers. rheumatoid factor. and other parts of the body for inflammation. The detection of rheumatoid nodules (described above). and anti-CCP) is present in most people with rheumatoid arthritis. A doctor with special training in arthritis and related diseases is called a rheumatologist.(rheumatoid nodules) develop within the lungs. The rheumatoid disease can reduce the number of red blood cells (anemia) and white blood cells. feet. The sed rate is used as a crude measure of the inflammation of the joints. Joint X-rays can also be helpful in monitoring . Even though these nodules usually do not cause symptoms. How is rheumatoid arthritis diagnosed? The first step in the diagnosis of rheumatoid arthritis is a meeting between the doctor and the patient. A test for citrulline antibodies is most helpful in looking for the cause of previously undiagnosed inflammatory arthritis when the traditional blood test for rheumatoid arthritis. can suggest the diagnosis. Inflammation of the tissue (pericardium) surrounding the heart. The diagnosis will be based on the pattern of symptoms. An antibody called "rheumatoid factor" can be found in 80% of patients. the diagnosis of rheumatoid arthritis becomes more difficult.
can also be used to demonstrate the inflamed joints. evidence of bone thinning around a joint with or without slight bone damage y slight cartilage damage possible y joint mobility may be limited. although there may be signs of bone thinning Stage II y on X-ray. 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. no joint deformities observed y atrophy of adjacent muscle y abnormalities of soft tissue around joint possible Stage III y on X-ray.the progression of disease and joint damage over time. Bone scanning. evidence of cartilage and bone damage and bone thinning around the joint y joint deformity without permanent stiffening or fixation of the joint y extensive muscle atrophy y abnormalities of soft tissue around joint possible Stage IV . MRI scanning can also be used to demonstrate joint damage. Stage I y no damage seen on X-rays. This system helps medical professionals classify the severity of your rheumatoid arthritis. a radioactive procedure.
such as infection and gout. evidence of cartilage and bone damage and osteoporosis around joint y joint deformity with permanent fixation of the joint (referred to as ankylosis) y extensive muscle atrophy y abnormalities of soft tissue around joint possible Rheumatologists also classify the functional status of people with rheumatoid arthritis as follows: y Class I: completely able to perform usual activities of daily living y Class II: able to perform usual self-care and work activities but limited in activities outside of work (such as playing sports. maximize joint function. general health.y on X-ray. cortisone medications are injected into the joint during the arthrocentesis in order to rapidly relieve joint inflammation and further reduce symptoms. rest. the goal of treatment in rheumatoid arthritis is to reduce joint inflammation and pain. Early medical intervention has been shown to be important in improving outcomes. joint-strengthening exercises. work. To date. Treatment is customized according to many factors such as disease activity. Occasionally. . types of joints involved. and prevent joint destruction and deformity. In this procedure. and patient (and family) education. and prevent work disability. How is rheumatoid arthritis treated? There is no known cure for rheumatoid arthritis. stop damage to joints as monitored on X-rays. a sterile needle and syringe are used to drain joint fluid out of the joint for study in the laboratory. and other activities The doctor may elect to perform an office procedure called arthrocentesis. joint protection. Analysis of the joint fluid in the laboratory can help to exclude other causes of arthritis. Arthrocentesis can also be helpful in relieving joint swelling and pain. household chores) y Class III: able to perform usual self-care activities but limited in work and other activities y Class IV: limited in ability to perform usual self-care. Aggressive management can improve function. Optimal treatment for the disease involves a combination of medications.
and etodolac (Lodine) are examples of nonsteroidal anti-inflammatory drugs (NSAIDs). surgery may be necessary. abdominal pain. "First-line" medications Acetylsalicylate (aspirin). corticosteroids can have serious side effects. and swelling. 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). easy bruising. Therefore. In some cases with severe joint deformity. NSAIDs are usually taken with food. and destruction of large joints. especially when given in high doses for long periods of time. NSAIDs are medications that can reduce tissue inflammation. Newer NSAIDs include selective Cox-2 inhibitors. Corticosteroid medications can be given orally or injected directly into tissues and joints. risk of infection. These medications include antacids. and misoprostol(Cytotec). less destructive forms of the disease or disease that has quieted after years of activity ("burned out" rheumatoid arthritis) can be managed with rest and pain and anti-inflammatory medications alone. 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. patient. Those with uncommon. but they are not anti-inflammatory agents. The newer NSAIDs are just as effective as aspirin in reducing inflammation and pain and require fewer dosages per day. function is improved and disability and joint destruction are minimized when the condition is treated earlier with second-line drugs (disease-modifying antirheumatic drugs). Aspirin has been used for joint problems since the ancient Egyptian era. such as gold. in addition to anti-inflammatory agents. In general. however. facial puffiness.sucralfate (Carafate). naproxen(Naprosyn). thinning of the skin and bone. please read the article on prednisone. Corticosteroids are useful for short periods during severe flares of disease activity or when the disease is not responding to NSAIDs. methotrexate. Treatment is most successful when there is close cooperation between the doctor. and patient occupation. which offer anti-inflammatory effects with less risk of stomach irritation and bleeding risk. promote disease remission and prevent progressive joint destruction. NSAIDs are not cortisone. ulcers. ibuprofen (Advil. and hydroxychloroquine (Plaquenil). These side effects include weight gain. cataracts. In order to reduce gastrointestinal side effects. pain. The degree of destructiveness of rheumatoid arthritis varies among affected individuals. They are more potent than NSAIDs in reducing inflammation and in restoring joint mobility and function. such as methotrexate. . These side effects can be partially avoided by gradually tapering the doses of corticosteroids as the individual achieves improvement in symptoms. Patients' responses to different NSAID medications vary. even within months of the diagnosis. is an effective anti-inflammatory medication for rheumatoid arthritis. Most people require more aggressive second-line drugs. in doses higher than those used in treating headaches and fever. Thinning of the bones due to osteoporosis may be prevented by calcium and vitamin D supplements. Sometimes these second-line drugs are used in combination. and even gastrointestinal bleeding. such as aspirin and cortisone (corticosteroids). such as celecoxib(Celebrex). such as the hips. The most common side effects of aspirin and other NSAIDs include stomach upset. Motrin). are used to reduce pain and inflammation. proton-pump inhibitors (Prevacid and others). muscle wasting. Additional medications are frequently recommended to protect the stomach from the ulcer effects of NSAIDs. Aspirin. For further information on corticosteroids. The slow-acting secondline drugs. However. The first-line drugs.age. Corticosteroids also carry some increased risk of contracting infections. and family members. Medipren. Abruptly discontinuing corticosteroids can lead to flares of the disease or other symptoms of corticosteroid withdrawal and is discouraged.
It can affect the bone marrow and the liver. Common side effects include rash and upset stomach. kidney damage with leakage of protein in the urine. Oral gold can cause diarrhea. Methotrexate has gained popularity among doctors as an initial second-line drug because of both its effectiveness and relatively infrequent side effects. muscle weakness. D-penicillamine can rarely cause symptoms of other autoimmune diseases and is no longer commonly used for the treatment of rheumatoid arthritis. If maximally effective.azathioprine (Imuran). a metallic taste in the mouth. chills. Side effects are similar to those of gold. Trexall) as described above."Second-line" or "slow-acting" drugs (Disease-modifying anti-rheumatic drugs or DMARDs) While "first-line" medications (NSAIDs and corticosteroids) can relieve joint inflammation and pain. Immunosuppressive medicines are powerful medications that suppress the body's immune system. Recent research suggests that patients who respond to a DMARD with control of the rheumatoid disease may actually decrease the known risk (small but real) of lymphoma(cancer of lymph nodes) that exists from simply having rheumatoid arthritis. even rarely causing cirrhosis. Those receiving gold treatment are regularly monitored with blood and urine tests. They include fever. and easy bruising. As with the firstline medications. people taking Plaquenil should be monitored by an eye doctor (ophthalmologist). The medications needed for ideal management of the disease are also referred to as disease-modifying antirheumatic drugs or DMARDs. Rheumatoid arthritis requires medications other than NSAIDs and corticosteroids to stop progressive damage to cartilage. They come in a variety of forms and are listed below. was introduced in the 1980s. initially on a weekly basis. Hydroxychloroquine (Plaquenil) is related to quinine and is also used in the treatment ofmalaria. the doctor may need to try different second-line medications before treatment is optimal. stomach upset. they do not necessarily prevent joint destruction or deformity. thereby retarding the progression of joint destruction and deformity. auranofin (Ridaura). such as ulcerative colitis andCrohn's colitis. These "second-line" or "slow-acting" medicines may take weeks to months to become effective. and vision changes. Sulfasalazine (Azulfidine) is an oral medication traditionally used in the treatment of mild to moderately severe inflammatory bowel diseases. These gold drugs have lost favor because of the availability of more effective treatments. Azulfidine is used to treat rheumatoid arthritis in combination with anti-inflammatory medications. It also has an advantage in dose flexibility (dosages can be adjusted according to needs). for months to years. Gold salts have been used to treat rheumatoid arthritis throughout most of the past century. Cuprimine) can be helpful in selected cases of progressive forms of rheumatoid arthritis. skin rash. All people taking methotrexate require regular blood tests to monitor blood counts and liver function. D-penicillamine (Depen. mouth sores. at varying doses. Gold thioglucose (Solganal) and gold thiomalate (Myochrysine) are given by injection. and bone marrow damage with anemia and low white cell count. Even though vision changes are rare. chlorambucil (Leukeran). They include methotrexate (Rheumatrex. skin rashes. Sometimes a number of DMARD second-line medications are used together as combination therapy. . even years. The various available DMARDs are reviewed next. Azulfidine is generally well tolerated. it should be avoided by people with known sulfa allergies. It is used over long periods for the treatment of rheumatoid arthritis. DMARDs can promote remission. People taking this medication require routine blood and urine tests. Possible side effects include upset stomach. kidney and bone marrow damage. Because Azulfidine is made up of sulfa and salicylate compounds. Oral gold. cyclophosphamide (Cytoxan). Side effects of gold (oral and injectable) include skin rash. bone. and adjacent soft tissues. A number of immunosuppressive drugs are used to treat rheumatoid arthritis. and many companies no longer manufacture them. Methotrexate is an immune-suppression drug. They are used for long periods of time. mouth sores.
A low white count can increase the risk of infections. and the importance of balancing rest and activity . The exception is methotrexate. which is not frequently associated with serious side effects and can be carefully monitored with blood testing. Immunosuppressive medications can depress bone-marrow function and cause anemia. Methotrexate rarely can lead to liver cirrhosis and allergic reactions in the lung. while a low platelet count can increase the risk of bleeding. immunosuppressive medications are used in low doses. a low white cell count. James¶s work schedule. such as blood vessel inflammation (vasculitis). Discuss ways to delegate household tasks to other family members. using cold packs as needed Teach techniques to minimize joint stress while performing ADLs. Methotrexate has become a preferred second-line medication as a result. Because of potentially serious side effects.andcyclosporine (Sandimmune). Provide information about the disease process and its manifestations. Cyclosporine can cause kidney damage and high blood pressure. Explore ways to incorporate 30-minute rest breaks into Mrs. prescribed medications with desired and adverse effects. Because of potentially serious side effects. and low platelet counts. immunosuppressive medicines (other than methotrexate) are generally reserved for those who have very aggressive disease or those with serious complications of rheumatoid inflammation. usually in combination with anti-inflammatory agents. including: Scheduling NSAIDs at equal intervals throughout the day Taking morning NSAID dose with milk and crackers approximately 30 minutes before rising Performing ROM exercises in shower or bathtub Applying local heat with paraffin dip or compress. Provide Arthritis Foundation literature and information. PLANNING AND IMPLEMENTATION Teach techniques for relieving pain and morning stiffness.
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