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Rheumatoid arthritis
Rheumatoid arthritis (RA) is a long-term (chronic) disease that causes inflammation of the joints and surrounding tissues. It can also affect other organs.
RA destroys the protective tissue (cartilage) surrounding the joints. Healthy cartilage allows bones to glide smoothly over one another, and absorbs the shock of physical movement. With RA, the cartilage breaks down and wears away. As a result, the bones rub together. Patients with this disease have joint swelling, pain, and stiffness.
RA usually affects joints on both sides of the body equally. Wrists, fingers, knees, feet, and ankles are the most commonly affected.
Signs and Symptoms
RA usually develops slowly over time, with the following symptoms:
• Morning stiffness -- waking up with stiff joints (often the wrists and base of the fingers, ankles, balls of the feet, elbows, or knees)
• Joint pain with warmth, swelling, tenderness, and stiffness of the joint after inactivity
• Limited range of motion in the affected joints
• Fatigue
• Low grade fever (when joints are acutely inflamed)
• Small, round, firm bumps (called nodules) under the skin; you can feel these, but they are generally painless
Juvenile rheumatoid arthritis (JRA, also known as Still's disease) is usually preceded by a high fever and shaking chills. A pink skin rash may also be present.
Causes
The cause of RA is unknown. It is considered an autoimmune disease. The body's immune system normally fights off foreign substances, like viruses. But in an autoimmune disease, the immune system
confuses healthy tissue for foreign substances. As a result, the body attacks itself.
RA can occur at any age. It usually occurs in people between 25 - 55 years of age. Women are affected more often than men.
The course and the severity of the illness can vary considerably. Infection, genes, and hormones may contribute to the disease.
RA usually affects joints on both sides of the body equally. Wrists, fingers, knees, feet, and ankles are the most commonly affected.
Risk Factors
• Age. Although the disease can occur at any age, RA generally starts in young adulthood usually between ages 25 and 55. Juvenile rheumatoid arthritis affects 70,000 - 75,000 children in the United
States.
• Female. Women are affected two and a half times more often than men, and have a greater chance of having a severe case.
• Family history. Having relatives with this type of arthritis increases your risk of getting it yourself.
• Cigarette smoking. It appears that heavy smoking over a long period of time increases your risk of getting RA.
• Coffee intake. This is controversial. One Finnish study reported a direct association between coffee consumption and an increased risk for RA, but the study did not account for other factors,
such as the way coffee is prepared in Finland (typically without filters). A study in the U.S. of 121,701 women found little evidence of an association between coffee or decaf coffee and the risk
of RA. Further investigation is needed.
• Medication. Interferon-alpha, a drug used to treat hepatitis, autoimmune diseases, and other diseases has triggered RA in rare cases.
Other risk factors include:
• History of blood transfusions
• Obesity
Diagnosis
RA can be difficult to diagnose because it resembles many other conditions, and symptoms develop so gradually they can go unnoticed. Even after RA has been diagnosed, it is extremely important
to determine how the disease is progressing in order to treat it appropriately.
Your doctor will take your medical history and perform a physical exam. Blood tests, x-rays, and aspiration (the removal of fluid from the joint) may also be needed. A blood test may be performed
to determine if an antibody called rheumatoid factor is present. Most patients with rheumatoid arthritis eventually have this abnormal protein in their blood. However, it may not present when symptoms
first develop. If rheumatoid factor is present, a positive diagnosis is made. If patients test negative but rheumatoid arthritis is suspected, a health care provider may recommend treatment to
reduce symptoms. Another test may be performed in the future to confirm a diagnosis.
Treatment Approach
RA usually requires lifelong treatment, including various medications, physical therapy, education, and possibly surgery. Treatment is aimed at relieving symptoms and preserving joint function.
Regular visits to your health care provider will be necessary to monitor the progress of the disease and side effects of drugs you may be taking. This might also entail regular blood and urine
tests.
Frequently, the disease can be controlled with a combination of treatments. Treatment may vary depending on the severity of the symptoms. Surgery may be needed, if medications fail.
For the past 10 years, studies have shown that early, aggressive treatment for RA can delay the onset of joint destruction. In addition to rest, strengthening exercises, and anti-inflammatory agents,
the current standard of care is to start therapy with disease-modifying anti-rheumatic drugs (DMARDs) -- these are drugs that actually alter the course of the disease rather than just relieve symptoms.
Studies show that certain dietary supplements, particularly omega-3 fatty acids, show promise in helping to relieve symptoms. Other symptom-relieving measures might include bathing in sulfur baths
or warm pools, applying capsaicin to the skin for pain, and having electrical stimulation to increase muscle strength.
Lifestyle
Range of motion exercises and individualized exercise programs prescribed by a physical therapist can help to maintain joint motion and strength and delay the loss of joint function.
Joint protection techniques, such as heat and cold treatments and splints or orthotic (straightening) devices to support and align joints, may be very helpful.
Medications
The following drugs are used to treat RA:
• Disease-modifying anti-rheumatoid drugs (DMARDs) methotrexate is used most often.
• Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) -- NSAIDS are commonly used to relieve joint pain and inflammation. Although NSAIDs work well, long-term use can cause stomach problems,
such as ulcers and bleeding, and possible heart problems. In April 2005, the U.S. Food and Drug Administration (FDA) asked drug manufacturers of NSAIDs to include a warning label on their product
to alert users of an increased risk for heart problems and gastrointestinal bleeding.
• Cyclo-oxgenase-2 (COX-2) inhibitors -- COX-2 inhibitors block an inflammation-promoting enzyme called COX-2. This class of drugs was initially believed to work as well as traditional NSAIDs,
but with fewer stomach problems. However, numerous reports of heart attacks and stroke have prompted the FDA to re-evaluate the risks and benefits of the COX-2s. Rofecoxib (Vioxx) and valdecoxib
(Bextra) were withdrawn from the U.S. market following reports of heart attacks in patients taking the drugs. Celecoxib (Celebrex) is still available, but it is labeled with strong warnings and
a recommendation that it be prescribed at the lowest possible dose for the shortest duration possible. Patients should ask their doctor whether the drug is appropriate and safe for them.
• Corticosteroids -- Also known as steroids, these medications are injected directly into the joint. They may also be used to reduce inflammation and pain. Steroids for inflammation inlclude prednisone
(Deltasone) and dexamethasone (Decadron). Steroids, however, may cause side effects such as weight gain, nausea, and fluid accumulation (edema). Steroids may also cause drug interactions. Ask a
pharmacist or doctor.
• Immune suppressants -- used for serious cases of RA when all other medications have failed. These include azathioprine (Imuran) and cyclophosphamide (Cytoxan).
• Tumor necrosis factor (TNF) modifiers -- such as rituximab (Rituxan) and infliximab (Remicade®). Both are FDA-approved for moderate-to-severe cases of RA. These drugs block TNFs (inflammatory
proteins). They are injected into an IV.
Surgery and Other Procedures
Occasionally, surgery may be required to treat severely affected joints. The most successful surgeries are those on the knees and hips. Removal of the synovium (called synovectomy) is a common
surgical procedure.
A later alternative is total joint replacement with a prosthesis (an artificial joint). Surgeries may relieve pain, correct deformities, and modestly improve joint function. In extreme cases, total
knee or hip replacement can mean the difference between being completely dependent on others and having an independent life at home.
Nutrition and Dietary Supplements
Diet. It is important to eat a nutritious diet full of whole foods, including protein, which is needed in the body's healing process. Foods rich in B vitamins, vitamin E, zinc, and selenium may
be particularly important. Although several types of diets may be effective for RA, no one diet has been found to work for everyone.
There are reports of people with RA who experienced an improvement in their symptoms when they switched from a typical Western diet (high in animal protein and simple sugars) to a vegan diet with
lots of uncooked berries, fruits, vegetables, nuts, roots, seeds, and sprouts. Vegan diets contain no animal products and obtain protein from vegetable sources.
Elimination/provocation diets (also called elimination/re-challenging diets), are designed to detect allergens by systematically taking certain foods out of the diet and reintroducing them one
at a time. Such diets should be strictly supervised by a qualified physician or dietitian. If this process is followed, you should keep careful track of your symptoms in a food diary to see if
the dietary changes impact your symptoms.
These general nutritional tips may help reduce symptoms:
• Remove known food allergens or irritants. The most common food allergens are dairy products, wheat, corn, peanuts, citrus, soy, eggs, fish, and tomatoes. Your health care provider may want to
test for food sensitivities.
• Avoid refined foods such as white breads, pastas, and sugar.
• Eat fewer red meats and more lean meats, cold-water fish, tofu (soy, if no allergy) or beans for protein.
• Use healthy cooking oils, such as olive oil or vegetable oil.
• Reduce or eliminate trans-fatty acids, found in commercially baked goods such as cookies, crackers, cakes, French fries, onion rings, donuts, processed foods, and margarine.
• Taking digestive enzymes 20 minutes before meals can help enhance digestion and normalize bowel function.
• Avoid coffee and other stimulants, alcohol, and tobacco.
• Drink 6 - 8 glasses of filtered water daily.
• Exercise where possible, 30 minutes daily, 5 days a week.
Nutritional deficiencies may be addressed with the following supplements:
• Glucosamine/chondroitin, 500 - 1,500 mg daily, for joint health.
• Omega-3 fatty acids, such as fish oil, 1 - 2 capsules or 1 tablespoonful oil daily, to help decrease inflammation and improve immunity.
• A multivitamin daily, containing the antioxidant vitamins A, C, D, E, the B-vitamins and trace minerals, such as magnesium, calcium, zinc, and selenium.
• Coenzyme Q10, 100 - 200 mg at bedtime, for antioxidant and immune support.
• Alpha-lipoic acid, 25 - 100 mg twice daily, for antioxidant effects.
• N-acetyl cysteine, 200 mg daily, for antioxidant effects.
• Probiotic supplement (containing Lactobacillus acidophilus), 5 - 10 billion CFUs (colony forming units) a day, for maintenance of gastrointestinal and immune health. Some probiotic supplements
may need refrigeration for best results. Check the label carefully.
• Grapefruit seed extract (Citrus paradisi), 100 mg capsule or 5 - 10 drops (in favorite beverage) three times daily, for antibacterial or antifungal activity and immunity.
• Vitamin C, 500 - 1,000 mg one to three times daily, as an antioxidant, and for immune support.
• SAMe (s-adenosyl-L-methionine), 100 - 200 mg before breakfast daily, for joint health.
• L-theanine, 200 mg one to three times daily, for stress and nervous system support.
Herbs.You can use herbs in the form of dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, make teas with 1 tsp.
herb per cup of hot water. Steep covered 5 - 10 minutes for leaf or flowers, and 10 - 20 minutes for roots. Drink 2 - 4 cups per day.
• Green tea (Camelia sinensis) standardized extract, 250 - 500 mg daily, for antioxidant effects. Use caffeine-free products. You may also prepare teas from the leaf of this herb.
• Cat's claw (Uncaria tomentosa) standardized extract, 20 mg three times a day, for inflammation and antibacterial or antifungal activity.
• Reishi mushroom (Ganoderma lucidum), 150 - 300 mg two to three times daily, for inflammation and for immunity. You may also take a tincture of this mushroom extract, 30 - 60 drops two to three
times a day.
• Olive leaf (Olea europaea) standardized extract, 250 - 500 mg one to three times daily, for antibacterial or antifungal activity and immunity. You may also prepare teas from the leaf of this
herb.
• Bromelain (Ananus comosus) standardized, 40 mg three times daily, for pain and inflammation.
• Turmeric (Curcuma longa) standardized extract, 300 mg three times a day, for pain and inflammation.
• Devil's claw (Harpagophytum procumbens) standardized extract, 100 - 200 mg one to two times daily, for inflammation.
• Willow bark (Salix alba) standardized extract, 500 mg up to three times daily.
Capsaicin (Capsicum frutescens) Cream
Capsaicin is the main component in hot chili peppers (also known as cayenne). Researchers believe that when applied to the skin, it may deplete stores of a substance that contributes to inflammation
and pain in arthritis. Pain reduction generally begins three to seven days after initially applying the capsaicin cream to the skin, but may be most pronounced after about four weeks of use. Wash
hands well with vinegar after use and avoid touching the eyes.
Acupuncture
There is little to no scientific evidence supporting the use of acupuncture for RA. However, there is much anecdotal evidence to support trying acupuncture for symptom relief and improvement in
overall health in patients with RA. Acupuncturists treat people with RA based on an individualized assessment of the excesses and deficiencies of qi, or energy, located in various meridians. A
qi deficiency is usually detected in the spleen and kidney meridians.
Acupuncturists may use moxibustion [a technique in which the herb mugwort (Artemesia vulgaris) is burned over specific acupuncture points] to strengthen the entire energy system. Qualified acupuncturists
may also provide lifestyle, dietary, and herbal advice to people with RA. Practitioners may apply local treatment to the painful areas and related sore points, either with a needle or moxibustion.
However, given the current lack of evidence, acupuncture should be used as a supportive treatment with conventional medical therapy.
Chiropractic
Chiropractors do not treat red, swollen joints, and high velocity chiropractic manipulation is considered inappropriate in areas of the body affected by this condition. However, some chiropractors
report that spinal manipulation may decrease pain and enhance joint mobility when used in between flare ups for people with RA.
Exercise
It is important to maintain a balance between rest (which will reduce inflammation) and exercise (which will relieve stiffness and weakness). Clinical studies suggest that as little as three hours
of physical therapy over six weeks will help you people who have RA, and these benefits are sustained.
The goal of exercise is the following:
• To maintain a wide range of motion
• To increase strength, endurance, and mobility
• Improve general health
• Promote well-being
While traditional guidelines have restricted RA patients to only gentle exercise, research suggests that more intense exercise may not only be safe, but may actually produce greater muscle strength
and overall functioning. Signs from your body are the best guides for how long or hard you should exercise.
• If you feel sharp pains while exercising, stop immediately.
• If lesser aches and pains continue for more than 2 hours afterwards, try a lighter exercise program for awhile.
• Using large joints instead of small ones for ordinary tasks can help relieve pressure. For example, use your hip to close doors or the palm of your hand to push buttons.
Balneotherapy (Hydrotherapy or spa therapy)
Balneotherapy is one of the oldest forms of therapy for pain relief for people with arthritis. The term "balneo" comes from the Latin word for bath (balneum) and refers to bathing in
thermal or mineral waters. For example, sulfur-containing mud baths have been shown to relieve symptoms of arthritis. The goals of balneotherapy for arthritis include:
• Improving range of joint motion
• Increasing muscle strength
• Eliminating muscle spasm
• Enhancing functional mobility
• Easing pain
• Exercising and swimming in a heated pool may also be beneficial
Mechanical Aids
A variety of mechanical devices, called orthoses, are available for people with RA to help support and protect joints. Made from lightweight metal leather, elastic, foam, and plastic, orthoses
allow some movement within the affected joint and do not restrict nearby joints. For example, splints or braces help align joints and properly distribute weight. Shock-absorbing soles in shoes
can help in daily activities and during exercise. These mechanical aids are used most frequently to treat arthritic hands, wrists, knees, ankles, and feet. A physical or occupational therapist
should custom-fit orthoses.
Compression gloves are another potentially helpful aid. Two studies on the overnight use of compression gloves (close-fitting nylon-spandex gloves) concluded that the gloves reduced pain and stiffness
in people with RA in the fingers.
Other possibilities for symptom relief include:
• Transcutaneous nerve stimulation (TENS) -- small clinical studies show that at 70Hz, TENS, a technique used by many physical therapists, may provide short-term pain relief for people with RA
• Magnetic devices -- devices employing static magnetic fields may help reduce pain
• Heat and cold applications -- some people find these applications comforting; may reduce pain
Homeopathy
Recent trials evaluating the use of homeopathy in the treatment of RA found that the remedies were no more effective than placebo in reducing symptoms. These studies contradict an older trial that
showed beneficial effects with homeopathic treatment. Despite the lack of definitive evidence, professional homeopaths might recommend one of the following treatments for RA based on their knowledge
and clinical experience, as well as successful trials for homeopathy to treat OA. Before prescribing a remedy, homeopaths take into account an individual's constitutional type-- your physical,
emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a particular individual.
Potential remedies include:
• A topical homeopathic gel containing comfrey (Symphytum officinale), poison ivy (Rhus toxicodendron), and marsh-tea (Ledum palustre)
• A combination homeopathic preparation containing R. toxicodendron, Arnica Montana (arnica), Solanum dulcamara (climbing nightshade), Sanguinarra Canadensis (bloodroot), and Sulphur
• A liquid homeopathic preparation containing R. toxicodendron, Causticum (potassium hydrate), and Lac vaccinum (cow's milk)
Mind-Body Medicine
Chronic pain and disability can make daily functioning difficult. A holistic approach to your care may positively affect both your lifestyle and how you feel overall. Many people report that relaxation
techniques, such as guided imagery and meditation, are an important part of general care and help alleviate pain and other symptoms of RA.
Yoga
This ancient Indian practice is well known for its physical, psychological, emotional, and spiritual benefits and is often recommended to relieve musculoskeletal symptoms. People with arthritis
should begin asanas slowly and they should be performed only after a warm up. Yoga is best performed under the careful guidance of a reputable instructor.
Tai Chi
This gentle exercise program practiced in China for centuries has been shown to produce a number of benefits, including the following:
• Improved fitness
• Increased muscular strength
• Enhanced flexibility
• Reduced percentage of body fat
• Diminished risk of falls in the elderly
Several clinical trials have found that Tai Chi produces significant improvement in those with rheumatoid arthritis. Improvements were found in:
• Overall sense of quality of life
• Diminished feelings of stress/tension
• Increased satisfaction with general health
• Decreased fatigue
• Easier self management of arthritis symptoms
These benefits are likely to apply to individuals with RA as well. A review of the literature found that Tai Chi benefits lower extremity range of motion for people with RA.
Prognosis and Complications
RA is associated with many complications.
• Joint deformities
• Cervical spine problems (can be life threatening)
• Painless, hard, round or oval masses called nodules that appear under the skin
• Pleuritis (inflammation of the lungs)
• Anemia
• Rheumatoid vasculitis (inflammation of the blood vessels)
• Pericarditis (inflammation of the outer lining of the heart)
• Myocarditis (inflammation of the heart muscle)
• Heart failure
• Eye inflammation
The course of the disease varies between individuals. People with a certain antibody in the blood (rheumatoid factor) or nodules seem to have more severe disease. People who develop RA at younger
ages also tend to have faster disease progression.
Remission is most likely to occur in the first year and decreases over time. About 20% of people will experience remission and be able to care for themselves 10 - 15 years after diagnosis.
Although complications may shorten the life expectancy of people with RA, treatment is constantly improving and the occurrence of severe disability and life-threatening complications appears to
be decreasing.
Reviewed By: Harvey Simon, MD, Editor-in-Chief, In-Depth Reports; Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.
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