One of the systemic autoimmune diseases is rheumatoid arthritis (RA). In fact, this type of arthritis is inflammatory and involves the synovial joints. It's safe to distinguish rheumatic arthritis by its symmetrical inflammation. In other words, when it affects fingers on one hand, it affects the other hand fingers as well. Besides, this autoimmune disease affects many peripheral joints but it can also affects proximal ones upon neglect. Indeed, a repetition of joint inflammation causes bone, joint and cartilage destruction. In contrast to osteoarthritis which induces a wear-and-tear damage, RA causes the immune system to attack the joints lining (tissues).
What causes rheumatoid arthritis?
Up until today, it's still unclear how rheumatoid arthritis occurs. However, it's mostly suggested that the genome interaction with environmental factors induces the disease. Such environmental factors include smoking, alteration in the gut microbiome, and a viral or a bacterial infection. As for the changes in the intestinal microbiome, it's prevalent among RA patients that they obtain a decrease in the microbiome diversity. Moreover, the dominance of certain genera including Collinsella provokes the severity of the disease.
Symptoms of rheumatoid arthritis:
An early rheumatoid arthritis is the one with symptoms lasting less than 6 months. On the other hand, an established RA is when the symptoms last longer than 6 months. The symptoms include:
- Joint pain especially upon movement and applied pressure
- Swelling and stiffness of the joints especially in the morning
- Peripheral joints primarily affected such as hands and feet fingers joints
- Several small joints are affected symmetrically (3 joints at least)
- Synovial thickening
- Joint redness and heat is uncommon
- Reduction in grip strength
- Symptoms of carpal tunnel syndrome
- Rheumatoid nodules
Risk factors of rheumatoid arthritis:
There are many risk factors that increase your chances of acquiring RA. In general, the risk factors are:
- Age: People who age around 50 years are more prone to rheumatoid arthritis.
- Sex: Females gets the disease more often than men.
- Family history: Having a family member who suffers from RA increases the risk.
- Smoking: It's considered one of the environmental factors that triggers your genes responsible for the disease and adds up its severity.
- Obesity: A person who is over weight or obese tends to have a high risk to this type of arthritis.
Diagnosis:
Laboratory testing:
- A big population of rheumatoid arthritis patients shows the presence of rheumatoid factor (RF), ACPA, or both. Thus, these patients are seropositive. Notably, when both RF and ACPA test postive, the diagnosis gets more trustworthy.
- A high erythrocyte sedimentation rate (ESR) is high if the disease is present.
- An elevation in the level of C-reactive protein (CRP) confirms RA.
- A synovial fluid examination revealing a high leukocyte count (1500-25000 or >25000/cubic mm), low C3 and low C4 is associated with RA.
Imaging:
Radiograph is a method for severe RA to test for bone and cartilage erosion, narrowing of joint space and periarticular osteopenia. However, magnetic resonance imaging (MRI) and ultrasonography can show if there's RA before severity occurs. As a matter of fact, MRI can detect a future possibility of a bony erosion by showing a synovial thickening.
Rheumatoid arthritis treatment:
The treatment of RA joins both pharmacological and non-pharmacological measurements. In fact, there's no cure for rheumatoid arthritis but there's treatments to manage the disease and control symptoms.
Medication:
- Disease-modifying anti-rheumatic drugs (DMARDs): these conventional DMARDs include methotrexate, sulfasalazine, hydroxychloroquine and leflunomide. Also, they are meant to slow the disease progression.
- Biologic DMARDs: Such as entanercept, adalimumab, infliximab, certolizumab pigol and golimumab. These are also known as biologic response modifiers.
- Targeted synthetic DMARDs: These are a replacement of both conventional and biologic DMARDs when unefficient. Besides, they are baricitinib, upadacitinib, and tofacitinib.
- Non steroidal anti-inflammatory drugs (NSAIDs): Are painkillers and they reduce inflammation. The most commonly used NASIDs include ibuprofen (Advil, profinal, etc.) and naproxen sodium (Apronax).
- Steroids: The goal of corticosteroids (prednisone) is to diminish pain and inflammation. Furthermore, it slows any joint damage resulting from the disease.
Physical/occupational therapy:
It's vital to keep the joints flexible and easy to move while doing tasks, which can be met with the help of a therapist. Therefore, the therapist suggests exercises and ways to avoid joint pain while doing tasks.
Surgery:
When the joint damage is severe, surgery is the only option to restore or restore the joints. In general, the surgery is necessary to reduce pain, inflammation and enhance the function of the joints. Rheumatoid arthritis surgeries include:
Joint fushion: Or arthrodesis, is a method that joins bones with a joint. Basically, it involves cutting the bad cartilage, cutting off bone ends and fusing the bones together. Joint fusion is necessary when replacement isn't possible, and it stops pain by realigning the joint.
Total joint replacement: By using a plasyic/metal prosthesis, the surgeon replaces the distressing joints.
Tendon repair: It's only natural that the damage reaches tendons upon joints inflammation. Fortunately, it's possible for the surgeon to repair the tendons.
Synovectomy: Removing the synovium (the lining tissue of the joints) that has inflammation improves its function and reduces pain drastically.
Complications:
Heart disease and diabetes: To avoid such diseases it's important to stop smoking and lose weight.
Osteoporosis: A high risk of developing osteoporosis is due to both RA and its medication.
Sjogren's syndrome: This involves dryness of the eyes and mouth.
Rheumatoid nodules: Not only it forms around joints having pressure such as elbows, it also forms on the lungs and hearts.
Lower immunity: Due to RA and its medicines, the immunity becomes lower and the patients is more prone to infections.
Body composition changes: Here the fat to lean ratio becomes high despite the normal body index (BMI).
Lymphoma: Blood cancers of the lymphatic system can develop because of RA.
Lung problems: These lead to breath shortness due to scarring and inflammation of the lungs.
Carpal tunnel syndrome: Compression of the nerve that leads its way to the fingers and hand due to inflammation of the wrist caused by rheumatoid arthritis.
References:
-Chauhan K, Jandu JS, Goyal A, et al. Rheumatoid Arthritis. [Updated 2022 Apr 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441999
-Mayo clinic "Rheumatoid arthritis"
-Centers for disease control and prevention (CDC) "Rheumatoid arthritis"
-Image credits: https://www.freepik.com/vectors/cartoon-svg
