My Rheumatologist
  • What is Rheumatoid Arthritis?

    Rheumatoid arthritis is an auto immune disease that causes inflammation in your joints. The main symptoms are joint pain and swelling. Research shows that the sooner you start treatment for rheumatoid arthritis, the more effective it’s likely to be, so it’s important to see your doctor if you have joint pain and morning stiffness.

  • What are the symptoms of rheumatoid arthritis?

    Symptoms of rheumatoid arthritis tend to come and go. You may have flare-ups when your joints become more inflamed and painful.

    • Joint pain and swelling
    • Stiffness
    • Fatigue
    • Anaemia
    • Flu-like symptoms, such as feeling generally ill, feeling hot and sweating
    • Rheumatoid nodules
    • Inflammation of other body parts, for example, the lungs and blood vessels and the membrane around the heart, but this is rare

    Rheumatoid arthritis varies from person to person, but it usually starts quite slowly. A few joints–often the fingers, wrists or the balls of the feet–become uncomfortable and may swell. You may feel stiff when you wake up in the morning. For about 1 in 5 people with rheumatoid arthritis, the condition develops very rapidly, causing pain and swelling in joints, severe stiffness in the morning and difficulty in doing everyday tasks. You may feel tired, depressed or irritable, even when your joints symptoms are very mild. Joint inflammation can make. Some people feel generally unwell, which can sometimes lead to over whelming tiredness.

  • How is rheumatoid arthritis diagnosed?

    No single test can give a definite diagnosis of rheumatoid arthritis in the early stages of the condition. Doctors have to arrive at a diagnosis based on your symptoms, a physical examination and the results of a variety of x-rays, scans and blood tests. Because rheumatoid arthritis can affect other parts of the body, it’s important to tell your doctor about all the symptoms you’ve had, even if they don’t seem to be related.

    Two kinds of tests may help in confirming the diagnosis. These are:

    • Blood tests
    • X-rays and other scans

    Blood tests may be used to detect changes in your blood that are produced by inflammation.The tests to measure inflammation are

    • Erythrocyte sedimentation rate (ESR)
    • C-reactive protein (CRP)

    Both of these may show a high value when inflammation is present. The test you have depends on the laboratory your doctor uses. Blood tests can show if you’re anaemic and may be used to detect rheumatoid factor.

    Rheumatoid factor is an antibody produced by a reaction in the immune system. The rheumatoid factor test is sometimes called the test for rheumatoid arthritis, but a diagnosis can’t be made based on this alone.

    About four out of five people with rheumatoid arthritis have positive tests for rheumatoid factor. However, about 1 in 20 people without rheumatoid arthritis have positive results as well, so having a positive rheumatoid factor test doesn’t confirm that you have rheumatoid arthritis.

    On the other hand, only about half of all people with rheumatoid arthritis have a positive test for rheumatoid factor when the condition starts, so having a negative rheumatoid factor test doesn’t confirm that you don’t have rheumatoid arthritis. Some people with rheumatoid arthritis never develop rheumatoid factor.

    Another antibody test known as anti-CCP (anti-cyclic citrullinated peptide) is also available. People who test positive for anti-CCP are very likely to develop rheumatoid arthritis. Those who test positive for both rheumatoid factor and anti-CCP may have more severe rheumatoid arthritis.

    X-rays will show any damage caused to the joints by the inflammation in rheumatoid arthritis. These changes often show up in x-rays of the feet before they appear in other joints, so your doctor may want to x-ray your feet even if they’re not causing you any problems. Doctors are assessing imaging techniques such as ultrasound scanning and magnetic resonance imaging (MRI) scans to see how useful they are for early diagnosis and monitoring the condition’s progress.

  • Causes of rheumatoid arthritis

    In autoimmune diseases your immune system, the body’s defence against disease, starts attacking the body’s own tissues as well as attacking germs, viruses and other foreign substances. Attack by the immune system causes inflammation. Where the immune system is attacking a foreign substance it normally stops after that substance has been removed, but in autoimmune diseases. Like rheumatoid arthritis the inflammation is long-lasting (chronic). Finding out why autoimmune diseases develop is key to discovering a cure for them. Different autoimmune diseases attack different tissues, and in rheumatoid arthritis the joints area affected most. The genes you inherit from your parents don’t cause rheumatoid arthritis but they may increase your chances of developing it.

  • Treatments

    Drugs

    There are different types of drugs used to treat rheumatoid arthritis:

    • Painkillers (analgesics)
    • Non-steroidal anti-inflammatory drugs (NSAIDs)
    • Disease-modifying anti-rheumatic drugs (DMARDs), including anti-TNF and other biological therapies
    • Steroids

    Therapies

    Looking after your joints is very important in the treatment of rheumatoid arthritis: A physiotherapist can suggest different exercises that may help ease your symptoms. A podiatrist can give advice on how to look after your feet and what footwear might be suitable. An occupational therapist can suggest ways that you could do day-to-day jobs, both at home and at work, without putting too much strain on your joints.

    Hydrotherapy (exercises done in a special warm-water pool) may ease joint pain.

    Although there’s no cure for rheumatoid arthritis yet, a variety of treatments are available that can slow down the disease and keep joint damage to a minimum. Once joints have been damaged by inflammation they don’t heal very well. Because of this, modern treatment aims to dampen down the inflammation early on in order to limit the damage that occurs.We know that the earlier treatment is started the more effective it’s likely to be. There are four main groups of drugs that are used to treat rheumatoid arthritis.

    These are:

    • Painkillers (analgesics)
    • Non-steroidal anti-inflammatory drugs (NSAIDs)
    • Disease-modifying anti-rheumatic drugs (dmards)
    • Steroids (also known as corticosteroids)

    Many people with rheumatoid arthritis need to take more than one drug. This is because different drugs work in different ways. A common combination is a painkiller, an NSAID and one or more DMARD. Because DMARDs take some time to start working, you may also be given a steroid, which can reduce the inflammation in your joints and ease your symptoms while the other drugs are taking effect.

    Non-steroidal anti-inflammatory drugs (NSAIDs)

    NSAIDs reduce pain and swelling without using steroids, and they start working within a few hours. The effects of some will only last for a few hours but others are effective all day. Your doctor will help you to find the preparation and the best dose for you.

    Possible side-effects

    Like all drugs, NSAIDs can sometimes have side-effects, but your doctor will take precautions to reduce the risk of these–for example, by prescribing the lowest effective dose for the shortest possible period of time.

    NSAIDs can cause digestive problems (stomach upsets, indigestion or damage to the lining of the stomach) so in most cases NSAIDs will be prescribed along with a drug called a proton pump inhibitor(PPI),which will help to protect the stomach. Your doctor will be cautious about prescribing NSAIDs if there are other factors that may increase your overall risk–for example, smoking, circulation problems, high blood pressure, high cholesterol or diabetes.

    Disease-modifying anti-rheumatic drugs (DMARDs)

    DMARDs act by altering the underlying disease rather than treating the symptoms. They are slow-acting and are not painkillers, but over a period of weeks or months they slow down the disease and its effects on the joints, which should bring an improvement in your symptoms. In the short term you may need faster-acting drugs like NSAIDs and/or steroids to ease the pain and stiffness while the DMARDs start to work.

    There are two types of DMARD:

    • Conventional DMARDs
    • Biological therapies

    These drugs are most effective when treatment is started early on in the disease. Most people with rheumatoid arthritis should expect to take them form any years or even for life. You’ll need regular check-ups when you’re taking DMARDs, which may include blood and urine tests. This is to look for any possible side-effects but also to assess how well the drugs are working for you. With careful supervision, these drugs are well tolerated and very effective.

    Conventional DMARDs

    These are slow-acting and can take several weeks to work, so it’s important to keep taking them even if they don’t show any initial benefit

    Biological therapies

    Biological therapies (also known as biologics) are newer drugs that have been developed in recent years as a result of research into the processes in the body that lead to inflammation and damage in the joints. Biological therapies target individual molecules involved in these processes and have proved very effective in the treatment of rheumatoid arthritis. Several biological therapies target a protein called tumor necrosis Factor (anti-TNF drugs), while others target different proteins

    Biological therapies tend to work more quickly than conventional DMARDs, though it may still be several weeks or months before you feel the full benefit.

    Biological therapies are only given when conventional DMARDs alone haven’t worked well enough. In most cases, they are given in combination with a conventional DMARD such as methotrexate. However, in some cases biological therapies may be given on the ground if conventional DMARDs aren’t suitable for you.

    Possible side-effects

    As with any drug, side-effects are possible. The side-effects of DMARDs can be more complex than with NSAIDs, although most people will have only minor problems (if any) such as:

    • Nausea or stomach upsets
    • Skin rashes
    • Headaches
    • Dizziness

    When taking any of the biological therapies, you may also experience some of the following:

    • Sore throat
    • Fever
    • Wheeziness
    • Unexplained bruises, bleeding or paleness symptoms of infection Steroids can be given
    • By injection into the joint itself (intra-articular)
    • By injection into a muscle (intramuscular) or vein (intravenous)–these are sometimes called pulses
    • In tablet form

    Possible side-effects

    Steroid injections have few side-effects, but they may include:

    • Thinning and other changes in the skin at the site of the injection (atrophy)
    • Interference with the menstrual cycle
    • Changes in mood, although this is more common in people with a history of mood disturbances

    Steroid tablets tend to have more side-effects, particularly when they’re used in high doses

    These include the same side-effects as for the injections, but may also include:

    • Weight gain
    • Thinning of the bones (osteoporosis)
    • Muscle weakness
    • Cataracts
    • A rise in blood sugar or blood pressure
    • Increased risk of developing infections

    Doses of steroid tablets are kept as low as possible to keep the risk of side-effects to a minimum. Your doctor may also advise that you take calcium and vitamin D supplements or drugs called bisphosphonates along with the steroids to help protect your bones against osteoporosis

    Physical therapies

    Looking after your joints is very important in the treatment of rheumatoid arthritis. Exercise is an important part of this, and a physiotherapist can suggest different exercises that may help ease your symptoms, strengthen muscles and stretch your joints safely. They can also teach you about joint protection and can refer you to other healthcare professionals if necessary

    A podiatrist can help with problems with your feet and ankles. They can advise you on how to reduce pain when you’re standing or walking and can suggest suitable foot wear for both daily lives.

    Managing a flare-up

    Overtime, you may get better at noticing the early signs of a flare-up. Sometimes a few days rest a you need, though it’s important to do gentle exercise to help ease stiffness. Some of the following tips will also help you to cope with a flare-up and to manage your symptoms in general. Don’t forget that you can also take painkillers, and applying hot or cold pads (for example a hot-water bottle or pack of frozen peas) to affected joints may ease pain too. Make sure you don’t apply them directly to the skin to avoid injury. If you’re having regular flare-ups, you should mention this to your doctor. It may be that you need to review your treatment.

    Exercise

    It’s important to strike a balance between rest and exercise. Rest will make inflamed joints feel more comfortable, but without movement your joints will stiffen and muscles will become weaker. It’s possible to exercise the muscles without even moving the joint by doing isometric exercises. These exercises are done in static positions so the joint angle and muscle length doesn’t change

    Swimming is a particularly good way of exercising for people with rheumatoid arthritis. It exercises the whole body but puts minimal strain on your joints because the water supports your weight. Contact sports and vigorous types of exercise should be avoided. Whichever sport or exercise you do, make sure you warm up properly. If you go to a gym or health club, tell the instructor about your conditions so that they can draw up a suitable exercise plan for you. Your physiotherapist can advise you about this too. Take care when you choose footwear for sports. Good shoes with shock-absorbing soles are essential. A podiatrist will be able to advise you on suitable footwear if necessary.

    Diet and nutrition

    You might see stories in the media about diets that claim to cure rheumatoid arthritis. Although a specific diet won’t cure rheumatoid arthritis, there’s some scientific evidence that certain diets help ease the symptoms for some people. The diets most likely to help are low in saturated fats and high in unsaturated fats, especially omega-3 fatty acids, which are found in oily fish. Increasing your intake of vitamin C may also help. There’s some evidence that a very strict vegetarian diet can help to ease the symptoms of rheumatoid arthritis, although the reasons for this aren’t clear. People who eat a lot of red meat may have as lightly increased risk of developing rheumatoid arthritis. Speak to your doctor or a dietician.

  • For Further Reading