Rheumatoid arthritis

What is rheumatoid arthritis?

Rheumatoid arthritis is an autoimmune disease. This means that your immune system mistakenly attacks the cells that line your joints. This results in painful swelling and stiffness in any joint in the body, but the hands, feet and wrists are affected in most cases. 

If the condition is diagnosed and treated early, its progression can be slowed. In some severe cases the joints may become permanently damaged or deformed. The cartilage (the stretchy connective tissue between bones), tendons (the tissue that connects bone to muscle), ligaments (the tissue that connects bone and cartilage) and nearby bones can all be affected and this can result in the need for surgery.

What are the symptoms of rheumatoid arthritis?

Sometimes, your symptoms can get worse (called relapses or flare-ups) or improve (called a remission) over time. Flare-ups are often difficult to predict but can be managed with medicine.

The most common symptoms of rheumatoid arthritis are:

• Stiffness and swelling in the wrists, feet and hands, which means that you can’t fully bend your fingers or form a fist and your joints could be hot and tender to touch

• A throbbing and aching pain, which might be worse after a period of inactivity or in the mornings

Other symptoms can include:

• Lack of energy and tiredness

• High temperature and sweating

• Lack of appetite

• Weight loss

• Dry eyes 

• Chest pain 

Symptoms usually develop gradually over several weeks, but in some cases they can progress quickly over a number of days.

If you have persistent pain, swelling or stiffness in your joints, you should go and see a GP so that the underlying cause can be identified. The earlier the condition is diagnosed, the earlier treatment can begin which can reduce the risk of joint damage in the longer-term.

What causes rheumatoid arthritis?

Normally your immune system helps to fight infection by producing antibodies that attack bacteria and viruses. However, in rheumatoid arthritis your immune system mistakenly attacks the tissue surrounding the joint instead. As a result, the synovium (the thin layer of cells that covers your joints) releases chemicals which cause damage and can mean that the joint loses its shape and alignment in time.

Although the exact cause ofrheumatoid arthritis isn’t clear, there are some lifestyle factors which may increase your risk:

• Gender – Women are more commonly affected than men possibly due to the hormone oestrogen

• A family history of rheumatoid arthritis 

• Smoking

How is rheumatoid arthritis diagnosed?

As many conditions cause joint stiffness and inflammation and there's no set test for rheumatoid arthritis, it can be difficult to diagnose.

If you have symptoms, then you should go and see a GP, who may refer you to a specialist in joint conditions (a rheumatologist) for an assessment. Some tests they might recommend include:

• A physical examination of your joints for swelling

• Blood tests – such as 

  • Erythrocyte sedimentation rate (ESR) – measures inflammation 

  • C-reactive protein (CRP) – measures inflammation

  • Anti-cyclic citrullinated peptide (anti-CCP) 

  • Rheumatoid factor

  • Full blood count

Rheumatoid factor and anti-CCP can be helpful in diagnosing rheumatoid arthritis. However, a negative test does not rule the disease out – about 20% of people with rheumatoid arthritis are negative for rheumatoid factor. 

• X-ray or MRI scans of your joints to check for inflammation and damage

• An assessment of your physical ability to perform everyday tasks like walking, eating and dressing

Rheumatoid arthritis treatment

If you’re diagnosed with rheumatoid arthritis, the GP, rheumatologist and a multidisciplinary team will work together to provide your care. This may include: 

• Specialist nurse – They will usually be your first point of contact.

• Physiotherapist – Will help keep your joints mobile through an exercise plan

• Occupational therapist – Specialises in helping people live independent lives and maintain the skills they need for day-to-day living

• Psychologist – Will provide counselling support, if required

Treatment options for rheumatoid arthritis aim to slow the progression of the condition, improve your quality of life and relieve symptoms. They may include:

Medication

Rheumatoid arthritis can not be cured but medication may be prescribed to help treat your symptoms:

• Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, naproxen or diclofenac, or COX-2 inhibitors (coxibs) like celecoxib or etoricoxib which will reduce inflammation and pain. You may also be prescribed a proton pump inhibitor (PPI) when taking these to protect your stomach.

• Corticosteroids, which reduce swelling and pain and are administered by a tablet or injection into the muscle or the joint itself

• Disease-modifying anti-rheumatic drugs (DMARDs) like leflunomide, hydroxychloroquine, sulfasalazine or methotrexate which reduce the effects of the chemicals that your immune system releases when it attacks your joints. These can cause side effects and you will be carefully monitored whilst you are taking them. It may take a while to work and you may need to try different medications to find that suits you. 

• JAK inhibitors are very new medications such as tofacitinib or baricitinib. These are often taken in combination with methotrexate, and can help adults who have severe symptoms.

• Painkillers like paracetamol and codeine

• Steroids that reduce stiffness, pain, and inflammation and are taken as a tablet (prednisolone) or as an injection into the joint or muscle

Biological treatments

This is a newer type of treatment for rheumatoid arthritis, and you’ll usually be offered this if DMARDs are not suitable or have not worked.

Examples include etanercept and infliximab, which prevent certain chemicals in the blood causing the immune system to attack the lining of the joints. They’re given by an injection.

Surgery for arthritis

In severe cases of rheumatoid arthritis, damage may occur to joints and surgery may be recommended to treat any deformities and reduce pain:

• Finger, hand and wrist surgery like carpal tunnel release (where a ligament in the wrist is cut to relieve pressure on a nerve), releasing tendons in the fingers to treat abnormal bending or removing inflamed tissue from the finger joints

• Arthroscopy, where inflamed joint tissue is removed using an arthroscope (a thin tube with a light and camera attached to it) 

• Joint replacement for all or part of a joint in the feet or hands

Supportive treatments

Other services which may help your rheumatoid arthritis symptoms include:

• Physiotherapy to improve your muscle strength and fitness, and the flexibility of your joints 

• Occupational therapy to find practical solutions that will make your day-to-day life easier, like a splint to support your joints 

• Podiatry to help with feet problems, like shoe insoles to ease pain

Complications of rheumatoid arthritis

As with other types of inflammatory arthritis, having rheumatoid arthritis may cause you to develop other complications:

Cardiovascular disease

Cardiovascular disease (CVD) conditions like stroke or heart disease affect the blood vessels and heart. A GP will usually carry out annual tests to monitor your blood pressure and cholesterol to check whether you’ve developed CVD.

You can also reduce your risk of developing CVD by:

• Losing weight

• Stopping smoking

• Reducing your intake of alcohol

• Eating a healthy diet

Widespread inflammation

You may experience inflammation in other parts of your body:

• The lungs, which can cause pleurisy or pulmonary fibrosis and lead to chest pain, shortness of breath and a persistent cough

• The heart, leading to pericarditis which causes chest pain

• The eyes, which can result in scleritis or Sjögren's syndrome and cause eye redness, pain, and dry eyes

• The blood vessels, resulting in vasculitis which causes thickening, weakening, narrowing and scarring of blood vessel walls, which can be life threatening in serious cases

Cervical myelopathy

Long-term rheumatoid arthritis can cause cervical myelopathy, which causes the dislocation of joints at the top of the spine and puts pressure on the spinal cord. Over time this can affect your mobility and requires surgery, but before the operation you may need a special assessment of your neck to check that general anaesthetic can be given safely.