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Rheumatoid arthritis Causes, Symptoms and Treatment

The  rheumatoid arthritis  is the most common of the various forms of  rheumatism chronic inflammatory collectively known as “chronic arthritis.” It is part of what is called autoimmune diseases, diseases where immunity attacks the body of the person with the disease. It is also a system disease that does not always reach only the joints, but sometimes other areas of the body as well.

It causes inflammation of several  joints  at once, which swell, become painful and are limited in their range of motion. Without treatment, these joints tend to deform gradually over time. Rheumatoid arthritis most commonly affects the  hands ,  wrists ,  knees  and small joints of the  feet . Over time, and sometimes early in the illness, the shoulders, elbows, neck, jaws, hips and ankles can also be affected.

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The evolution  of  rheumatoid arthritis  is difficult to predict. In many cases, it develops in flares, interspersed with periods when symptoms subside or even disappear temporarily. As a rule, the disease tends to get worse, to reach and damage more and more joints. If not properly treated, arthritis can become very disabling in 20% of cases. However, in 10-15% of people with recent disease, the disease may cease forever or for very long years, spontaneously, and more with recent treatments. And there is rheumatoid arthritis of relatively benign evolution.

Prevalence

Rheumatoid arthritis affects 0.25% of the general population, and women three times more often than men. It is the most common chronic inflammatory rheumatism. Although the disease may appear at any age, the first symptoms usually occur around age 40 to age 60.

Causes of Rheumatoid arthritis

The  rheumatoid arthritis  is a  disease self immune  : the immune system attacks the synovial membrane of joints, including the production of antibodies called “autoantibodies”. The synovial membrane lines the inside of our joints and its role is to make a liquid, the synovial fluid allowing the lubrication of the movements. When it is attacked by autoimmune, this membrane thickens, makes too much liquid that contains abnormal inflammatory enzymes, likely to attack the entire joint, cartilage, tendons and bone.

The disease is likely to be triggered by a combination of genetic, biological and environmental factors, particularly smoking.

In recent years, advances in genetics have detected more than 30  genetic factors involved in the onset of arthritis. Only the involvement of certain genes, such as HLA-DRB1 and PTPN22, is clearly demonstrated. However, polyarthritis is not a “purely” genetic disease. It is estimated that the weight of genetics in triggering rheumatoid arthritis is less than 30% 2 .

The inflammation involved

The symptoms of polyarthritis are due to an  autoimmune reaction triggering abnormal inflammation within the joint. Inflammation first affects the synovial membrane, the membrane surrounding the joints (see diagram above). This membrane thickens, then lets out fluid and some elements of the blood in the joint, which explains the joint swelling. Then, progressively, in aggressive polyarthritis, inflammation damages the joint, cartilage, capsule, tendons, ligaments, muscles and bone, eroding the bone  and damaging the joint more and more .

Evolution

The evolution of  rheumatoid arthritis  is very variable from person to person. In the majority of cases, the disease sets in gradually, by outbreaks over several weeks or months. Symptoms can also occur suddenly. The outbreaks of the disease are interspersed with periods of improvement more or less long, ranging from a few weeks to a few years.

In 10 to 15% of people with rheumatoid arthritis for less than 3 to 6 months, the disease goes away on its own, permanently or, at least, for a very prolonged period (several months or years). However, despite this apparent healing, a new outbreak may occur.

As a general rule, the disease tends to worsen and affect more and more joints . Some forms of arthritis are very “aggressive” because they also affect organslike the heart, lungs, vessels or kidneys and can be life threatening. Others can cause very rapid joint destruction, especially in the first 2 years (about 10% to 20% of polyarthritis). Conversely, there are “benign” forms that cause little pain and no joint deformity, even after several years. If they are not treated, however, it is considered that more than half of those affected will have a significant functional disability after 10 years. This often requires the cessation of professional activities.

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Diagnostic of Rheumatoid arthritis

It is important to get an  early diagnosis  of the disease to be able to benefit quickly from an effective treatment. Current treatments can block the progression of the disease, thus avoiding handicaps.

There is no specific sign to say with certainty that it is  rheumatoid arthritis . The signs described by the sick person must be taken into account, in particular the presence of several joint swellings, pain, and their location, as well as fatigue.
There are also exams that go through a health scan that can give clues about the risk of arthritis and indicate inflammation:

  • elevation of the sedimentation rate,
  • increased C-reactive protein),
  • increased auto antibodies (rheumatoid factors and / or anti-citrullinated protein antibodies

The presence of rheumatoid factor in a person’s blood does not mean that they necessarily suffer from rheumatoid arthritis. This antibody is present in some healthy people and is also found in other diseases.

In the face of a suspected rheumatoid arthritis, the medical assessment also includes X-rays of the hands, feet and other inflammatory joints to see typical signs from the beginning of the disease. Joint ultrasound or joint MRI can also be requested by the doctor.

Complications

A  joint deformity may occur over time. For example, fingers are said to deform into “goose neck” or “buttonhole” and toes, “hammer”. When not properly treated, the disease can result in a  loss of dexterity . Simple gestures, such as turning a doorknob or holding a pencil, then become laborious. In rare cases, the disease becomes so disabling that it requires wheelchair access.

Rheumatoid arthritis is also often complicated by disorders outside the joints.
– Dryness in the eyes and mouth (Sjögren’s syndrome),
– Rheumatoid nodules, balls located under the skin often at the elbows or near the joints of the fingers,
– Damage to the lungs,
– Damage eyes,
attacks of the heart or vessels,
attacks of the nerves.
– Infectious problems.

Fortunately, appropriate treatments, adopted early in the disease, can limit disability  and joint destruction. In addition, by adopting a way of life that allows them to reduce the pain, the majority of the people reached manage to have a good quality of life.

When poorly controlled , arthritis can reduce life expectancy by 5 to 10 years. Indeed, a state of chronic inflammation increases the risk of cardiovascular disorders, for example heart attacks , similarly to a rise in cholesterol or the presence of diabetes.

The symptoms of rheumatoid arthritis (rheumatism, arthritis)

Initial symptoms

  • Of  pain  (or sensitivity) to the affected joints. The pains are stronger at night and in the early morning, or after a period of prolonged rest. They often cause a night awakening in the second half of the night. They can be continual and play a lot on morale.
  • The  swelling  (edema) of one or, most often, several joints. As a rule, the damage is “symmetrical”, that is to say that the same group of joints is touched on both sides of the body. It is often the wrists or joints of the fingers, especially those closest to the hand;
  • Affected joints are also hot and sometimes red;
  • A  stiff  morning joints, which persists for at least 30 to 60 minutes. This stiffness subsides after the “rustling” of the joints, that is to say after having mobilized and “warmed up”. However, stiffness can return in the day, after a period of prolonged inactivity;
  • Fatigue is very prevalent in this disease, often from the beginning. It can be very disabling and difficult to understand for those around you. It is related to the autoimmune process and inflammation. It can be associated with a lack of appetite.
  • Fever may be present during outbreaks of the disease.

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Evolution of symptoms

  • The more the disease evolves, the more difficult it is to use or move normally the affected joints;
  • New joints can be affected;
  • Small,  hard  (painless) lumps can form under the skin, especially in the back of the ankles (Achilles tendon), at the elbows and near the joints of the hands. These are “rheumatoid nodules”, present in 10 to 20% of people with the disease;
  • Depression, caused by pain, the chronicity of the disease, and any life changes it imposes, can occur.

Other symptoms (not affecting the joints)

In some people, the autoimmune process of rheumatoid arthritis can attack various  organs  in addition to joints. These forms may require a more aggressive therapeutic approach.

  • A dry  eye  and  mouth  (Sjögren’s syndrome), present in about a quarter of people affected;
  • An impairment of the  heart , especially its envelope (called pericardium) which does not always cause symptoms;
  • Impairment of the  lungs  or  kidneys , which may also be related to or aggravated by the medication
  • Inflammatory anemia
Note

The rheumatoid arthritis often presents in a symmetrical manner, reaching the same joints on two sides of the body. This sign distinguishes it from osteoarthritis, which usually affects the joints on one side at a time.

People at risk for Rheumatoid arthritis

  • The women. They are 2 to 3 times more affected than men;
  • People between 40 and 60, the most common age of onset;
  • People who have a family member with rheumatoid arthritis because some genetic factors contribute to the onset of the disease. Having an affected parent doubles the risk of rheumatoid arthritis.

Risk factors

  • Smokers are more likely to suffer one day in rheumatoid arthritis, with more severe symptoms than average. See our page Smoking.
  • People who have positive rheumatoid factor or positive citrullinated peptides during a blood test are at a higher risk of having rheumatoid arthritis.
  • Women who have had many pregnancies or have been taking hormonal contraception for a long time are at risk for rheumatoid arthritis.

Prevention

Can we prevent?
There are few ways to prevent the onset of rheumatoid arthritis.

No smoking or exposure to second-hand smoke  is the best prevention at the moment. When a close relative has this condition, it is strongly advised to avoid smoking.

Measures to prevent or mitigate joint pain
See the Arthritis fact sheet for advice that, as a preventive measure, helps to relieve pain. For example, we must aim for a good balance between  rest and physical activity , and we can apply in case of crisis of heat or cold on the joints.

Because  rheumatoid arthritis  often affects the fingers and wrists, it can cause significant discomfort in everyday life. Hand exercises, performed as directed by a doctor or physiotherapist, should be done daily to limit stiffness of the joints and improve muscle strength. However, in case of severe pain, do not force, as this may aggravate the inflammation.

Certain gestures must be avoided, especially those that may accelerate the deformation of the joints. For people who work on the computer, it is necessary for example to make sure that the hand remains in the axis of the wrist. It is also not recommended to carry heavy pots by the handle or to force with the wrist to unscrew a lid.

Medical treatments for rheumatoid arthritis (rheumatism, arthritis)

Many advances have been made in recent years for the relief and control of rheumatoid arthritis . Research has shown that treatment with anti-rheumatic drugs during the first 3 to 6 months of the disease increases the chances of prolonged remission . It is often the same treatments that control the disease and prevent its progression. Therefore, these drugs are a vital part of treatment.

The goals of the treatment are:

  • relieve symptoms
  • to attempt to induce and maintain remission of the disease;
  • restore or maintain proper functioning of the joints;
  • Prevent disability and the damage of the disease to other organs.
What is meant by “remission”?

– The absence of symptoms of inflammation , such as morning stiffness and pain;
– The absence of signs of inflammation on physical examination, joints and elsewhere in the body;
– The absence of signs of inflammation in the blood, in blood tests;
– Stop the progression of joint damage, visible on X-ray.

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Pharmaceuticals

Two types of  drugs  are generally used for the treatment of rheumatoid arthritis: symptomatic or  relief  medications (nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids) and basic  treatments . The purpose of these is to prevent relapses and control symptoms over a long period of time. They combine conventional treatments (such as immunosuppressants) and biotherapies or modifiers of the biological response.

Symptomatic medications (relief)

Anti-inflammatory drugs reduce pain and joint stiffness . They do not slow the evolution of the disease and do not prevent the occurrence of any joint deformities. They are mainly used at the beginning of the disease, and then intermittently, in case of pain to relieve. It is recommended to use them in combination with a DMARD to slow the progression of the disease.

  • Classical non-steroidal anti-inflammatory drugs (NSAIDs) Ibuprofen (eg, Advil and Motrin), naproxen (eg, Anaprox and Naxen) and all other anti-inflammatory drugs are useful for relieving symptoms. Aspirin (acetylsalicylic acid) is not widely used because it is less well tolerated by the digestive system.
    Side effects.The use of conventional nonsteroidal anti-inflammatory drugs on a regular basis may be associated with gastrointestinal disorders, such as heartburn, ulcers or sometimes serious digestive bleeding, as well as other side effects such as hypertension or kidney failure. They are therefore used for the shortest period possible, only when needed. They are sometimes associated with a medicine to protect the stomach, such as omeprazole (Mopral), or misoprostol (Cytotec).

Anti-inflammatory drugs may have significant adverse effects, particularly cardiovascular, with an increased risk of heart attack or stroke. These treatments must be followed very closely by the doctor. A worrying aspect is that these complications can occur quickly, in some cases in the first week. Even a brief use presents a certain risk.

NSAIDs with the lowest risk are naproxen and ibuprofen (low dose); the risk would be low to zero. It is clear, therefore, that these drugs should not be taken lightly.
  • Corticosteroids . Corticosteroids (cortisone, prednisone, prednisolone) are very effective drugs to reduce inflammation and relieve joint pain and stiffness. They could also delay the progression of rheumatoid arthritis, especially when used in combination with a background antirheumatic 37. These drugs are taken in tablet form or injected directly into the joints. They are often prescribed early in the disease, but their long-term use is limited by the significant adverse side effects. Their anti-inflammatory action is fast, but ephemeral. The doctor always proposes the lowest effective dose for the shortest possible time in order to limit the undesirable effects.
    Side effects. In the long term, corticosteroids can cause serious side effects, sometimes even very serious. These vary according to the dose taken. For example: weight gain, increased risk of osteoporosis, high blood pressure and infections …
Injections or infiltrations of corticosteroids intra-articularly. They are very effective in case of crisis, especially if the number of joints reached is not too high. However, it should not be abused, because repeated injections of corticosteroids in the joints can damage the joints and / or cause the same adverse effects as if taken orally. In general, doctors are limited to 3 or 4 infiltrations per joint and per year.
  • Of acetaminophen (paracetamol) or morphine derivatives are sometimes used to reduce the pain when it is strong.

Background antirheumatic drugs

Anti-rheumatic drugs are prescribed when symptoms persist for several weeks. They act directly on the disease by fighting the immune cells that attack the joints. This gives them the ability to prevent or delay joint damage . These drugs (many of which are immunosuppressive ) are especially beneficial if taken early in the illness. They are fully effective after a few weeks to a few months. They can be combined without problems with NSAIDs or corticosteroids.

In this category of drugs, methotrexate (Novatrex) is the most commonly used first-line drug,  in the form of tablets or subcutaneous injections. People taking this medication are advised to consume folic acid supplements, which helps reduce side effects. The  leflunomide  (Arava) can be used in people who have cons-indications or side effects to métothrexate37; more rarely, it can be used in combination with methotrexate.

Other DMARDs used are hydroxychloroquine (Plaquenil) and  sulfasalazine (eg, Salazopyrine), administered alone or preferably in combination with methotrexate.
The azathioprine  (Imuran, Imurel is used in some sévèves polyarthritis. Each of these drugs have specific side effects.

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Biotherapies or modifiers of the biological response

In recent years, a new class of drugs has appeared on the market. They are known as biological response modifiers, or  biotherapies. Unlike other antirheumatic drugs, which fight the immune system in a non-specific way, these new therapies are designed to target more precisely substances that are believed to be directly responsible for inflammation and joint destruction. Several types of biotherapies are available, of which anti-TNF agents are the most used. There are now 5 anti-TNF agents: infliximab (Remicade), etanercept (Enbrel) and adalimumab (Humira), certolizumab (Cimzia) and golimumab (Simponi). Also licensed in Canada are biotherapies that counteract the effect of interleukin-1 (anakinra, Kineret) or interleukin-6 (tocilizumab, Roactemra), 2 substances that contribute to inflammation in conjunction with TNF , as well as 2 other biotherapies with different mechanisms of action, rituximab (Rituxan) and abatacept (Orencia). These drugs are administered all by injection , some intravenously and others subcutaneously. In addition to their mechanisms of action, these drugs differ in their frequency of administration and some specific side effects.

These drugs have a very high cost and a potential for serious side effects . Possible side effects of these drugs include a reduction in immune defenses against certain infections.
But they are also extremely effective and have revolutionized the evolution of rheumatoid arthritis, suppressing pain, inflammation, deformity in many patients.

Surgery

When joint damage makes it difficult to function well on a daily basis, surgical procedures can be performed. They help restore joint function, reduce pain and restore a normal appearance to a deformed joint.

  • Synovectomy . It involves totally or partially removing the synovial membrane affected by arthritis. This procedure can be performed by surgery or by injection into the joint of a chemical or radioactive product (synoviorthèse). In the latter case, the excess synovial membrane is destroyed by the injected product. These measures give good results, but relapses are possible in the more or less long term.
  • Replacement of the joint . It is possible to replace the joint reached by an artificial joint, the prosthesis. This intervention restores mobility while reducing pain. It can also make it possible to correct a deformation. This type of surgery is sometimes suggested before the lesions of the bones and joints become too big.

Physical exercise

Although  rheumatoid arthritis  is a painful disease, it should not prevent physical activity , on the contrary. Exercise helps maintain maximum joint strength and flexibility while improving overall health and quality of life. Regular physical activity and muscle building are among the international recommendations, provided they are adapted to each person’s physical health. In fact, it is important not to overload the damaged joints and not to force in case of painful thrusts. The  exercises aerobic are recommended, just like walking, swimming or cycling. Ask your doctor or a physical activity specialist for advice.

Physiotherapy and rehabilitation

Physiotherapy and rehabilitation are useful additions to drug treatment as soon as the disease becomes disabling (and even before, in prevention). Physiotherapist helps to find physical exercises that maximize joint flexibilityand avoid deformations. If the illness causes significant disability, rehabilitation sessions can help regain independence and live better with this disability. The occupational therapist can offer real-world solutions to people with rheumatoid arthritis so they can do their daily tasks without too much trouble. For example, there are several tools or equipment that help prevent wrist pain, and some postures help reduce pain and fatigue.

The intervention of a physiotherapist, and in some cases an occupational therapist, helps to maintain physical abilities in both personal and professional life.

Food

Adopting good eating habits is essential to maintain good health and avoid excess weight, which can worsen the symptoms. The intake of antioxidants, found in good quantities in  fruits and vegetables , is essential.
Here are some tips about fruits and vegetables:
– Eat at least one dark green vegetable (broccoli, romaine lettuce and spinach) every day.
– Eat at least one orange vegetable (carrots, sweet potatoes and winter squash) each day.

– Choose vegetables and fruit made without fat, sugar or salt or with few of these ingredients.

– Instead of frying your vegetables, eat them steamed or baked or stir

It is observed that a diet rich in fat, protein and meats tend to cause more pain. However, according to The Arthritis Society of Canada, no food or diet can completely eliminate the symptoms of arthritis.
See the  dietary recommendations  proposed by nutritionist Hélène Baribeau in our tailored Diet: Rheumatoid Arthritis.

Omega-3 fatty acids would present an interesting effect in combination with conventional medication, for a more rapid remission and decrease the rate of treatment failure. They can be taken in the diet (linseed oil, rapeseed, nuts, fish), or in addition (3 grams per day)

A glass of alcohol a day seems to tend to improve the symptoms of rheumatoid arthritis. But two glasses a day would tend to aggravate it. The ideal is probably to stick to recommendations of the type: 1 glass of alcohol per day maximum with at least one day per week without alcohol.

Vegetarian diets have proven beneficial long-term in some people with rheumatoid arthritis. This effect may be related to the decrease in saturated fat consumption and the increase in the amount of ingested fruits and vegetables, as well as whole grains, which may improve inflammation. Overall, any anti-inflammatory diet could be beneficial.

The removal of certain foodsis offered by many very diverse diets in an effort to improve the symptoms of rheumatoid arthritis. Their interest is not scientifically proven. Nevertheless, on an individual basis, they could sometimes be of interest, particularly in the case where an allergic reaction to a food would occur, which may then perhaps exacerbate the autoimmunity involved in the disease.
For people wishing to test these diets, it is recommended not to delete several foods at the same time, but rather to talk to his doctor before doing a test for stopping a food for 4 to 6 weeks in order to observe the reactions of the body. Then, after 6 weeks, talk again to his doctor to define a course of action: whether or not to remove this food, and how to compensate for its eviction if it is the chosen conduct. The foods concerned may be dairy products, animal fats, meat and fish, cereals containing gluten, citrus fruit, eggs. Be careful not to delete everything without medical advice and not to expose to dietary deficiencies harmful to health.

Psychological support

Expert societies recommend that the psychological impact of rheumatoid arthritis be considered. The intervention of a psychotherapist can sometimes be very beneficial. The  cognitive and behavioral therapies , for example, help people better manage pain and disease. The different patient associations can also provide important emotional support. See the Sites of Interest and Support Groups sections.

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