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Rheumatoid Arthritis

  1. What is rheumatoid arthritis?
  2. Symptoms
  3. Treatment
  4. Causes
  5. Risk factors
  6. Prevention
  7. Diagnosis
  8. FAQs
  9. Other names

What is rheumatoid arthritis?

Rheumatoid arthritis (RA) is a chronic inflammatory condition of the joints, which develops gradually and is caused by an autoimmune reaction. This means that the immune system mistakenly forms proteins which are meant to fight infections, known as antibodies, that attack the body tissue instead.

The symptoms of rheumatoid arthritis occur in episodes or flare-ups of pain and swelling in the joints. Usually the joints are affected symmetrically, especially the hands, wrists and feet, and many joints may be inflamed. It can also affect other parts of a person’s body, including the lungs, heart and eyes. Onset may include symptoms such as fever and fatigue.

Women are affected more commonly than men. The onset of rheumatoid arthritis usually occurs over the age of 35, and the likelihood of developing the condition increases as a person gets older. Onset is highest among adults in their 60s. However, the condition can occur at any age.[1] Rheumatoid arthritis is normally a lifelong condition that worsens with age.

If RA is not treated early, it can cause irreversible damage to joints, leading to disability. However, it can normally be well managed with medications to slow down the immune system, as well as pain medications for relief of symptoms. There is currently no specific rheumatoid arthritis cure.

Rheumatoid arthritis generally appears in adults. However, a related condition may sometimes appear in children, when it is known as juvenile idiopathic arthritis, previously known as juvenile rheumatoid arthritis. This condition may clear up by the time adulthood is reached. Many children with this condition also experience regular fevers.

Read more about Juvenile Idiopathic Arthritis » for more information about rheumatoid arthritis in children.

Symptoms

In most people, rheumatoid arthritis (RA) symptoms begin very subtly, and it may be many weeks or months before symptoms become troublesome enough to seek medical attention.

Early symptoms of rheumatoid arthritis may include:[2][3]

  • Joint stiffness, often in the hands and feet, usually worse in the morning
  • Joint pain and swelling
  • Fatigue
  • Muscle pain
  • Low-grade fever
  • Numbness and tingling in the hands

RA typically affects the small joints first, such as the first two joints of the fingers and the first joints of the toes. It can also start in one large joint, such as the knee or the shoulder, and may move from one joint to another or disappear for a long time before recurring. Think you or someone you know may be experiencing symptoms of rheumatoid arthritis? Try the Ada app for a free assessment.

Complications

As the condition progresses, further signs and symptoms of rheumatoid arthritis may develop, such as:[2][4]

Rheumatoid arthritis in hands: The swelling associated with rheumatoid arthritis causes some people to develop carpal tunnel syndrome. This is the compression of a nerve running through the wrist, characterized by tingling, numbness and weakness in the hand. Certain permanent bone alterations can also occur with long-term rheumatoid arthritis, such as swan neck deformities, boutonniere deformities and the bowstring sign.

Rheumatoid arthritis in knee: Inflammation of the knee is associated with difficulty bending the knee, damage to the bones that meet at the knee, and excessive looseness of the supporting ligaments of the knee. This may cause the development of a Baker’s cyst, a cyst which fills with joint fluid in the hollow space at the back of the knee.

Rheumatoid arthritis in feet: Pain in the feet may cause a person with rheumatoid arthritis to stand with weight on the heels and the toes bent upwards. The top of the foot may be red and swollen and the heel may be painful.

Rheumatoid arthritis nodules: These are firm lumps which develop under the skin, usually near joints which are inflamed or near pressure points. Common locations include the underside of the forearm, the elbow, and the fingers and knuckles of the hands.

Rheumatoid arthritis can cause inflammation of tissues other than the joints, for example:[2]

Rheumatoid arthritis in the lungs: may cause shortness of breath and a dry cough.

Inflammation of the blood vessels, known as vasculitis: may cause a characteristic rheumatoid arthritis rash of spots which look like ulcers, and a wide variety of other symptoms, depending on the location of the affected blood vessels.

Inflammation of the tissue surrounding the heart, known as Pericarditis: may cause chest pain and shortness of breath.

Treatment

It is very important to start treatment as soon as possible, to prevent any permanent joint damage. Rheumatoid arthritis (RA) can usually be effectively managed with early, appropriate treatment. There is currently no rheumatoid arthritis cure, and it is usually a chronic condition requiring lifelong treatment.

The main aims of treatment for RA are:[5][6]

  • To prevent joint damage
  • To minimize pain and other symptoms, and maintain quality of life
  • To prevent the development of associated conditions such as osteoporosis and cardiovascular disease

There are three main aspects of rheumatoid arthritis treatment:

  • Medication
  • Physical therapy
  • In some cases, surgery

Medications

Rheumatoid arthritis is usually treated with a combination of medications. The five main types of rheumatoid arthritis drugs used are:[6]

Nonsteroidal anti-inflammatory drugs (NSAIDs): These offer pain relief and reduce minor inflammation, though they do not reduce the long-term damaging effects of RA.

Disease-modifying anti-rheumatic drugs (DMARDs): These work by blocking the effects of chemicals released by the immune system, which can damage nearby bones, tendons, ligaments and cartilage.

Biologic agents: Also known as biologic response modifiers, these are a newer class of DMARDs. Biologic DMARDs are most effective when paired with a nonbiologic DMARD.

Steroids: These quickly improve symptoms such as joint pain, stiffness and swelling and are generally recommended where rheumatoid arthritis severely limits a person’s ability to function normally, until slower acting joint damage-preventing DMARDs begin to work.

Painkillers: These offer pain relief but have no effect on inflammation, and may be recommended in the case of a badly damaged joint that cannot be replaced with surgery.

Physical therapy

People with rheumatoid arthritis often become inactive due to joint pain and stiffness. However, inactivity can lead to inflexibility, muscle and tendon shortening, and muscle weakness. In turn, weakness further increases fatigue and decreases stability of the joints.

A physiotherapist can recommend safe exercises to strengthen muscles, restore joint range-of-motion joints and ease symptoms.

An occupational therapist may recommend ways to approach day-to-day activities without putting too much strain on the joints. They may also recommend splints if needed for hand and wrist support.

A podiatrist may work with a person on ways to ease problems with the feet and ankles, such as by using appropriate footwear.

Surgery

Occasionally, surgery is needed to treat joints affected by rheumatoid arthritis. These can be minor surgeries, such as to release a nerve or tendon or more major surgeries such as hip, knee, shoulder and elbow replacements.

Diet

There are no clear-cut answers as to what diet to follow with rheumatoid arthritis, as there is a lot of conflicting evidence, and different diets may affect people in different ways. However, it is generally recommended that a person eat:[7][8]

  • A balanced and varied diet with plenty of fruit, vegetables, fish, pulses, nuts and olive oil to get all the vitamins, minerals, antioxidants and other nutrients you need
  • Omega-3 fatty acid-rich food regularly, such as oily fish, seaweed and walnuts
  • Calcium-rich food, such as dairy products and calcium-enriched non-dairy products
  • Vitamin-D-rich food, such as eggs
  • Iron-rich food, such as dark green vegetables

Weight loss may be recommended for overweight people to reduce stress on affected joints. However, sometimes people with rheumatoid arthritis lose their appetite, and dietary therapy may be recommended to help ensure that an adequate amount of calories and nutrients are consumed.

Natural treatment

Natural treatments have not conclusively been shown to stop or slow rheumatoid arthritis progression, but may help with pain relief when used in conjunction with prescribed rheumatoid arthritis medications.

Supplements for rheumatoid arthritis containing gamma-linolenic acid (GLA) have been shown to modestly improve joint pain, stiffness and grip strength.[9] This includes evening primrose oil or borage oil, especially when combined with fish oil, which reduces the synthesis of inflammatory by-products of GLA.[10]

Calcium and vitamin D supplements may be recommended if not enough is consumed through diet. These can help to minimize bone loss, which is associated with steroid therapy.[6]

Good to know: rheumatoid arthritis should never be treated exclusively with natural supplements or without seeing a doctor.

Causes

Rheumatoid arthritis (RA) is an autoimmune disease, which means that it is caused by abnormal functioning of the immune system. In a healthy immune system, the body attacks foreign bacteria and viruses. In the case of autoimmune disease, the body accidentally attacks healthy tissue instead. In rheumatoid arthritis, the body attacks its own joint tissue. Healthy joints are needed to absorb shock and allow for smooth movement between the bones.

People with RA produce an excess of white blood cells in the synovial membrane, the tissue that lines the cavities of joints; this causes inflammation. This can lead to joint erosion, loss of motion and occasionally damage to other associated parts of the body, such as the lungs, heart, blood vessels and eyes.

If RA is left untreated, pannus tissue may form, in which there is excess, uneven tissue growth in a joint, which can further erode and damage cartilage and bone.

Risk factors

It is not certain what causes rheumatoid arthritis (RA), but some possible contributing factors have been identified, including:

Genetics

Specific variants in the human leukocyte antigen (HLA) genes are associated with a higher risk of developing RA. These variations make the white blood cells attempt to correct abnormalities in the joints more quickly than usual, which may be what leads to the inflammation and associated tissue damage that results from rheumatoid arthritis.

However, rheumatoid arthritis is not an inherited condition; not everyone with RA has a variant HLA system and not everyone with a variant HLA develops RA. Genes do not cause the condition, but affect the risk of it developing.[11] Other non-HLA genes have also been linked to RA.[12]

Bacteria and viruses

People with rheumatoid arthritis seem to get infections more often than people without the condition. It is thought that this may affect the joints in several ways, including:[13]

Bacteria or viruses may leave the original infection site and move into the joint capsule. Some people with rheumatoid arthritis have been found to have the Herpes Simplex virus, which causes mouth or genital sores (see herpes simplex and the Epstein Barr virus, which causes mononucleosis, also known as mono or glandular fever, in their joint fluid.

Infection may trigger an attack by the immune system on the joints, as some joint cells may be registered by the immune system as similar to the cells of the infecting disease.

Infection may alter the joint cells, inducing rheumatoid arthritis. This has been found to be the case with some types of gum infections.

Joint tissue may be damaged by the immune system as it attacks a nearby infection in what is known as bystander effect. If the body does not sufficiently signal to turn off the immune response, it may then continue to target those originally affected tissues, even after the infection has cleared.

The immune system may become overactive after infection, continuing to attack cells that are similar to the originally infecting cell.

Smoking

Research has shown that exposure to certain irritants in the air may play a role in a person’s risk of developing rheumatoid arthritis, including:[14][15]

  • Tobacco smoke
  • Silica dust, mainly affecting people in the mining industry
  • Certain mineral oils, such as found in hydraulic oil

Good to know: Once rheumatoid arthritis has developed, smoking can also increase the severity of rheumatoid arthritis symptoms and interfere with rheumatoid arthritis medication. Smoking may also cause a debilitating increase in heart rate and breathing rate, which may lead to a loss of will to exercise, in turn leading to further joint weakening. Tobacco smoking can also increase the risk of complications if surgery is needed for rheumatoid arthritis.

Gender

Rheumatoid arthritis is far more common in women, who make up about 70 percent of people diagnosed. It is not known exactly why women are more likely to develop the condition, but hormonal factors are thought to play a part. The condition tends to decrease or disappear during pregnancy and people with the condition may experience flares in the weeks after giving birth.[16] It has been suggested that this may be due to production of prolactin, the milk production hormone, having an inflammatory effect.[15]

Physical trauma

Physical trauma has been linked to rheumatoid arthritis onset, such as with sports injuries. Physical trauma can trigger inflammation, which it is thought may contribute to the development of rheumatoid arthritis, possibly at a much later date. However, it is not known why this might be. Some people may have a predisposition to such inflammation.[17]

Obesity

Research has found that obesity may have an impact on the development of the condition.[18][19] It is not known why this is, but one reason postulated is that fat cells release proteins called cytokines, which create inflammation throughout the body.[20]

Good to know: Obesity may also have a negative impact on the effectiveness of rheumatoid arthritis treatment, particularly with some disease-modifying antirheumatic drugs (DMARDs).[21] It can also lead to earlier deterioration of the main joints, such as the knees, due to increased pressure.

Prevention

While there is no known way to prevent the onset of rheumatoid arthritis, there are a few known ways in which a person can reduce the risk. These include:

  • Quitting tobacco smoking
  • Being physically active and eating a healthy diet
  • Taking steps to maintain a healthy weight

It is also important to see a doctor as soon as symptoms develop, as early treatment can greatly minimize the rheumatoid arthritis progression, as well as any permanent damage caused by flare-ups.

Diagnosis

Diagnosis of rheumatoid arthritis (RA) is generally confirmed after referral to a rheumatologist, a type of doctor specializing in inflammation and pain in the joints, muscles, or fibrous tissues.

RA can take a long time to diagnose as its early onset can be subtle and present similarly to other, less long-term conditions, such as flu, also known as influenza. It also often presents similarly to other types of arthritis, such as reactive arthritis.

Unlike other types of arthritis, there is no specific test for rheumatoid arthritis. Instead, a rheumatologist relies on gathering information to rule out other conditions and identify the cause of a person’s symptoms. Diagnosis may be made from a combination of reported medical history and symptoms, a physical examination, laboratory tests and medical imaging. Try the Ada app for a free symptom assessment.

Interview and physical exam

It is important that a person describe any joint pain and other symptoms, as well as how long they have been going on for.

A doctor will look for signs of rheumatoid arthritis, such as swollen, tender, warm joints with painful or limited movement, and rheumatoid nodules. They may also ask for family medical history; if another member of their family has the disease, then a person has a higher risk of having the condition themselves.

Laboratory tests

If a doctor suspects rheumatoid arthritis, one or more tests may be done to help make a diagnosis. These include:[22]

Testing for rheumatoid factor (RF) and anti-cyclic citrullinated peptide (CCP) antibodies: RF is a protein that attacks healthy tissues. If it is present, there is about an 80 percent chance that a person has or may develop rheumatoid arthritis or another inflammatory disease. Anti-CCP antibodies indicate that a person is very likely to develop RA.

Measuring inflammatory markers: Abnormally high levels of certain markers in the blood would support a diagnosis that symptoms are caused by an inflammatory condition such as rheumatoid arthritis. Inflammatory markers which may be detected by a blood test include:

  • Tumor necrosis factor-alpha
  • Erythrocyte sedimentation rate (ESR or sed rate)
  • C-reactive protein (CRP)

Good to know: The presence of anti-CCP antibodies in the blood indicates that a person with RA may be more likely to develop severe symptoms, requiring more intensive treatment.

Medical imaging

A doctor may also recommend an X-ray, ultrasound or magnetic resonance imaging (MRI) scan of the affected joint. This can help to rule out other conditions that present with similar symptoms, such as gout. However, at an early stage of rheumatoid arthritis, any characteristic damage caused by the condition may not be apparent.[22]

FAQs

Q: Osteoarthritis vs. rheumatoid arthritis - what is the difference?
A: Both rheumatoid arthritis (RA) and osteoarthritis (OA) are types of chronic, untreatable arthritis which may be confused due to having the similar symptom of joint pain and inflammation. However, they have different causes. Rheumatoid arthritis is an autoimmune disease with a typically sudden onset of symptoms and occurs in episodes of inflammation on symmetrical joints of the body. OA is a “wear and tear” condition associated with factors such as older age, injury or obesity. It develops slowly, caused by continuous use of particular joints. RA tends to involve additional symptoms such as fever and fatigue, whereas OA only affects the joints. Rheumatoid arthritis onset tends to occur from 30 to 60 years old, while OA tends to develop later in life.[23]

Q: Is rheumatoid arthritis hereditary?
A: One’s genetics can increase the chances of developing the condition, and a number of genetic markers have been identified that increase this risk. However, not everyone with RA has these, nor does everyone who has such genetic markers develop RA. Many genetic and environmental factors appear to be involved in whether a person develops rheumatoid arthritis.[24]

Other names for rheumatoid arthritis

  • RA
  • Inflammatory arthritis (This is a group of conditions including rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, juvenile idiopathic arthritis and [systemic lupus erythematosus,]/(conditions/systemic-lupus-erythematosus/) also known as lupus, among others)

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  10. NCBI - NIH "Addition of eicosapentaenoic acid to gamma-linolenic acid-supplemented diets prevents serum arachidonic acid accumulation in humans." Accessed 10 May 2018.

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  18. BMJ Journals. "Differential impact of obesity on the pathogenesis of RA or preclinical models is contingent on the disease status."18 October 2016. Accessed 30 May 2018.

  19. American College of Rheumatology. "Overweight and Obesity Increase Risk of Rheumatoid Arthritis in Women in a Large Prospective Study." Accessed 30 May 2018.

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