Overview

Rheumatoid arthritis or RA is a chronic autoimmune disorder that affects your joints, causing inflammation, pain, and stiffness in your joints. RA can also affect other parts of your body, including your skin, eyes, lungs, heart, and blood vessels.

In rheumatoid arthritis, the immune system mistakenly attacks the body's own tissues, particularly the synovium which is a thin layer of tissue that lines your joints. This leads to inflammation and damage to your joint, surrounding cartilage and bone. Over time, this damage can cause your joint to lose its shape and alignment, leading to chronic pain, disability, and reduced mobility.

Prevalence

Rheumatoic Arthritis is more common in certain populations, with higher prevalence rates reported in developed countries. For example, in the United States, the Centers for Disease Control and Prevention (CDC) estimates that around 1.3 million adults (0.6% of the population) have been diagnosed with RA.

It's worth mentioning that rheumatoid arthritis affects women more frequently than men. The condition is 2–3 times more common in women, with a peak onset between the ages of 30 and 60. However, RA can occur in people of all ages, including children and older adults.

Prevalence rates can also vary based on factors such as ethnicity, genetics, and environmental influences. For instance, some studies have shown that certain ethnic groups, such as Native Americans and Indigenous populations, may have a higher prevalence of RA compared to other groups.

Signs and Symptoms

The signs and symptoms of rheumatoid arthritis can vary from person to person, and can range from mild to severe.

Some common signs and symptoms of rheumatoid arthritis include the following:

• Joint pain and swelling: RA causes pain and swelling in multiple joints. The joints affected are often symmetrical, meaning if one joint is affected on one side of the body, the corresponding joint on the other side is also affected.
• Joint stiffness: People with RA often experience stiffness in the joints, particularly in the morning or after periods of inactivity. This stiffness can last for an hour or more.
• Fatigue
• Loss of appetite and weight loss: These symptoms may occur as a result of your body's inflammatory response.
• Low-grade fever: Some people with rheumatoid arthritis may experience low-grade fevers, especially during periods of disease activity.
• Rheumatoid nodules: These are firm lumps that develop under your skin, usually over bony areas.
• Joint deformity: Over time, rheumatoid arthritis can cause joint damage that can lead to joint deformity and reduced mobility.
• Systemic involvement: In addition to joint symptoms, RA can affect other organs and body systems. This may include inflammation of the eyes (e.g., dryness, redness), lungs (e.g., shortness of breath, cough), heart (e.g., inflammation of the heart lining), and blood vessels.

Keep in mind that your symptoms of rheumatoid arthritis can come and go, and periods of disease activity, called flares, may alternate with periods of remission, during which symptoms improve or disappear.

It’s important to seek medical attention if you experience joint pain, stiffness, and/or swelling tha

Causes, Triggers, and Risk Factors

The exact cause of rheumatoid arthritis (RA) is still not fully understood. However, research suggests that a combination of genetic, environmental, and immune system factors contribute to its development.

Here are some known causes, triggers, and risk factors associated with RA:

• Genetic factors

  There is evidence of a genetic predisposition to developing RA. Certain genes, such as the HLA-DRB1 gene, have been linked to an increased risk of RA. However, having these genetic factors does not guarantee the development of the disease, and many individuals with these genes do not develop RA.

• Autoimmune response

  RA is an autoimmune disorder, meaning that your body's immune system mistakenly attacks healthy tissue, including the synovial membrane that lines your joints.

  It’s not yet clear why your immune system begins to attack the synovial membrane, but it’s believed that certain cells in your immune system, called T cells and B cells, play a key role in the development of rheumatoid arthritis.

• Environmental factors

  Various environmental factors may contribute to the development of RA or trigger disease flares in individuals who are genetically predisposed. Some potential environmental triggers include exposure to certain infections (such as Epstein-Barr virus or bacteria), smoking tobacco, and exposure to certain occupational hazards like silica dust.

• Hormonal factors

  Women are more commonly affected by RA than men, suggesting that hormonal factors may play a role. The onset and severity of RA symptoms can fluctuate during pregnancy and after menopause, indicating a potential influence of hormones such as estrogen.

• Age and gender

  Although RA can occur at any age, it most commonly starts between the ages of 30 and 60. Women are more likely to develop RA than men.

• Obesity

  Obesity has been associated with an increased risk of developing RA, as well as a worse prognosis and more severe symptoms in those already diagnosed with the disease.

It's important to note that while these factors may contribute to the development or progression of RA, they do not provide a definitive explanation for the disease. The interplay between genetic, environmental, and immune system factors is complex and not yet fully understood. Further research is needed to gain a clearer understanding of the causes and triggers of rheumatoid arthritis.

Diagnosis

The diagnosis of rheumatoid arthritis is usually based on a combination of clinical exams, medical history, blood tests, and imaging studies.

• Blood tests: Blood tests can help to confirm the diagnosis of rheumatoid arthritis and rule out other conditions. Blood tests may include the following:

  Rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) antibodies: These are antibodies that are often present in individuals with rheumatoid arthritis.

  Complete blood count (CBC): A CBC can help to identify anemia, which is common in individuals with rheumatoid arthritis.

  Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP): These blood tests measure inflammation levels in the body and can help to assess disease activity.

• Imaging studies: Imaging studies, such as X-rays, ultrasounds, or MRI scans, may be ordered to assess the extent of joint damage and inflammation.

To be diagnosed with rheumatoid arthritis, you must meet certain criteria established by the American College of Rheumatology. These criteria take into account the number and location of affected joints, blood test results, and other clinical factors.

A rheumatologist, or a doctor who specializes in the treatment of rheumatic diseases, will typically make the diagnosis and develop a treatment plan for you.

Treatment

The treatment options for rheumatoid arthritis aim to reduce inflammation, relieve pain, prevent joint damage, and improve your overall quality of life. The following are some common treatment options for rheumatoid arthritis:

Medications

There are several types of medications used to treat rheumatoid arthritis, including nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, disease- modifying antirheumatic drugs (DMARDs), and biologic agents. These medications work in different ways to reduce inflammation and prevent joint damage.

(Non-biologic) Disease-modifying anti-rheumatic drugs (DMARDs)—first-line drug treatment for RA

Disease-modifying anti-rheumatic drugs (DMARDs) are a drug class of medications that work by slowing the disease process as well as helping prevent further joint damage.

Individuals that experience symptoms of rheumatoid arthritis should be started on a DMARD, regardless of the severity of the disease.

It’s important to keep in mind that the treatment goal is remission of the disease (or low disease activity).

Examples of DMARDs include:

• Methotrexate: initial therapy for RA

  Black box warning (the strictest warnings for prescriptions): This medication may cause severe liver damage (alcohol use can increase the risk of liver toxicity), decrease bone marrow activity (myelosuppression), and should not be used to treat arthritis when pregnant since it may harm or kill the fetus.

  Common side effects: nausea, vomiting, diarrhea, stomatitis (inflamed and/or sore mouth sensitivity to sunlight), joint pain, muscle pain

• Hydroxychloroquine

  This medication should be taken with food or milk.

  Common side effects: nausea, vomiting, diarrhea, abdominal pain, rash, headache, vision changes

• Sulfasalazine (Azulfidine)

  This medication should be taken with food or a cup (8 oz.) of water to prevent crystalluria (crystals in your urine, indicating renal irritation).

  Common side effects: headache, rash, nausea, vomiting, diarrhea, folate deficiency, crystalluria, yellow-orange discoloration of your skin and/or urine

• Leflunomide (Arava)

  Black box warning: This medication should not be used to treat arthritis when pregnant since it may harm or kill the unborn child, as well as severe liver damage.

  Common side effects: nausea, diarrhea, rash, headache, respiratory infections, chest pain/discomfort

• Tofacitinib (Xeljanz, Xeljanz XR)

  Common side effects: upper respiratory tract infection (URTI), urinary tract infection (UTI), diarrhea, headache, high blood pressure

Biologic DMARDs

For individuals who do not respond to non-biologic DMARD therapy or who have severe rheumatoid arthritis, further therapies are available. A biologic DMARD can be used in place of another DMARD or as a stand-alone therapy.

This drug class of medications is administered as subcutaneous (SC) injections (injected under your skin) and works by targeting immune system pathways. They frequently block a variety of inflammatory proteins, receptors, and cells.

Examples of biologic DMARDs include the following

• Etanercept (brand: Enbrel)
• Adalimumab (Humira)
• Certolizumab (Cimzia)
• Golimumab (Simponi)

Common side effects: infections and injection site reactions (rash, swelling, itching, and/or bruising), headache, nausea

The choice of medication depends on the severity of the disease, the presence of other medical conditions, and/or other individual factors.

Physical therapy

Physical therapy can help to improve joint mobility, reduce pain, and strengthen muscles. A physical therapist can develop an exercise program tailored to the individual needs of the individuals with rheumatoid arthritis.

Occupational therapy

Occupational therapy can help to improve your ability to perform daily activities, such as dressing and bathing, by teaching new ways to perform tasks or providing assistive devices.

Surgery

In severe cases of rheumatoid arthritis, surgery may be necessary to repair or replace damaged joints.

Lifestyle modifications

Lifestyle modifications can also help to manage rheumatoid arthritis symptoms. These can include maintaining a healthy weight, eating a balanced diet, getting regular exercise, and managing stress.

Complications

Rheumatoid arthritis (RA) is a chronic condition that can lead to various complications, some of which may affect different organs and systems of the body.

• Joint damage and deformity: Over time, untreated or poorly controlled RA can result in progressive joint damage and deformities. The inflammation in the joints can erode the cartilage and bone, leading to joint instability, joint deformities, and loss of function.
• Rheumatoid nodules: Firm lumps or nodules may develop under the skin. These nodules are typically painless and often occur near pressure points or on areas exposed to friction, such as the elbows.
• Carpal tunnel syndrome: Rheumatoid arthritis can cause inflammation in your wrist that can compress the median nerve and cause carpal tunnel syndrome, which leads to numbness, tingling, and/or weakness in your hand(s).
• Osteoporosis: RA and the chronic inflammation it causes can lead to bone loss and osteoporosis, increasing the risk of fractures.
• Heart and lung complications: Rheumatoid arthritis can increase your risk of heart disease, stroke, and/or lung problems, such as inflammation of your lungs or the lining around your lungs.
• Infections: Rheumatoid arthritis and the medications used to treat it can suppress your immune system, which can increase your risk of infections.
• Emotional and psychological impact: Living with a chronic condition like RA can significantly impact a person's mental and emotional well-being. Depression, anxiety, and reduced quality of life are common among individuals with RA.

Prevention

Although there is no cure for rheumatoid arthritis, some lifestyle modifications may help to reduce the risk of developing this medical condition, or delay its onset or progression.

These include the following:

• Maintaining a healthy lifestyle: Being overweight or obese can increase your risk of developing rheumatoid arthritis, specifically in women. Maintaining a healthy weight through a balanced diet and regular exercise may help to reduce your risk.
• Smoking cessation: Smoking has been linked to an increased risk of rheumatoid arthritis and can also make the disease worse. Quitting smoking may help to reduce your risk of developing rheumatoid arthritis or slow its progression in those who already have the disease.
• Reducing exposure to environmental factors: Exposure to certain environmental factors, such as pollution, may increase your risk of developing rheumatoid arthritis. Reducing exposure to these factors may help to reduce your risk of developing this condition.
• Eating a healthy diet: A healthy diet rich in fruits, vegetables, whole grains, and lean protein sources may help to reduce inflammation in your body and improve overall health, which may in turn reduce your risk of developing rheumatoid arthritis.
• Regular exercise: Regular exercise can help to maintain joint health, reduce inflammation, and improve your overall health and wellbeing.

It’s important to note that while these lifestyle modifications may help to reduce your risk of developing rheumatoid arthritis, they cannot guarantee prevention.

Additionally, if you have a family history of rheumatoid arthritis or other risk factors (listed above) for this condition, it’s important to be aware of your symptoms and seek medical attention if they develop. As previously mentioned, early diagnosis and treatment can help to prevent or slow joint damage and improve your overall quality of life.