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Rheumatoid arthritis (RA) is an inflammation that can affect many joints and even other systems of the body. Rheumatoid arthritis belongs to a group of diseases called autoimmune disorders, in which the body directly attacks itself or produces antibodies against its own tissues.

What is going on in the body?

In a person with rheumatoid arthritis produces, the immune system attacks his or her own tissues, for unknown reasons.

Antibodies are protein molecules that the body uses to fight infection. These antibodies are produced by the immune system in response to a trigger called an antigen. This trigger is normally a substance that the body recognizes as "foreign." These foreign substances include things like bacteria and viruses.

In rheumatoid arthritis, for reasons unknown, the body's immune system malfunctions and begins producing antibodies against its own tissues. This causes the body's immune system to attack its own joints, causing inflammation, swelling and pain. Chronic inflammation of the synovial membrane lining the joint causes destruction of cartilage and bone within the joint.

Sometimes this form of arthritis is mild, but 70% of people who have it develop chronic problems, and 15% have severe crippling disease.

Young children can have a form called juvenile rheumatoid arthritis.

What are the signs and symptoms of the disease?

Joint pain, swelling, and stiffness, which are especially severe and prolonged in the morning, are the most common symptoms of rheumatoid arthritis. The problems may migrate from one joint to another. When one joint is involved, the corresponding joint on the other side will usually become involved too. Usually many joints throughout the body are affected at the same time.

Rheumatoid arthritis can cause deformities such as misshapen fingers, bunions, hammertoe, and knock-knees. The affected joints are swollen and warm.

Bumps called rheumatoid nodules can occur on the back of the elbow under the skin. The rheumatoid process can also involve the eye, known as episcleritis, and the lungs, known as interstitial disease.

• fatigue
• malaise, or a vague feeling of illness
• occasional fever

What are the causes and risks of the disease?

The causes of rheumatoid arthritis are not yet fully understood. There is a possibility that some type of infection or injury may alter the immune system, causing the body to react against its own tissues.

Rheumatoid arthritis can develop at any age, but it most commonly starts between the ages of 25 to 40 years. Women make up two thirds of the people with rheumatoid arthritis.

There is currently research into a number of factors that may trigger rheumatoid arthritis, including the following:

• certain abnormal genes found in some, but not all, individuals with rheumatoid arthritis
• certain viruses or bacteria that trigger the autoimmune response of rheumatoid arthritis
• hormonal influences since women are affected more often than men

What can be done to prevent the disease?

Rheumatoid arthritis cannot be prevented at this time. However, there is some evidence that people consuming high amounts of dietary olive oil have a decreased risk of developing RA. And, population-based research suggests that older women who have a higher intake of vitamin D from foods or supplements tend to have a lower risk of developing RA.

How is the disease diagnosed?

The diagnosis of rheumatoid arthritis is made by observing the person and the pattern of the disease. A blood test for the rheumatoid factor is positive in 75% to 80% of cases but some persons may have a positive rheumatoid factor test without having the condition.

Rheumatoid arthritis with a negative rheumatoid factor is called seronegative. A newer test called anti-cyclic citrullinated peptide may be positive in some cases with a negative rheumatoid factor test and is less likely to be falsely positive.

Other blood tests, such as red blood cell counts, or RBC; C-reactive proteins, or CRP; and antinuclear antibody, or ANA; tests may be done.

Joint aspiration, which involves removing joint fluid with a needle under local anesthesia, might be done. Synovial fluid that is cloudy, milky, or dark yellow and that contains many inflammatory cells will help confirm rheumatoid arthritis.

Joint X-rays may be ordered to help diagnose rheumatoid arthritis. It is important to rule out other diseases and conditions, such as systemic lupus erythematosus and Lyme disease.

What are the long-term effects of the disease?

Rheumatoid arthritis may be progressive and can affect many joints. This can make walking very difficult and can interfere greatly with the function of the hands. Disability can be severe which may also cause depression.

Other organs can also be affected by rheumatoid arthritis. Inflammation of blood vessels or the lining around the heart are known respectively as vasculitis or pericarditis. Osteoporosis , or bone thinning, is also more common in people with rheumatoid arthritis than in the general population.

What are the risks to others?

Rheumatoid arthritis is not contagious and poses no risk to others.

What are the treatments for the disease?

The overall goal of treatment is to prevent destruction of the joints. Education is important for improving daily self-management of the disease.

A wide variety of medicines are used to treat RA:

• antibiotics, such as doxycycline (i.e., Adoxa, Doryx, Oracea, Periostat, Vibramycin) and minocycline (i.e., Minocin, Solodyn)
• non-steroidal anti-inflammatories (NSAIDs) or acetaminophen (i.e., Tylenol)
• corticosteroids, such as prednisone, which can be taken orally or by injection into the joint
• the COX-2 specific inhibitor Celecoxib (i.e., Celebrex)
• disease-modifying medicines may slow down the progression of the disease. The fastest acting, best tolerated and most commonly prescribed DMARD is methotrexate (MTX). Although often used alone, many studies have shown that the outcome of two or three of these medications used in combination, is more effective at managing the disease.
• Other DMARDs used on their own or in combination with MTX, include hydroxychloroquine (i.e., Plaquenil), sulfasalazine (i.e., Azulfidine), azathioprine (i.e., Imuran), and leflunomide (i.e., Arava).
• Older DMARDs, such as gold therapy (Myochrisine) and D-penicillamine are virtually never used anymore.
• another option for treating RA is a class of drugs called biological response modifiers (BRMs), or biologics. In people with RA, proteins called Tumor Necrosis Factor (TNF) and Interleukin-1 (IL-1) are present in the blood and joints in excessive amounts where they increase inflammation (pain, swelling, and stiffness).
• Biologics are specially engineered medications which block the effects of TNF or IL-1 and are used to treat moderate to severe RA. These medications work quickly to ease inflammation and are often used in combination with other DMARDs such as methotrexate.
• BMRs in the U.S. include infliximab (i.e., Remicade), etanercept (i.e., Enbrel), and adalimumab (i.e. Humira), which block the effects of TNF.
• Anakinra (i.e. Kineret) is an Il-1 receptor antagonist.
• newer treatments include abatacept (i.e., Orencia) and rituximab (i.e., Rituxan)

Symptom control and disease management may be enhanced when medications are started early in treatment. The disease-modifying medications are usually started soon after the diagnosis of rheumatoid arthritis is made. Methotrexate is considered for more severe cases.

There has been a great deal of interest lately in the use of supplements in treating arthritis, especially for osteoarthritis. According to the Natural Medicines Comprehensive Database, several supplements are "likely effective" in treating osteoarthritis:

• Glucosamine sulfate significantly improves symptoms of pain and functionality in patients with osteoarthritis of the knee in studies lasting up to three years. It seems to reduce pain scores by 28 to 41 percent and improve function by 21 to 46%. Glucosamine hydrochloride may not be as effective as glucosamine sulfate.
• Chondroitin sulfate may also relieve the symptoms of osteoarthritis, but 2-4 months is required before significant improvement is experienced. Adding chondroitin sulfate to NSAIDs has been shown to be more effective than NSAIDs alone in osteoarthritis of the hip and knee and may allow lower doses or discontinuation of NSAIDs after 6-8 weeks of use.
• SAMe has been shown in several clinical trials to be superior to placebo and comparable to NSAIDs, including the COX-2 inhibitor celecoxib (i.e., Celebrex) for decreasing symptoms associated with osteoarthritis and is associated with fewer side effects than NSAIDs. Symptom relief with SAMe may require up to 30 days of treatment compared to 15 days with NSAIDs.

In addition, the Natural Medicines Comprehensive Database rates several supplements as "likely effective" in treating RA:

• Borage seed oil in combination with conventional NSAIDs might help decrease symptoms of RA after six weeks of treatment. The improvement appears to be sustained for up to 24 weeks.
• Bovine Cartilage administered subcutaneously seems to help reduce symptoms of RA.
• Cat's Claw, specifically the extract Uncaria tomentosa orally (which contains pentacyclic oxindole alkaloids, but is free of tetracyclic oxindole alkaloids) appears to modestly improve symptoms of RA. Taken orally in combination with sulfasalazine or hydroxychloroquine for 24 weeks, cat's claw seems to reduce the number of painful and swollen joints.
• Fish Oil supplements taken orally, alone or in combination with naproxen (Naprosyn), seems to significantly decrease the duration of morning stiffness in patients with RA. Use of fish oils might also reduce nonsteroidal anti-inflammatory drug (NSAID) requirements when used together.
• Superoxide Dismutase, given as an injection, seems to be effective for treating RA
• Thunder God Vine taken orally appears to produce symptom relief in patients with RA, including improvements in pain, tender and swollen joints, and physical function. It may work even better is taken with NSAIDs. In addition, one study showed applying a tincture of thunder god vine topically over affected joints seemed to decrease joint tenderness, stiffness, and swelling.
• Vitamin E taken orally in conjunction with standard therapy seems to be superior to standard therapy alone for reducing pain, but not inflammation in patients with RA.

The Natural Medicines Comprehensive Database has judged the following a being "Possibly Ieffective" for RA:

• Creatine
• Feverfew
• Flaxseed oil
• Histidine
• New Zealand green-lipped mussel
• Selenium
• Zinc

They have also judged the following as having "Insufficient Evidence" to use in the treatment of RA:

• Devil's claw
• DMSO
• Evening Primrose Oil (EPO)
• Fluoride
• Ginger
• Hyperimmune egg
• Indian frankincense
• Pantothenic acid (Vitamin B5)
• Turmeric
• Willow bark

Treatment of rheumatoid arthritis may also include these recommendations:

• reduction of stress
• splints to rest acutely inflamed joints
• assistive devices, such as zipper pulls, to decrease strain on joints
• healthy diet following the food guide pyramid, with adequate calories, protein, and
• calcium

Exercise is important in the treatment of arthritis. Thirty minutes of moderate exercise a day can help prevent complications of arthritis, as well as heart disease, stroke, and diabetes. A person exercising at a moderate level can talk normally without shortness of breath and is comfortable with the pace of the activity.

The 30 minutes a day can be done in one session or broken up into several smaller segments. Low impact aerobics and water aerobics are examples of exercises that minimize joint stress.

Surgery may be performed when pain cannot be controlled or when function is lost. Several types of surgery may be done, such as the following:

• arthroscopy, a procedure that uses a small scope and instruments to get inside the joint without opening it
• arthrotomy, which means opening the joint through a larger incision
• synovectomy, or removal of the lining of the joint
• osteotomy, which refers to the realignment of the bone next to the joint
• arthroplasty, which is the partial or total replacement of the joint.

Individuals with severe arthritis are often candidates for a knee joint replacement or a hip joint replacement .

A blood-filtering technique called the Prosorba column can be used for advanced cases of rheumatic arthritis that have not responded well to other therapies. Blood is filtered through the Prosorba column once a week for 12 weeks as an outpatient procedure.

The filtering removes particular antibodies that contribute to pain and inflammation in the joints. The treatment is not recommended for those on angiotensin-converting enzyme, or ACE inhibitors, or for those with heart or blood clotting problems or high blood pressure.

Approximately 30% of those who receive the treatment will have a 20% improvement in their symptoms.

What are the side effects of the treatments?

Medications used to treat rheumatoid arthritis may cause stomach upset, allergic reaction, decreased resistance to infection, and other side effects. Surgery may cause bleeding, infection, or reactions to anesthesia. Nearby bones, ligaments, tendons, nerves, or blood vessels can also be accidentally injured.

What happens after treatment for the disease?

Treatment of rheumatoid arthritis may be lifelong unless the condition goes into remission. There is no cure for the disease, but careful management can help to minimize some of its effects.

How is the disease monitored?

A healthcare provider will monitor the person's level of comfort and function of the joint. Any new or worsening symptoms should be reported to the healthcare provider.