Rheumatoid Arthritis

Rheumatoid arthritis (RA) is the most common crippling form of arthritis in the U.S. It affects over 2 million Americans, and is the biggest cause of lost wages and lost productivity in the country. The disease strikes all ethnic groups in all countries, whether they are warm and humid or cool and arid. It does not differentiate between the sexes, though it is slightly more common in women.

The disease can start overnight. Sufferers can go to bed one evening and awake the next morning with every joint in their body sore, stiff and swollen. The disease usually strikes the body symmetrically so that both shoulders, both wrists, both knees are hit at the same time. 

It can begin in just one joint, however, and over several weeks spread to others. It’s very common for the knuckles to be involved, especially the first knuckles at the base of the fingers. The joints become very swollen, warm and tender, and they’re stiff and difficult to move, especially on awakening. This stiffness can last several hours and sometimes throughout the day. The pain and swelling are constant. It can make life miserable for a patient, and certainly limit his or her ability to work or to enjoy leisure time.

RA generally begins in the twenties or thirties, though it can strike at any age. When it happens after the age of fifty or so, it is usually less severe, and often involves the shoulders and the hip joints. Children can develop a form of the disease. It sometimes disappears in childhood, but it may progress through the teens and into adulthood.

We don’t know what causes RA. It’s definitely associated with several genes, and the illness can run in families to a degree. The genetic bomb may be set off by a virus infection, by exposure to pollutants, by trauma to the body. The interaction between the genes and the environment is far from clear, and is the subject of great interest in research and academic circles.

We do know what happens in the joints after the trigger for the disease process is pulled. The cellophane-thin membrane that lines the joint gets thick, like a paper towel. It pours out more and more fluid, much more than needed to lubricate bony movement, and the joint swells. 

Immune cells are attracted to the area and they release chemicals that cause inflammation…redness and pain. The swollen joint membrane has nowhere to go and it starts to eat into the bone and the surface cartilage on the end of the bone. As the cartilage dissolves and the bone erodes under this attack, the joint space gets permanently narrower and finally is crippled to the point where movement is impossible.

There is one specific blood test for RA called the rheumatoid factor, and it’s present in the blood of about 80% of patients. The other twenty percent may have the illness, but are simply not positive for this test. 

Other tests may be elevated: the sedimentation rate or ESR, a sign of inflammation in the body; the C reactive protein or CRP, another inflammation chemical; the clotting cell count, the platelets, may be higher than normal. If the illness is severe, patients may become anemic with a low red blood cell count. Sometimes, all test results are normal, and it’s up to the skill of the rheumatologist to make the diagnosis of RA based on the overall history of the illness and the appearance of the patient.

The disease can affect not just the joints, but the internal organs when it’s very severe. Severe RA can cause fever, fluid around the heart or in the chest, an enlarged spleen, inflammation of the eyes, both the white sclera and the liquid that keeps the eyeball round. In the worst cases, this system-wide involvement can be fatal.

The treatment has changed over the last fifty years. RA was first treated with high dose aspirin, which did reduce joint swelling and pain, but was also associated with ulcers in the stomach. Worse, the illness still progressed despite the patient feeling better. 

Drugs like ibuprofen or Motrin, naproxen and Voltaren were used in place of aspirin. They were easier to take. Aspirin was used in doses of twelve to fourteen tablets a day, whereas these newer non-steroid anti-inflammatory drugs or NSAID’s were taken only once or twice a day. Still-newer NSAID’s were tried: Vioxx, Celebrex and Bextra. Some ended up with heart-related toxicities and none resulted in real improvement of disease progression.

DMARD’s or disease-modifying anti-rheumatic drugs seemed to be better than the NSAID’s, especially for severe illness. They actually made a change in the course of the illness, slowing it down as well as controlling symptoms. 

Prednisone sits on the border between being a DMARD and a strong anti-inflammatory drug. It's a corticosteroid or steroid for short. It seems to put the illness into complete remission, and it actually won a Nobel Prize for its use in RA…until the side effects came along. Diabetes, high blood pressure, thinning of the skin, osteoporosis, increased risk of some cancers all attended use of high dose prednisone over long periods. It fell out of vogue as a DMARD and is now used in low doses as an anti-inflammatory to get patients through bad periods until other drugs can start working.

Gold was another of the original DMARD’s. It was the actual metal hooked up to a carbohydrate so it would dissolve in the blood. It was given by a shot in the muscle every month, and it worked in about 60 to 70% of RA patients. No one has ever figured out how or why it worked, but it was an advance in RA care. It had side effects, however, and its use fell when Methotrexate came along. It's still used orally in a pill called Ridaura to treat mild cases of the disease.

Methotrexate is taken by mouth, so it’s easier to use than gold injections for more severe RA. It has fewer side effects than gold, and seems to work for a greater number of patients. It’s also used as a cancer chemotherapy agent, but the doses used in RA are about 1/100th as high as the cancer treatment doses. Though it’s a decent drug, in high doses it causes side effects such as loss of hair, mouth sores, liver inflammation and bone marrow changes. Worse, it only slowed down the disease; it didn’t stop it from moving along.

In the last few years have come the biologic drugs. The best news is that unlike any previous drugs, these stop the progression of the illness. Cartilage and bone within the joints stop being eaten away, and there may even be some healing of previous damage. The biologic drugs are much more effective and effective in more patients than any previous DMARD.

There are side effects to these drugs. They may increase the risk of infection, especially in the elderly. As with some of the DMARD’s, they rarely may increase the risk for leukemia and lymphoma, immune system cancers. The confusing point is that having  RA itself increases this risk, even if no drugs at all are used to treat the illness. This side effect is perhaps the most serious concern with all the DMARD’s, and the FDA keeps a careful watch on the biologics for any increase in cancers beyond what the older treatments may cause.

Treating a crippling and sometimes life-threatening illness is always a matter of balancing the risks of the drug with the benefits to the patient. These latest medications are the best that have come along in the last thirty years, and despite the risks that are similar to older agents, the anti-TNF drugs stop the illness in its tracks, and offer more hope for a remission of the illness than any previous treatment. 

A last note: if RA treatment is stopped at any age, the illness comes back with a vengeance. All rheumatologists and patients hope that with time and research, more drugs with greater effectiveness and lower toxicity will come along that will allow safe life-long treatment…until an actual cure is found.

For more, see information on Rheumatoid Arthritis from the Arthritis Foundation and the American College of Rheumatology.

© Jay Adlersberg 2015