Arthritis is a common health problem in the global population, affecting more than 350 million people and a leading cause of disability. In fact, among chronic diseases in North America, for example, arthritis causes more disability than any other condition, including heart disease, diabetes, and back or spine problems.
Arthritis is an umbrella term for over 100 different types of disease that affect people of all ages, races, both genders – but more women develop it than men – and from babies to older people.
Rheumatoid arthritis is the most common form of the auto-immune types of arthritis.
Contrary to popular belief, arthritis is not a disease of the elderly; more than three in five people diagnosed with arthritis are under the age of 65.
The burden of arthritis worldwide is expected to have significant consequences in terms of health care costs and loss of productivity by patients today, and over the next 30 years.
The more than 100 types of arthritis fall into two major groups:
Osteoarthritis- Caused by a breakdown of cartilage in joints causing bones to rub together resulting in pain, stiffness and eventual loss of use. There are some forms of osteoarthritis that appear to be genetically driven, and others that are a result of injury, overuse or advanced age.
Inflammatory (or “autoimmune) arthritis- is a general term used to describe autoimmune forms of the disease. In inflammatory arthritis, the body's own immune system attacks healthy joints and tissues, causing inflammation and joint damage. Rheumatoid arthritis is the most common form of inflammatory arthritis. Other forms include ankylosing spondylitis, psoriatic arthritis, lupus and many others.
Rheumatoid arthritis (RA) falls into the inflammatory arthritis (also “autoimmune”) disease category. Its hallmark symptoms include inflammation and resulting pain in the knees and wrists, and larger joints in the hands and feet. It is a disease process (like cancer or diabetes) where the body's immune system mistakenly attacks its own healthy joints. It is a relatively common disease-approximately 1 in 100 people get it-and is often devastating to a person's body if not treated properly. The disease process causes swelling and pain in and around joints and can affect the body's organs, including the eyes, lungs, and heart. Rheumatoid arthritis most commonly affects the hands and feet. Other joints often affected include the elbows, shoulders, neck, jaw, ankles, knees, and hips. Within ten years of the onset of the disease, up to 50% of people living with RA are work disabled if untreated. For those living with RA, related inflammation in the arteries result is an increased risk of mortality.
When moderate to severe, the disease reduces a person's life span by as much as a dozen years. Today, effective RA treatments exist, which can change these outcomes.
While it affects all age groups, more than one half of all new cases occur between the ages of 40 and 70 years. Interestingly, rheumatoid arthritis affects women two out of three times more often than men.
Burden of Rheumatoid Arthritis
Approximately, one per cent of the world population is affected by rheumatoid arthritis. Estimates from the “Global Burden of Rheumatoid Arthritis” 2010 study estimated RA affects more than 17.6 million people worldwide.
Experts predict the number of patients with RA may double by 2030 because of:
The baby boom generation moving across the age demographic
Increased recognition of RA by practitioners
Slightly higher incidence of RA in the over 70 yr. old population
What This Means for Health Care
The implications of the changing demographic of the rheumatology profession and RA patient population are two fold:
- As the RA patient population ages, there will be a greater number of them who will develop other co-morbidities, such as heart disease, which further complicates long-term disease management
- As RA cases increase worldwide, many countries will be facing a decrease in the number of rheumatologists because one-third of those practicing today will be retiring in the next 10 years
RA has several "hallmark" symptoms – things you feel or experience – when the disease first presents itself. These include:
Morning stiffness, lasting longer than 30 minutes
Pain and/or inflammation in the same joints on both sides of your body
Pain in three or more joints at the same time
Loss of motion in affected joints
If you experience two or more of these symptoms you should speak with your family physician. Be sure to tell your doctor about any history of RA in your family. While there is no known cause of rheumatoid arthritis, research indicates that heredity may likely play a role in that a susceptibility to the disease may be inherited. Smoking is also closely linked with
If your doctor believes you may have rheumatoid arthritis, you will usually be referred to a rheumatologist, a specialist in the treatment of arthritis. Rheumatologists have many years of extra training on top of their regular medical schooling, and are experts at diagnosing and treating all forms of arthritis, including rheumatoid arthritis.
To confirm a diagnosis of rheumatoid arthritis, a doctor may run several tests. These may include:
blood tests, including those to look for abnormal blood antibodies and to get baseline liver and blood counts
x-ray imaging, to check for joint damage or deterioration
bone scans are infrequently used but sometimes can help to check for joint inflammation
joint fluid tests, or arthrocentesis, in which a small amount of joint fluid is extracted using a needle and then analyzed in the laboratory
While these tests are helpful at confirming a diagnosis of RA, they are not definitive on their own. They complement the findings of a thorough joint exam and your family history and symptom profile.
Once a rheumatologist has diagnosed RA, there are effective treatments available to help a person manage the symptoms and minimize joint damage. While there is no known cure for RA, good treatments now exist and rheumatologists are the best people to discuss these with and formulate a treatment plan to address all aspects of the disease.
Scientific evidence now shows that early treatment – within the first six weeks of symptom onset – of RA increases the chances that patients will either achieve remission or maintain a low level of disease activity, preventing damage to joints and organs.
Today specialists recommend a well-rounded treatment plan that includes:
Medication (often a combination of medications)
Appropriate amounts of range-of-motion, cardiovascular and muscle strengthening exercises
Rest when needed
Vitamins and mineral supplements and a well-balanced diet.
The early treatment and long-term management of RA has changed dramatically over the past 30 years. Prior to the early 1990s, few medications existed and were only partly effective at supressing the disease. Finding the right dose vs. toxicity balance was difficult from patient to patient. As well, the therapies available at that time were started late, sometimes months or years after disease onset. The treatment target was relief of symptoms rather than attempting to put the disease into remission or a state of low disease activity.
Today there are numerous highly efficacious medications to treat RA. There are six major medication groups:
- Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (for example Advil® or Motrin IB®), naproxen (or Naprosyn®), diclofenac (or Voltaren® and Arthrotec®)
- COX-2 NSAIDs, such as celecoxib (Celebrex®)
- Steroids, such as prednisone
- Conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) such as methotrexate, sulfasalazine, hydroxychloroquine, leflunomide and azathioprine
- Biologic response modifiers (originators “boDMARDs” or biosimilars “bsDMARDs), which have been approved in Canada for use in treating rheumatoid arthritis
- Targeted synthetic molecule (tsDMARDs) such as tofacitinib
These medications can work alone or in combination with one another. Today's "gold standard" of treatment looks like this:
A person with newly or recently diagnosed (ideally within 6 weeks of symptom onset) with moderate to severe rheumatoid arthritis is typically started on methotrexate, and possibly one or two other DMARDs in combination with methotrexate, such as sulfasalazine and hydroxychloroquine (called “triple therapy”). While waiting for the drugs to take effect, an NSAID or cox 2 inhibitor or in some cases prednisone, can be used to reduce inflammation quickly and help short-term the person from worsening.
If a person does not respond, or does not respond well enough to the above combination therapy (which is to say their inflammation is not well controlled), then they would be considered a good candidate for an advanced therapy, such as a biologic response modifier (only one is used at any given time) or a targeted small molecule medicine. They are usually used in combination with methotrexate, but some can be used without it, which is helpful for those who cannot take it.
This medication approach is like that used to treat cancer and other autoimmune diseases. In cancer, aggressive medication therapy is used to stop or reduce the size of tumours or lesions. In RA, early and aggressive medication therapy is used to stop or markedly reduce inflammation – think of inflammation as the equivalent of a tumour in RA.
Because people with active, moderate to severe RA are at high risk for irreparable joint damage caused by the disease's symptoms it is very important for them to closely follow their treatment regimen. It is this regimen that helps to prevent or reduce joint damage and disability and delivers the highest quality of life possible.
Exercise is also a very important component of a successful treatment plan in rheumatoid arthritis. Appropriate stretching and strengthening of muscles and tendons surrounding affected joints can help to keep them stronger and healthier and is effective at reducing pain and maintaining mobility. In addition, moderate forms of aerobic exercise can help to maintain a healthy body weight and lessens unnecessary strain on joints. Swimming, walking, and cycling are often recommended but they must be done at a level which safely "challenges" a person's aerobic capacity. A physiotherapist trained in rheumatoid arthritis is the ideal person to recommend a safe and effective exercise program for people living with the disease.
Heat and cold can be used to decrease pain and stiffness. Hot showers can often relax aching muscles and reduce pain; applying cold compresses-like ice packs-to swollen joints can help to reduce heat, pain and inflammation and allow a person to exercise more freely, or to recover from exercise more quickly.
Finally, maintaining a healthy lifestyle is also a critical part of a rheumatoid arthritis treatment plan. If a person with RA smokes, quitting is vitally important because it both makes RA disease activity worse, and reduces the effectiveness of the medications used to treat it. A nutritionally sound diet that includes appropriate levels of calcium, vitamin D and folic acid is important. Managing stress levels, getting appropriate amounts of rest, and good old-fashioned relaxation lead to a higher quality of life.
Here are two resources listing available treatments for RA:
American College of Rheumatology
Arthritis Consumer Experts JointHealth Arthritis Medications Guide