Rheumatoid arthritis is an autoimmune disease that causes chronic inflammation of the joints.
Rheumatoid arthritis can also cause inflammation of the tissue around the joints such as the tendons, ligaments, and muscles, as well as other organs in the body.Rheumatoid arthritis is a chronic illness, meaning it can last for years, patients may experience long periods without symptoms. Typically, however, rheumatoid arthritis is a progressive illness that has the potential to cause joint destruction and functional disability.
The cause of rheumatoid arthritis is a very active area of worldwide research. The cause of rheumatoid arthritis is unknown. Some scientists believe that the tendency to develop rheumatoid arthritis may be genetically inherited.It is suspected that certain infections or factors in the environment might trigger the immune system to attack the body's own tissues.
Environmental factors also seem to play some role in causing rheumatoid arthritis. Recently, scientists have reported that smoking tobacco increases the risk of developing rheumatoid arthritis.
The goal of treatment in rheumatoid arthritis is
1.to reduce joint inflammation and pain,
2.to maximize joint function, and
3.to prevent joint destruction and deformity.
There is no known cure for rheumatoid arthritis.
Optimal treatment for the disease involves a combination of medications, rest, joint strengthening exercises, joint protection, and patient (and family) education. Treatment is most successful when there is close cooperation between the doctor, patient, and family members. Treatment is customized according to many factors such as disease activity, types of joints involved, general health, age, and patient occupation.
Two classes of medications are used in treating rheumatoid arthritis:
1. Fast-acting "first-line drugs" which includes NSAIDs (non steroidal anti-inflammatory drugs), COX-2 Inhibitors, Pain Medication (analgesics), Corticosteroids.
Acetylsalicylate (Aspirin), naproxen (Naprosyn), ibuprofen (Advil, Medipren, Motrin), and etodolac (Lodine) are examples of nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs are medications that can reduce tissue inflammation, pain and swelling. NSAIDs are not cortisone. Aspirin, in doses higher than that used in treating headaches and fever, is an effective antiinflammatory medication for rheumatoid arthritis. Aspirin has been used for joint problems since the ancient Egyptian era.NSAIDs are usually taken with food. Additional medications are frequently recommended to protect the stomach from the ulcer effects of NSAIDs.
Corticosteroid medications can be given orally or injected directly into tissues and joints. They are more potent than NSAIDs in reducing inflammation, and in restoring joint mobility and function. Corticosteroids are useful for short periods during severe flares of disease activity, or when the disease is not responding to NSAIDs. However, corticosteroids can have serious side effects, especially when given in high doses for long periods of time. These side effects can be partially avoided by gradually tapering the doses of corticosteroids as the patient achieves improvement of the disease. Abruptly discontinuing corticosteroids can lead to flares of the disease or other symptoms of corticosteroid withdrawal, and is discouraged.
2. Slow-acting "second-line drugs" (also referred to as Disease-Modifying Antirheumatic Drugs or DMARDs) which includes gold, methotrexate, hydroxychloroquine (Plaquenil),Sulfasalazine (Azulfidine) and D-penicillamine (Depen, Cuprimine) promote disease remission and prevent progressive joint destruction, but they are not anti-inflammatory agents.
Both classes are mixed for certain patients to obtain relief. Some patients are treated by injecting certain drugs directly and locally into the joints.
Newer "second-line" drugs for the treatment of rheumatoid arthritis include leflunomide (Arava), and the "biologic" medications etanercept (Enbrel), infliximab (Remicade), anakinra (Kineret), and adalimumab (Humira). Leflunomide (Arava) is available to relieve the symptoms and halt the progression of the disease. It seems to work by blocking the action of an important enzyme that has a role in immune activation.
Etanercept (Enbrel), infliximab (Remicade), and adalimumab (Humira) are biologic medications. These medications intercept a protein in the joints (tumor necrosis factor, or TNF) that causes inflammation before it can act on its natural receptor to "switch on " inflammation.
Anakinra (Kineret) is another biologic treatment that is used to treat moderate to severe rheumatoid arthritis. Anakinra (Kineret) works by binding to a cell messenger protein (IL-1, a proinflammation cytokine).
Rituxan can be effective in treating autoimmune diseases like rheumatoid arthritis because it depletes B-cells, which are important cells of inflammation and in producing abnormal antibodies that are common in these conditions. Rituxan is now available to treat moderate to severely active rheumatoid arthritis in patients who have failed the TNF-blocking biologics.
Orencia (abatacept) is a recently developed biologic medication that blocks T-cell activation. Orencia (abatacept) is now available to treat adult patients who have failed a traditional DMARD or TNF-blocking biologic medication.
The Prosorba column therapy involves pumping blood drawn from a vein in the arm into an apheresis machine, or cell separator. This machine separates the liquid part of the blood (the plasma) from the blood cells. The Prosorba column is a plastic cylinder about the size of a coffee mug that contains a sand-like substance coated with a special material called Protein A. Protein A is unique in that it binds unwanted antibodies from the blood that promote the arthritis. The Prosorba column works to counter the effect of these harmful antibodies. The Prosorba column is indicated to reduce the signs and symptoms of moderate to severe rheumatoid arthritis in adult patients with long standing disease who have failed or are intolerant to disease-modifying anti-rheumatic drugs (DMARDs). The exact role of this treatment is being evaluated by doctors and it is not commonly used currently.
In some patients with severe joint deformity, surgery may be necessary that may range from arthroscopy to partial and complete replacement of the joint.
Some go for natural treatment which include Acupuncture / Acupressure, Biofeedback, Chiropractic, Magnets, Massage, Meditation, Tai Chi, Yoga.
Supplements such as fish oil, glucosamine, chondroitin, MSM are also used. It is not confirmed if these are effective.
complimentary medicine includes regular exercise, eating a nutritious diet and the stress management.Heat and cold applications are modalities that can ease symptoms after exercises.
Future treatments: Scientists throughout the world are studying many promising areas of new treatment approaches for rheumatoid arthritis. These areas include treatments that block the action of the special inflammation factors, such as tumor necrosis factor (TNFalpha) and interleukin-1 (IL-1), as described above. Many other drugs are being developed that act against certain critical white blood cells involved in rheumatoid inflammation. Also, new NSAIDs with mechanisms of action that are different from current drugs are on the horizon.
Studies involving various types of the connective tissue collagen are in progress and show encouraging signs of reducing rheumatoid disease activity. Finally, genetic research and engineering is likely to bring forth many new avenues of earlier diagnosis and accurate treatment in the near future. Gene profiling, also known as gene array analysis, is being identified as a helpful method of defining which people will respond to which medications. Studies are underway that are using gene array analysis to determine which patients will be at more risk for more aggressive disease. This is all occurring because of technology improvements. We are at the threshold of tremendous improvements in the way rheumatoid arthritis is managed.
Supportive therapies:
Medical rehabilitation plays an important role in its treatment. Team of rehabilitation helps patients manage everyday activities and work and live with chronic conditions. This team includes physical therapists, occupational therapists, psychologists, social workers and relaxation specialists. Led by rheumatologists, the team initiates and monitors rehabilitative therapies, including all elements of managing the patient's condition that do not involve traditional medical, drug and surgical procedures.
Treatment may include:
Physical therapy
Occupational therapy
Individualized home strengthening and stretching programs to improve range of motion, function and independence while protecting joints and reducing flare-ups
Integrative medicine (e.g., acupressure and acupuncture)
Manual therapy (e.g., massage and stretching)
Nutrition counseling
Sleep counseling
Patient education
Vocational counseling
Physical therapy can help alleviate the pain, stiffness and weakness associated with rheumatic diseases and to restore function, improve mobility and independence and prevent or limit permanent physical disabilities. The goal of occupational therapy is to help people regain, develop and build skills that are essential for independent functioning, health and well-being.
Assistive device can help a person with a rheumatic disease move better, manage pain or avoid fatigue. Such devices include:
*Braces (e.g., back braces)
*Canes
*Grab bars in showers and tubs
*Shoe inserts
*Special tools or gadgets that can help maintain an active, independent life without straining the joints (e.g., reaching aids)
*Splints
*Using luggage or grocery carts
Aquatic therapy: Warm water helps to loosen tight joints and muscles while the resistance of the water improves muscle strength.
Diet: people with rheumatic diseases require no special diet. Some general guidelines to follow include:
*Limit alcohol consumption.
*Control your weight. Excess weight puts added stress on joints in your back, hips, knees and feet - places where arthritis pain is commonly felt. Excess weight also can make joint surgery more difficult and risky.
*Eat a healthy diet. Eating a diet high in vegetables, whole grains and fruits helps you maintain a proper weight and good health.
Lifestyle Modifications
While there is much about having a rheumatic disease that is not under your control, managing a variety of lifestyle issues can help make your condition easier. These include:
*Apply cold to joints or painful areas for occasional flare-ups. Cold may dull the sensation of pain in the first day or two. Cold also has a numbing effect and decreases muscle spasms. *Do not use cold treatments if you have poor circulation or numbness.
*Apply heat to joints or painful areas. Heat will ease your pain, relax tense, painful muscles and increase the regional flow of blood. You may find it especially helpful before exercising. One of the easiest and most effective ways to apply heat is to take a 15-minute hot shower or bath. Other options are a hot pack, an electric heating pad on its lowest setting or a radiant heat lamp with a 250-watt reflector heat bulb. If your skin has poor sensation or if you have poor circulation, do not use heat treatment.
*Avoid actions that strain joints, including finger joints, if you have arthritis. Choose a purse with a shoulder strap rather than a clutch-style purse. Use hot water to loosen a jar lid and pressure from your palm rather than your fingers to open it.
*Avoid jobs or activities that require repetitive motions, heavy lifting or stress on joints. Other activities that should be avoided are ones that involve overuse or injury to a joint.
*Avoid stress and anxiety. These can cause changes in your body chemistry that can make your symptoms worse. Relaxation techniques or antidepressant drugs can help manage stress and anxiety. Hypnosis, guided imagery, deep breathing and muscle relaxation can all be used to control pain.
*Develop a support system to help you and your family best manage your condition.
*Eat a balanced, healthy diet that allows you maintain a proper body weight.
*Get enough exercise. This helps reduce pain, stiffness and stress while increasing your strength and flexibility.
*Get enough rest. Being tired and feeling pain are signs that it may be time to rest joints and muscles. The pain associated with rheumatic diseases can make getting a good night's sleep difficult. This prevents your body from producing the chemicals that help regulate pain.
*Keep a positive attitude. Make a plan with your doctor for managing your arthritis. This will help you feel that you are in charge of your disease, rather than vice versa. Studies show that people who take control of their treatment and actively manage their arthritis experience less pain and function better.
