Did you know that there are numerous different types of arthritis? Arthritis is a collective term that covers more than 100 conditions characterized by longterm joint inflammation that can result in permanent joint damage. Some of the more commonly known forms include osteoarthritis, gout, rheumatoid arthritis, psoriatic arthritis and fibromyalgia. Rheumatoid arthritis, or RA, is the third most prevalent form of arthritis, affecting 1.3 million Americans. This debilitating condition affects quality of life and can reduce a patient’s lifespan. Early intervention with treatment protocols can greatly improve these factors once assessment of a patient’s risk factors and symptoms and proper testing to diagnose the condition has been performed.
How Is RA Different from Osteoarthritis?
RA is a chronic inflammatory condition that targets the joints. Unlike osteoarthritis, which is also known as degenerative joint disease, remains the most commonly diagnosed form of arthritis and is characterized by reduction in bone mass and an increase in susceptibility to fractures, RA affects the synovial lining of the joints. This weakens the tendons and ligaments, the connective tissues which attach muscle to bone and bone to bone, respectively, resulting in restricted joint stability and mobility, pain, and deformity as the joint capsule erodes. The damage doesn’t stop there, however. Over time, the inflammation of RA can damage other tissues in the body, including those of the lungs and heart. Unlike osteoarthritis, which results from aging and wear and tear, RA is categorized as an autoimmune disorder, which is defined as a condition in which the body’s immune cells attack the body’s own healthy tissues. Lupus, multiple sclerosis, Crohn’s disease, Guillain-Barre syndrome, Hashimoto’s thyroiditis, Graves’ disease, celiac disease and type 1 diabetes are all other examples of autoimmune disorders.
RA’s disease progression varies from patient to patient. In some, the disease advances rapidly, while in others, it progresses more slowly. Many patients experience remission periods in which their symptoms abate, and then these durations of relief end with a return of the symptoms. When this occurs, the patient is said to be experiencing a disease flareup. A few lucky patients will experience a permanent remission.
What Are the Risk Factors of RA?
The exact cause of RA remains unknown, but several potential risk factors have been identified. These risk factors include:
Family history. Although there are patients who are diagnosed with RA without any known family history of the disease, if an individual who does have a first-degree relative, such as a parent, who has been diagnosed with RA, then that individual is at an estimated four times greater risk than someone without the family history for developing the condition.
Gender. Roughly 75 percent of individuals stricken with RA are women. This may be due in part to hormonal shifts that occur during perimenopause, as age appears to present another potential risk factor.
Age. RA can affect individuals at any age, but the condition is most prevalent in those aged 45 years and older.
Smoking and environmental hazards. Smoking appears to not only increase one’s risk for developing RA, but it may also heighten the severity of the condition. Exposure to certain hazardous materials, such as asbestos, is also suspected to increase the risk of RA development.
Obesity. Individuals who are overweight or obese may carry a greater risk for developing RA.
Again, these are potential risk factors. Since the cause of RA remains a bit of a mystery, these risk factors must be considered in addition to the patient’s symptoms before suspecting RA.
What Are the Symptoms of RA?
At the early stage of RA, joints in the fingers and toes are affected, presenting with swelling and discomfort. The joints maybe warm to the touch, and redness may be observed. Patients may experience stiffness in the joints upon awakening and following periods of inactivity. As RA advances, these symptoms gradually extend to the wrists, ankles, elbows, knees, shoulders and hips. One of the factors that typically differentiates RA from osteoarthritis us that in RA patients, affected joints are usually symmetrical, meaning that the same joint on both sides of the body are affected. For example, a patient may be experiencing discomfort in the left hand as well as in the right hand.
While localized joint pain and inflammation is the initial complaint, additional symptoms of RA may include:
- Chronic fatigue
- Decrease in appetite and weight loss
- General malaise
When four or more joints are affected, a patient complains of experiencing these symptoms for a duration of six months or longer or has any of the risk factors mentioned above in addition to their presenting symptoms, the diagnostic process should include testing for RA.
Which Tests Can Screen for RA?
Once an evaluation of a patient’s symptoms and history has been performed, laboratory tests are ordered to determine whether or not the patient’s arthritis is specifically RA. This determination can often be made through a combination of two laboratory tests: the rheumatoid factor screening test and the anti-cyclic citrullinated peptide test.
Rheumatoid factor (RF) is an immunoglobulin-M protein autoantibody which is present in roughly 80 percent of patients who have RA, indicating an inflammatory state and autoimmune condition. The normal reference range for an RF test is less than 20 u/ml. However, there are other conditions that can yield an elevated RF level, including other autoimmune disorders, cancer, diabetes, some chronic infections, some vaccines and even the normal aging process. It is also important to note that approximately 20 percent of patients who have RA will have normal RF levels. Therefore, it is important to order an anti-CCP test in conjunction with the RF test.
Anti-cyclic citrullinated peptide (anti-CCP) is another autoantibody that is present in 60 to 70 percent of RA patients. When a patient’s RF and anti-CCP tests both yield positive results, the diagnosis is known as seropositive RA. The normal reference range for an anti-CCP test is less than 20 u/ml.
The remaining percentage of symptomatic patients whose RF and anti-CCP tests both yield negative results are diagnosed with seronegative RA. These patients may yield results on other laboratory screenings that are indicative of inflammation.
Although not specific to RA detection, the erythrocyte sedimentation rate (ESR) test and the C-reactive protein tests, both of which indicate the presence of inflammation, can be helpful in diagnosing RA in that elevated levels in these two tests are typical results in RA patients, but not in patients with osteoarthritis. These tests can also be useful in monitoring the condition’s level of activity as the disease progresses and when patients experience RA flareups.
The ESR test evaluated the rate at which erythrocytes, or red blood cells, settle into the bottom of the test tube apart from the plasma portion of the blood. When there is an increased level of acute phase reactant proteins, such as C-reactive protein, the erythrocytes drop to the bottom of the tube at a faster rate. A higher than normal level of C-reactive protein, and thus a higher sedimentation rate, occur in the presence of inflammation. The normal reference ranges for these two tests are:
Men less than 50 years of age: 0 to 15 mm/hr. to 0 to 20 mm/hr.
Women less than 50 years of age: 0 to 20 mm/hr. to 0 to 30 mm/hr.
Normal results tend to be higher in patients who are 50 years of age and older.
Less than 1.0
The ESR and C-reactive protein tests alone cannot be used to attain a definitive diagnosis of RA, however, since other factors, such as advanced age, the presence of infection or obesity, can cause elevated results in both tests.
If the above tests yield results that do not facilitate a confident diagnosis of RA, then diagnostic imaging tests, such as radiographs and magnetic resonance imaging, will come into play to visualize the condition of the affected joints, allowing physicians to rule out other causes of discomfort, make the diagnosis and assess the severity of the disease. These imaging tests, along with the ESR and C-reactive protein tests, may also be utilized to monitor the disease progression. The RF and anti-CCP tests are not particularly helpful in monitoring disease progression in that a patient who had elevated levels at the time of diagnosis will continue to have elevated levels, even during periods of disease remission. Complete blood counts and metabolic profiles should be ordered periodically to monitor for potential RA complications as well as any side effects that can result from drug therapies used to treat the condition.
What Are Complications of RA?
As RA progresses, complications can come about. Some potential complications of RA include:
- Rheumatoid nodules, which are firm subcutaneous lumps that typically form in close proximity to joints
- Sjogren’s syndrome, an immune disorder that is characterized by dry mouth and dry eyes
- Carpal tunnel syndrome
- Cardiovascular problems, including pericardial inflammation, arterial hardening and obstruction
- Lung disease and respiratory compromises, such as COPD
- Increased infections
Frequent evaluations and longterm monitoring of patients with RA are imperative. Periodic laboratory and imaging tests are essential to track the disease’s progression as well as to identify complications and to treat accordingly.
What is the Treatment and Prognosis for RA Patients?
There is no cure for RA. Treatment goals are to reduce pain and inflammation and to retard the progression of the disease. Early treatment with disease-modifying antirheumatic drugs can slow the progression of a patient’s RA and increase the chances for remission. Other treatment options include:
- Non-steroidal anti-inflammatory drugs
- Corticosteroid drugs
- Physical therapy
- Exercise that improves joint stability and range of motion
- Mind-body exercise, such as tai chi
When other methods of treatment are ineffective, surgical intervention to repair or to remove and replace damaged joints may be considered.
Patients who are referred to a board-certified rheumatologist to begin treatment at the earliest possible stage of the disease, before extensive joint damage has been sustained, have the best chance at living a full and active life.