Rheumatoid arthritis (RA) is an autoimmune disease where the immune system attacks the lining of the joint causing damage to the cartilage and bone. if untreated, rheumatoid arthritis can result in joint destruction and deformity. The immune system may also attack other organs such as the lung or blood vessels as part of the disease. Some people get little nodules (rheumatoid nodules) under the skin in the hands and around the elbows.
A family history of rheumatoid arthritis, a personal history of other autoimmune disease, female gender and smoking are the main recognised risk factors for developing rheumatoid arthritis.
Rheumatoid arthritis is usually diagnosed by a specialist rheumatologist based on a history of "inflammatory" joint pain and swelling, the physical examination and specific blood test abnormalities (e.g. raised rheumatoid factor, anti CCP antibodies and inflammatory markers).
In early disease, ultrasound or MRI may be needed to help clarify the diagnosis.
Disease activity is measured by using a composite score (DAS score) which takes into consideration the total number of tender and swollen joints and blood tests showing levels of inflammation (CRP or ESR).
In addition, ultrasound is routinely used to look for any evidence of disease activity in the joints which can help in determining disease activity and guide treatment changes.
Effective treatments to manage rheumatoid arthritis and prevent joint damage are available. The goal of treatment is to induce remission (which means make the symptoms and signs of arthritis completely go away). This is a realistic goal for most patients with newly diagnosed disease - where the treatment paradigm is to treat very aggressively up front. Remission is much harder to achieve in long standing disease that has been inadequately treated, and the goal of treatment in this setting may be low disease activity.
The main stay of therapy is with a class of medications called Disease Modifying Anti Rheumatic Drugs (DMARDs). DMARDs work by modulating the immune system. The most common medications in this group of ‘traditional’ DMARDs are: methotrexate, leflunomide, sulfasalazine & hydroxychloroquine. You will need to be under the care of a specialist rheumatologist to start and monitor treatment given the potential side effects of these medications. In addition to DMARDs, anti-inflammatory medications are used to to treat symptoms. Corticosteroid medications in tablets form, intramuscularly and as joint injections are commonly used when the disease is newly diagnosed or particularly active.
A newer group of ‘designer drugs’ called biologic DMARDs are also available for patients who fail to respond adequately to the traditional DMARDs. The biological DMARDs are very effective but very expensive and their use is reserved for patients who have failed therapy with a combination of traditional DMARDs. The main medications in this group are the TNF inhibitors (Adalimumab, Etanercept and Infliximab), Anti-B-cell therapy (Rituximab), and Anti-IL6 (Tocilizumab).
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