It is estimated that approximately 17.6 million people worldwide suffer from rheumatoid arthritis, making it one of the most common and widespread autoimmune diseases globally.
It has been found that around 12 million of the diagnosed patients are women, indicating that rheumatoid arthritis is more than twice as common in women compared to men.
The prevalence and widespread nature of rheumatoid arthritis worldwide underscore the necessity and importance of developing rheumatoid arthritis treatment and diagnosing methods . Rheumatoid arthritis significantly impacts many aspects of an individual’s life, but with early diagnosis and personalized treatment, the negative effects can be reduced, symptoms can improve noticeably, and the overall quality of patient life can be enhanced.
Rheumatoid Arthritis (Rheumatism)
Rheumatoid arthritis is a chronic degenerative autoimmune disease and a type of arthritis. This disease primarily affects the joints, and the symptoms of rheumatoid arthritis usually appear symmetrically, meaning the condition manifests in both the affected joint and its counterpart on the opposite side of the body. Additionally, it affects various body organs and tissues such as the heart, lungs, and skin, impacting the overall health of the body due to the different symptoms and associated medical conditions it may cause.
In the case of rheumatoid arthritis, the immune system attacks healthy joints (especially the joints of the hands and feet), tissues, and organs of the body. This occurs because of an error in the body where the immune system mistakenly identifies its healthy cells as threats and attacks them, causing this inflammatory condition in the body.
Diagnosis of Rheumatoid Arthritis
Early diagnosis of rheumatoid arthritis helps significantly in controlling the symptoms and complications that this disease may cause and aids in determining the appropriate treatment plan.
The diagnosis of rheumatoid arthritis primarily relies on the patient’s clinical signs and symptoms, but there are many other factors that assist in making an accurate diagnosis, including:
Medical History
This includes various questions that guide the doctor toward the correct diagnosis. Most of the disease’s signs and symptoms that the patient may be experiencing are observed at this stage. These symptoms include:
- Symmetrical joint pain, especially in the joints of the hands and feet
- Swelling and redness in the joint
- Tenderness when moving the joint
- Morning stiffness in the joint
- Various systemic symptoms
Clinical Examination
During the clinical examination, it is important to assess the severity of the symptoms, such as evaluating the intensity of the pain and estimating the extent of the damage. The clinical examination for rheumatoid arthritis patients is divided into several stages that vary from one case to another, but generally focuses on:
- Examining the joints of the upper limbs, especially the joints of the fingers, wrists, and elbows, to estimate the degree of damage.
- Examining the joints of the lower limbs, especially the joints of the ankle, foot, knee, and hip.
- Examining the spine, particularly the cervical spine, and noting any nerve compression due to the condition.
- Examining and observing various signs of the disease that may appear on the skin, such as rheumatoid nodules.
Laboratory Tests and Imagining
Tests For Rheumatoid Arthritis
There is no specific test to diagnose rheumatoid arthritis, but laboratory tests help in the diagnosis process alongside clinical symptoms and signs. The laboratory studies that may help in diagnosing rheumatoid arthritis can be divided into three types: immune tests, inflammatory tests, and blood tests. These include the following:
Rheumatoid Factor test: This test measures a group of proteins that the body may produce when the immune system attacks healthy cells and tissues. The normal value for rheumatoid factor is between 0-20 IU/mL of blood. Any value above 20 is considered elevated. Studies have shown that 70% to 90% of patients with elevated RF levels have rheumatoid arthritis, but it can also be present in 5% of healthy individuals. If rheumatoid arthritis occurs without an elevated RF value, the disease is generally less severe.
Anti-Cyclic Citrullinated Peptide Antibodies (Anti-CCP): This test measures proteins produced by the body during inflammation. It is conducted alongside the RF test. Positive results for both tests, along with symptoms and signs of rheumatoid arthritis, are highly indicative of the disease and suggest a severe condition. Anti-CCP levels are markedly elevated in rheumatoid arthritis. This test is 94%-96% specific, but it can also be elevated in other inflammatory autoimmune conditions like systemic lupus erythematosus (SLE). The normal values for this test are below 20 IU/mL.
Erythrocyte Sedimentation Rate (ESR): This test measures the rate at which red blood cells settle in a tube over one hour. The sedimentation rate is low in healthy individuals but may increase in the presence of inflammation. It is a general indicator of an inflammatory condition and is not specific to rheumatoid arthritis. Normal values for this test are 0-20 mm/hour in men over 50 years, 0-15 mm/hour in men under 50, 0-30 mm/hour in women over 50, and 0-20 mm/hour in women under 50.
C-Reactive Protein (CRP): This test measures the level of a protein produced by the liver in response to inflammation. CRP levels often rise before symptoms appear, making it useful for early diagnosis. Elevated levels indicate significant inflammation or injury. It also helps monitor disease progression and the effectiveness of rheumatoid arthritis treatment. Normal values are generally less than 10 mg/L but can vary by individual and laboratory.
Complete Blood Count (CBC): This test measures the number of red blood cells, white blood cells, hematocrit, hemoglobin, and platelets. It helps detect conditions such as anemia, which may result from rheumatoid arthritis or the side effects of rheumatoid arthritis medications.
Antinuclear Antibodies (ANA): These tests detect the presence of abnormal antibodies in the blood. A positive result may indicate an autoimmune disorder. ANA tests are positive in 40% of rheumatoid arthritis cases, but they are not enough to diagnose the condition.
Imaging Tests
Radiographic images help in detecting many diseases, including rheumatoid arthritis, and they allow for early diagnosis of this disease as well as monitoring its progression and the effectiveness of the provided rheumatoid arthritis treatment.
- Plain Radiographs (X-rays): Plain radiography allows for the assessment of the progression and development of the disease. It can reveal erosions in the joints even in the absence of pain. It is the first choice for radiographic imaging in rheumatoid arthritis treatment because it is easily available, inexpensive, and can be used frequently.
- Magnetic Resonance Imaging (MRI): MRI provides a more accurate assessment of lesions and erosions caused by rheumatoid arthritis compared to plain radiography. It is useful for early diagnosis and is primarily used in patients with cervical spine injury. However, the small size of joints limits the widespread use of MRI.
- Ultrasound Imaging: Ultrasound imaging helps predict the onset of rheumatoid arthritis in patients experiencing musculoskeletal pain without visible synovitis. It can detect subclinical inflammation (not yet symptomatic) and differentiate between rheumatoid arthritis and other types of arthritis, such as psoriatic arthritis. Additionally, it is used to evaluate the response to rheumatoid arthritis treatment and any new symptoms that may arise due to this autoimmune disease.
Differential Diagnoses
- Myelodysplastic Syndrome (MDS)
- Osteoporosis
- Degenerative Arthritis
- Polymyalgia Rheumatica (PMR)
- Psoriatic Arthritis
- Systemic Lupus Erythematosus (SLE)
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Rheumatoid Arthritis Treatment
Early diagnosis and early initiation of rheumatoid arthritis treatment are crucial objectives when managing patients with this condition. The goal is to prevent irreversible joint damage and reduce the occurrence of various symptoms and complications associated with the disease’s inflammatory activity. The aim is to achieve long-term clinical remission and improve the quality of life for patients. If clinical remission cannot be achieved, low disease activity is an acceptable alternative.
Disease activity should be assessed monthly in patients with moderate to severe disease activity. For patients with low disease activity or those in clinical remission, disease activity should be evaluated every 3 to 6 months.
Several clinical assessment tools have been developed to help physicians determine the disease activity in patients with rheumatoid arthritis. It is important to remember that all patients about to start rheumatoid arthritis treatment should be screened for hepatitis B and C and tuberculosis. Methotrexate should be avoided in patients with liver diseases.
Rheumatoid arthritis treatment includes various approaches involving both pharmacological and non-pharmacological rheumatoid arthritis treatment, such as exercise, diet, physical therapy, and even surgery in some cases.
Rheumatoid Arthritis Treatment by Medications
There are many medications that may be used in rheumatoid arthritis treatment to alleviate its symptoms. These include:
- Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): NSAIDs do not have a disease-modifying effect but are commonly used to relieve pain and reduce symptoms associated with rheumatoid arthritis. These medications have several side effects, including gastrointestinal, kidney, and blood toxicity. There are various types of NSAIDs, such as indomethacin, piroxicam, and celecoxib. The choice of the appropriate NSAID depends on the patient’s condition and any comorbidities.
- Non-Biological DMARDs: This category includes methotrexate, hydroxychloroquine, azathioprine, sulfasalazine, leflunomide, and cyclosporine. Methotrexate is the first-line drug used in rheumatoid arthritis treatment, as these drugs modify the disease and effectively delay its progression. Methotrexate is administered in various oral doses and can be given subcutaneously in patients who do not respond to oral therapy.
- Corticosteroids: Corticosteroids are commonly used in patients with rheumatoid arthritis, particularly those with recent severe disease activity. Studies have shown that early use of corticosteroids improves outcomes and modifies the disease course positively. However, long-term use of corticosteroids has not demonstrated benefits and poses risks such as osteoporosis and other complications. About 50% of patients may require low-dose daily corticosteroids (prednisone 2.5-7.5 mg) to control symptoms.
- TNF Inhibitors: TNF inhibitors are not recommended before trying non-biological DMARDs. However, studies indicate that adding a TNF inhibitor in patients who do not respond to methotrexate is better than adding another non-biological DMARD. These drugs can lead to antibody formation against them, reducing their effectiveness over time. TNF inhibitors include etanercept, infliximab, adalimumab, certolizumab, and golimumab.
- Rituximab: Rituximab, a biological DMARD, can be added for patients with uncontrolled rheumatoid arthritis who do not respond to TNF inhibitors. It is administered intravenously, and the response is better in seropositive patients and those also taking methotrexate.
- Abatacept: Abatacept prevents T-cell activation by binding to CD80 and CD86. It is given as a monthly intravenous injection or a weekly subcutaneous injection. Patients with uncontrolled rheumatoid arthritis who do not respond to methotrexate and TNF inhibitors benefit from abatacept, which has proven efficacy for 6 months to 5 years of treatment.
- Interleukin-6 Inhibitors: Interleukin-6 inhibitors like tocilizumab are used in moderate to severe active rheumatoid arthritis in adults with poor response to TNF inhibitors, showing good clinical improvement.
- Janus Kinase (JAK) Inhibitors: JAK inhibitors (e.g., tofacitinib) are a class of tyrosine kinases involved in intracellular signaling for hematopoiesis and immune cell function. These oral agents reduce immune cytokine production and are approved as second-line drugs for rheumatoid arthritis treatment.
Exercise in Rheumatoid Arthritis Treatment
Muscle atrophy often accompanies rheumatoid arthritis (RA), exacerbated by inactivity, bed rest, splints, and medications. Working out and exercises for RA patients aim to relieve pain, enhance energy, increase muscle strength, reduce joint stiffness, limit disability, improve daily activity performance, and enhance quality of life. Types of exercise include:
- Walking
- Cycling
- Swimming
- Resistance exercises
- Stretching exercises
- Balance exercises
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Heat and Cold Therapy in Rheumatoid Arthritis Treatment
Applying heat, whether superficial or deep, effectively relieves joint pain and stiffness associated with RA. Heat therapy is used to prepare joints for exercises, stretching, and muscle strengthening. Both superficial and deep heating methods have been shown to increase intra-articular temperature in RA patients, alleviating symptoms and joint pain. Heat can be applied to the joint through various means, including hot packs and hot baths.
Cooling the joint also benefits acute joint inflammation by reducing pain and muscle spasms, achieved using ice packs or topical sprays.
Orthotics and Splints in Rheumatism Treatment
Orthotic devices play a crucial role in rehabilitating RA patients. These devices reduce pain and inflammation, improve joint function, decrease deformity, and correct movement misalignment.
Approximately 80% of RA patients have foot problems, easily managed by wearing deep, wide leather shoes. A metatarsal pad is often used to relieve pressure from painful metatarsophalangeal joints.
Surgery and Rheumatoid Arthritis Treatment
Surgery can alleviate pain, correct deformity, and improve symptoms in RA patients. Various surgical procedures are available, chosen based on the patient’s specific condition, including age, disease stage, and deformity level. These procedures include:
- Tenosynovectomy
- Joint reconstruction
- Joint fusion
- Joint replacement
Hand or wrist deformities can impair many daily activities. Surgical rheumatoid arthritis treatment in the hand and wrist include:
- Synovectomy
- Tendon sheath excision
- Tendon realignment
- Reconstructive surgery or arthroplasty
Diet and Rheumatoid Arthritis Treatment
Studies on Muslim patients have shown a significant reduction in rheumatoid arthritis symptoms during Ramadan fasting (from sunrise to sunset for a month). Disease activity scores assessed 6 months before Ramadan and after at least 7 days of fasting in 36 RA patients decreased from 4.3 to 3.5. Another study on 35 patients indicated that the positive effects of fasting could last up to 3 months.
Following a RA diet rich in fruits, vegetables, whole grains, and healthy fats, is a good rheumatoid arthritis treatment option that can help control the inflammation that damages the body. This diet also provides the nutrients your body needs and helps maintain a healthy body weight, which is important because excess weight increases pressure on the joints, leading to less severe pain. Additionally, excess weight can make some rheumatoid arthritis medications less effective. Recommended foods include:
- Salmon, tuna, sardines, herring, and other fish are rich in omega-3 fatty acids, which may help control inflammation.
- Nuts, filled with healthy monounsaturated fats, are known for their heart-protective properties and overall beneficial nutrients.
- Fruits and vegetables are rich in antioxidants, which help reduce molecules called free radicals that can lead to inflammation and cell damage.
- Oats, whole wheat, brown rice, and other whole grains may lower C-reactive protein levels and reduce the risk of heart disease, which is higher in people with RA.
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Significant progress has been made in rheumatoid arthritis treatment and diagnosis in recent years, greatly improving the quality of life for individuals with this chronic disease. Early and accurate diagnosis is critically important and is typically achieved through a combination of clinical examinations, laboratory tests, and imaging studies. This enables timely initiation of treatment, which is essential for reducing joint damage, controlling symptoms such as inflammation, relieving pain, maintaining joint function, and enhancing the overall well-being of the patient.
Ongoing and advanced research that supports understanding the pathophysiology of rheumatoid arthritis will offer more targeted rheumatoid arthritis treatment in the future. Through various mechanisms and methods, patients with rheumatoid arthritis can achieve longer periods of disease remission and live normal lives.
Resources:
- Medscape
- Arthritis Foundation