Rheumatoid Arthritis

HAND & WRIST ANATOMY

DISEASE EXPLAINED

SYMPTOMS

Signs and symptoms of rheumatoid arthritis may include:

Tender, warm, swollen joints
Joint stiffness that is usually worse in the mornings and after inactivity
Fatigue, fever and loss of appetite
Early rheumatoid arthritis tends to affect your smaller joints first — particularly the joints that attach your fingers to your hands and your toes to your feet.

As the disease progresses, symptoms often spread to the wrists, knees, ankles, elbows, hips and shoulders. In most cases, symptoms occur in the same joints on both sides of your body.

About 40% of people who have rheumatoid arthritis also experience signs and symptoms that don’t involve the joints. Areas that may be affected include:

Skin
Eyes
Lungs
Heart
Kidneys
Salivary glands
Nerve tissue
Bone marrow
Blood vessels

Rheumatoid arthritis signs and symptoms may vary in severity and may even come and go. Periods of increased disease activity, called flares, alternate with periods of relative remission — when the swelling and pain fade or disappear. Over time, rheumatoid arthritis can cause joints to deform and shift out of place.

CAUSES

As we seen above, rheumatoid arthritis is an autoimmune disease. Normally, your immune system helps protect your body from infection and disease. In rheumatoid arthritis, your immune system attacks healthy tissue in your joints. It can also cause medical problems with your heart, lungs, nerves, eyes and skin.

Doctors don’t know what starts this process, although a genetic component appears likely. While your genes don’t actually cause rheumatoid arthritis, they can make you more likely to react to environmental factors — such as infection with certain viruses and bacteria — that may trigger the disease.

RISK FACTORS
Factors that may increase your risk of rheumatoid arthritis include:

Your sex. Women are more likely than men to develop rheumatoid arthritis.
Age. Rheumatoid arthritis can occur at any age, but it most commonly begins in middle age.
Family history. If a member of your family has rheumatoid arthritis, you may have an increased risk of the disease.
Smoking. Cigarette smoking increases your risk of developing rheumatoid arthritis, particularly if you have a genetic predisposition for developing the disease. Smoking also appears to be associated with greater disease severity.
Excess weight. People who are overweight appear to be at a somewhat higher risk of developing rheumatoid arthritis.

COMPLICATIONS
Rheumatoid arthritis increases your risk of developing:

Osteoporosis. Rheumatoid arthritis itself, along with some medications used for treating rheumatoid arthritis, can increase your risk of osteoporosis — a condition that weakens your bones and makes them more prone to fracture.
Rheumatoid nodules. These firm bumps of tissue most commonly form around pressure points, such as the elbows. However, these nodules can form anywhere in the body, including the heart and lungs.
Dry eyes and mouth. People who have rheumatoid arthritis are much more likely to develop Sjogren’s syndrome, a disorder that decreases the amount of moisture in the eyes and mouth.
Infections. Rheumatoid arthritis itself and many of the medications used to combat it can impair the immune system, leading to increased infections. Protect yourself with vaccinations to prevent diseases such as influenza, pneumonia, shingles and COVID-19.
Abnormal body composition. The proportion of fat to lean mass is often higher in people who have rheumatoid arthritis, even in those who have a normal body mass index (BMI).
Carpal tunnel syndrome. If rheumatoid arthritis affects your wrists, the inflammation can compress the nerve that serves most of your hand and fingers.
Heart problems. Rheumatoid arthritis can increase your risk of hardened and blocked arteries, as well as inflammation of the sac that encloses your heart.
Lung disease. People with rheumatoid arthritis have an increased risk of inflammation and scarring of the lung tissues, which can lead to progressive shortness of breath.
Lymphoma. Rheumatoid arthritis increases the risk of lymphoma, a group of blood cancers that develop in the lymph system.

TREATMENT

TREATMENT OPTIONS

There is no cure for rheumatoid arthritis. But clinical studies indicate that remission of symptoms is more likely when treatment begins early with medications known as disease-modifying antirheumatic drugs (DMARDs).

NON-SURGICAL TREATMENT OPTIONS
The types of medications recommended by your doctor will depend on the severity of your symptoms and how long you’ve had rheumatoid arthritis.

NSAIDs. Nonsteroidal anti-inflammatory drugs (NSAIDs) can relieve pain and reduce inflammation. Over-the-counter NSAIDs include ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve). Stronger NSAIDs are available by prescription. Side effects may include stomach irritation, heart problems and kidney damage.
Steroids. Corticosteroid medications, such as prednisone, reduce inflammation and pain and slow joint damage. Side effects may include thinning of bones, weight gain and diabetes. Doctors often prescribe a corticosteroid to relieve symptoms quickly, with the goal of gradually tapering off the medication.
Conventional DMARDs. These drugs can slow the progression of rheumatoid arthritis and save the joints and other tissues from permanent damage. Common DMARDs include methotrexate (Trexall, Otrexup, others), leflunomide (Arava), hydroxychloroquine (Plaquenil) and sulfasalazine (Azulfidine). Side effects vary but may include liver damage and severe lung infections.
Biologic agents. Also known as biologic response modifiers, this newer class of DMARDs includes abatacept (Orencia), adalimumab (Humira), anakinra (Kineret), certolizumab (Cimzia), etanercept (Enbrel), golimumab (Simponi), infliximab (Remicade), rituximab (Rituxan), sarilumab (Kevzara) and tocilizumab (Actemra).

Biologic DMARDs are usually most effective when paired with a conventional DMARD, such as methotrexate. This type of drug also increases the risk of infections.

Targeted synthetic DMARDs. Baricitinib (Olumiant), tofacitinib (Xeljanz) and upadacitinib (Rinvoq) may be used if conventional DMARDs and biologics haven’t been effective. Higher doses of tofacitinib can increase the risk of blood clots in the lungs, serious heart-related events and cancer.
Therapy
Your doctor may refer you to a physical or occupational therapist who can teach you exercises to help keep your joints flexible. The therapist may also suggest new ways to do daily tasks that will be easier on your joints. For example, you may want to pick up an object using your forearms.

Assistive devices can make it easier to avoid stressing your painful joints. For instance, a kitchen knife equipped with a hand grip helps protect your finger and wrist joints. Certain tools, such as buttonhooks, can make it easier to get dressed. Catalogs and medical supply stores are good places to look for ideas.

SURGICAL TREATMENT OPTIONS
If medications fail to prevent or slow joint damage, you and your doctor may consider surgery to repair damaged joints. Surgery may help restore your ability to use your joint. It can also reduce pain and improve function.

Rheumatoid arthritis surgery may involve one or more of the following procedures:

Synovectomy. Surgery to remove the inflamed lining of the joint (synovium) can help reduce pain and improve the joint’s flexibility.
Tendon repair. Inflammation and joint damage may cause tendons around your joint to loosen or rupture. Your surgeon may be able to repair the tendons around your joint.
Joint fusion. Surgically fusing a joint may be recommended to stabilize or realign a joint and for pain relief when a joint replacement isn’t an option.
Total joint replacement. During joint replacement surgery, your surgeon removes the damaged parts of your joint and inserts a prosthesis made of metal and plastic.