Rheumatoid arthritis

What is rheumatoid arthritis?

Rheumatoid arthritis (RA) is a long-term autoimmune condition. The immune system, which is meant to defend the body against germs, mistakenly attacks the inner lining of the joint (the synovium). This lining becomes inflamed and thick, and if the inflammation is not brought under control, it gradually damages the cartilage and bone. The NHS points out that the exact reason this reaction starts is not known.

The disease mostly affects the joints of the hands, wrists and feet, and usually both sides of the body together. Sometimes the eyes, lungs, heart, skin or blood vessels are affected too. The ACR describes it as the most common type of autoimmune arthritis and writes that about 75 percent of those affected are women and symptoms usually begin between ages 30 and 50, although the disease can appear at any age. Risk factors given in the sources: being female, family history, and smoking (smoking can also make the disease more severe).

Symptoms

• Pain, swelling, warmth and stiffness in the joints, especially the fingers and wrists, usually worse in the morning or after rest.
• Morning stiffness that gradually eases with movement. NIAMS describes it as lasting more than 30 minutes and the ACR as more than an hour.
• Tiredness, loss of appetite and sometimes a mild fever.
• Sometimes firm lumps under the skin near the joints (rheumatoid nodules).
• The disease usually appears slowly over a few weeks, but sometimes faster. There are also periods when symptoms get worse (flares) that are not easy to predict.

The ACR writes that symptoms lasting more than six weeks are a sign of persistent inflammation and should be assessed.

Who should see a doctor?

If you have had joint pain and swelling for a few weeks, especially in the fingers and wrists of both hands, or morning stiffness that lasts a long time, book an appointment. The NHS and NIAMS both stress early diagnosis, because timely treatment can reduce joint damage. NIAMS warns that joint damage may begin in the first year or two.

If symptoms continue, do not wait: talk to your doctor or a rheumatologist.

How is it assessed?

No single test confirms the diagnosis. The doctor puts several things together:

• History and examination: they ask about your symptoms, when they started, your family history and your medicines, and examine the joints.
• Blood tests: markers of inflammation (ESR and CRP), a blood cell count, rheumatoid factor (RF) and anti-CCP antibody. The NHS says a positive RF on its own is not definitive and is positive in about one in twenty people without the disease. A positive anti-CCP raises the likelihood of the disease, but not everyone with the disease has it. NIAMS also writes that some people with the disease have normal tests.
• Imaging: X-ray, ultrasound or MRI. NIAMS says X-rays are often normal at first and ultrasound and MRI can show inflammation earlier.

The results of all of these are interpreted together.

What does treatment look like in general?

There is no cure, but the NHS writes that with early diagnosis and suitable treatment, many people have months or even years between flares, which helps them keep up their life and work. The ACR gives the aim of treatment as reducing inflammation, lessening pain and swelling and preventing long-term joint damage. NIAMS gives the aim as bringing the disease to a state where no symptoms remain or very few do.

• Disease-modifying medicines (DMARDs) such as methotrexate, leflunomide, hydroxychloroquine and sulfasalazine are usually the first choice and slow the course of the disease. They may take a few months to show an effect. The NHS says sometimes two or three types have to be tried to find the right one.
• Biologic medicines and JAK inhibitors are used, at the rheumatologist’s judgement, when disease-modifying medicines are not enough.
• Steroids are used for quick, short-term relief, for example in a flare or until a disease-modifying medicine takes effect. The NHS says long-term use has side effects such as thinning of the bones, easy bruising and muscle weakness. For this reason it is usually short-term.
• Painkillers and anti-inflammatories reduce pain but do not stop the disease.
• Physiotherapy and occupational therapy to keep joint strength and movement and to learn ways of protecting the joints.
• Surgery in particular cases, when joint damage has advanced despite medicine.

Disease-modifying and biologic medicines need regular tests. We explain this more in the guide “Rheumatology tests and drug monitoring”. Do not stop or reduce any medicine, especially steroids, on your own. NIAMS says stopping a medicine suddenly is one of the causes of flares.

What can you do?

• Take your medicines exactly as prescribed and tell your doctor about side effects.
• Keep notes of your symptoms (which joint, what time, how long it lasted). These notes help the doctor at your next visit.
• Balance rest and activity: more rest during a flare, and gentle, low-impact exercise such as walking or swimming when the disease is calm. The ACR and NIAMS recommend this.
• Do not smoke, or stop smoking. Both sources link it to more severe disease.
• Use aids and joint-protection methods; an occupational therapist can guide you.
• Talk to your doctor about alcohol, vaccines, diets and supplements before you start anything new. The NHS says there is no strong evidence for any particular diet.
• Pay attention to signs of depression and loneliness and talk about them. NIAMS counts emotional support as part of care.
• If you are planning a pregnancy, talk to your doctor before trying. See the guide “Pregnancy and family planning”.

When to get help urgently

• A joint has suddenly become hot, swollen and very painful, with or without a fever. The NHS says that in conditions such as rheumatoid arthritis the risk of a joint infection (septic arthritis) is higher, and a doctor must see you urgently. Contact a doctor or the emergency department the same day.
• Fever or a sign of infection while taking an immune-suppressing medicine. Contact your doctor or clinic the same day.
• Chest pain or sudden shortness of breath. The NHS says inflammation of the lungs or heart is a possible complication of the disease. Call Iran’s emergency number (115).
• A red, painful eye or sudden blurred vision: go to an eye doctor or an eye emergency department the same day. Sudden loss of vision: call 115 or go to the emergency department.

See the full list in the guide “When should I call urgently?”