Sonia Nagda, M.D., M.P.H.
There are several different types of arthritis, all of which cause swollen and painful joints. The most common form of arthritis for adults is osteoarthritis, which is related to “wear and tear” on joints that can be caused by being overweight or doing activities that are repetitive (like running). Osteoarthritis tends to be diagnosed in just one or a few joints, usually the hands, hips, or knees.[end Hinton R, Moody RL, Davis AW, Thomas SF. “Osteoarthritis: Diagnostic and Therapeutic Considerations.” American Family Physician 2002; 65(5):841-849.]
Unlike osteoarthritis, rheumatoid arthritis (RA) is an autoimmune disease, which means that the body’s defenses turn on itself, and begin attacking joints and other organs. Symptoms can include joint stiffness lasting one hour or more in the morning and after being inactive for long periods of time, joint pain, tiredness, weight loss, and low-grade fever.[end Wasserman AM. “Diagnosis and Management of Rheumatoid Arthritis.” American Family Physician 2011; 84(11): 1245-1252.] The joints most likely to be affected are the hands, feet, neck, and hips. Most people who have RA have joint pain on both sides of the body, but when it first develops, it may be on only one side of the body.
How do you know that you have rheumatoid arthritis, and not osteoarthritis? In 2010, the American College of Rheumatology, which is the medical association for rheumatologists, updated the criteria used to diagnose rheumatoid arthritis.[end Aletaha D, Neogi T, Silman AJ. et, al. “2010 Rheumatoid Arthritis Classification Criteria: An American College of Rheumatology/European League Against Rheumatism Collaborative Initiative.” Arthritis and Rheumatism 2010; 62(9):2569-2581.] These include:
- Joint swelling, particularly in small joints such as the fingers, but possibly also including large joints like the knee or hip
- Blood tests that show long-term immune activity (rheumatoid factor and anti-cyclic citrullinated protein, or anti-CCP)
- Blood tests that show short-term immune activity (C-Reactive Protein, or CRP, and erythrocyte sedimentation rate, or ESR)
- Symptoms lasting 6 weeks or longer
Even though no one is certain why RA begins when it does, we know that certain types of people are more likely to get RA. People who have a family member who has been diagnosed with RA or another autoimmune disease are especially likely to develop RA. Your chances of getting RA also increase if you are older, a woman, smoke, or have certain gene mutations.[end Wasserman AM. “Diagnosis and Management of Rheumatoid Arthritis.” American Family Physician 2011; 84(11): 1245-1252.]
Beyond the Joints
The typical sign of rheumatoid arthritis is swollen joints, but RA affects many other parts of the body, as well. Joints can press down on nerves, causing numbness, tingling, and pain. Swelling can occur in the joints and also in the eyes, blood vessels, and lining of the heart. Some people get hard lumps, called nodules, on their skin, and some even develop these nodules on their lungs, in addition to other lung diseases like fluid build-up or pulmonary fibrosis (scarring).[end Wasserman AM. “Diagnosis and Management of Rheumatoid Arthritis.” American Family Physician 2011; 84(11): 1245-1252.] RA patients are at an increased risk of dying compared to other people. For example, people diagnosed with RA have more than 3 times the risk of getting a heart attack that leads to hospitalization, and almost 6 times the risk of getting a “silent” heart attack that does not get noticed or treated.[end Boonen A, Severens JL. “The burden of illness of rheumatoid arthritis.” Clinical Rheumatology 2011; 30(Suppl 1): S3-S8.]
Treating Rheumatoid Arthritis
There are a few different medications that are used to treat rheumatoid arthritis, and each type of medication has a different purpose.
The most important type of drug for treating rheumatoid arthritis is called a DMARD, which stands for disease-modifying antirheumatic drug. One of the most commonly used DMARDs is methotrexate, which helps protect the joints from becoming more damaged.[end van Vollenhoven RF. “Treatment of Rheumatoid Arthritis: state of the art 2009.” Nature Reviews Rheumatology 2009; 5: 531-541.] Other DMARDs can also be used instead of, or in addition to, methotrexate, and they all help keep the disease from getting worse. However, they can also cause side effects such as stomach upset, allergic reactions, liver or kidney toxicity, and eye disease.[end van Vollenhoven RF. “Treatment of Rheumatoid Arthritis: state of the art 2009.” Nature Reviews Rheumatology 2009; 5: 531-541.]
Another important type of medication is called an anti-inflammatory, which lessens the swelling in the joints. Swelling is what causes much of the pain in RA, so taking these medications usually makes daily life more comfortable. Over-the-counter options include ibuprofen (Motrin or Advil) and naproxen (Aleve), though these can cause upset stomach and ulcers with frequent use. If those don’t work, your doctor may prescribe celecoxib (Celebrex), meloxicam (Mobic), or diclofenac (Volatren), which may have less risk of stomach upset than the much less expensive over-the-counter medications, but have other, potentially serious side effects. That’s why Vioxx, a similar drug in this class, was taken off the market in 2004; it was shown to increase the risk of heart attacks and death compared to over-the-counter pain medications.[end Avorn J. “Two Centuries of Assessing Drug Risks.” The New England Journal of Medicine 2012; 367: 193-197.] It is also important to remember that prescription anti-inflammatory drugs will not work if they are taken around the same time as aspirin.[end Fendrick AM, Greenberg BP. “A Review of the Benefits and Risks of Nonsteroidal Anti-inflammatory Drugs in the Management of Mild-to-Moderate Osteoarthritis.” Osteopathic Medicine and Primary Care 2009; 3:1.]
Voltaren also comes in a gel form that can be rubbed on the specific joints that are swollen and this is helpful for people who can’t tolerate the pills or are concerned about their side effects. Since less of the gel is absorbed into the bloodstream, the side effects are less common and less severe.[end “Voltaren Side Effects. Drugs.com. At: <http://www.drugs.com/sfx/voltaren-side-effects.html>. Accessed 17 September 2012.]
Acetaminophen (Tylenol) is sometimes taken for arthritis, but studies show that it does not work as well as anti-inflammatory medications for joint pain, or as well as either Voltaren or Celebrex for swelling.[end Fendrick AM, Greenberg BP. “A Review of the Benefits and Risks of Nonsteroidal Anti-inflammatory Drugs in the Management of Mild-to-Moderate Osteoarthritis.” Osteopathic Medicine and Primary Care 2009; 3:1.] High doses could cause liver damage, and should especially be avoided for those who are also taking methotrexate.[end Lee WM. “Drug-Induced Hepatotoxicity.” The New England Journal of Medicine 2003; 349: 474-485.]
The bottom line is that researchers reviewing all the studies found that the over-the-counter anti-inflammatory drugs worked equally as well as the prescription ones.[end Latimer N, Lord J, Grant RL, et.al. “Cost effectiveness of COX 2 selective inhibitors and traditional NSAIDs alone or in combination with a proton pump inhibitor for people with osteoarthritis.” BMJ 2009; 339:b2538.] While people may react or respond differently to these medications, or have personal preferences, the other deciding factor could be cost: over-the-counter drugs can be much cheaper than their prescription counterparts, even if the prescription medications are partially paid by health insurance.
When pain and swelling is worse than normal (during a “flare”), steroids can be used. Steroids can be given by mouth or injection, either into a vein or muscle or directly into a swollen joint. They take longer to work than anti-inflammatories, are more powerful, and also have serious side effects, such as increasing the risk of infection, osteoporosis (thinning bones), weight gain, depression, water retention, diabetes, and agitation. These risks should be carefully discussed with your doctor before considering steroids.
The newest types of RA medication are biologics that calm down the immune system and keep it from attacking the body. Biologics can be used if DMARDs fail, or in combination with DMARDs. These drugs can be very helpful for some people, but they are very expensive and have substantial risks. People using biologic medications are more likely to develop infections (or even reactivate infections that have been inactive, such as tuberculosis) and certain types of cancers because the immune system is being suppressed.
Rheumatoid arthritis is not curable. The goal is “remission,” which means that most or all of the symptoms have gone away and the person with RA can enjoy a good quality of life without taking any medicine for a period of time. Remission can be hard to achieve, because stress and other factors can trigger RA’s return, and also because medications can just stop working after years of use. For that reason, people with RA often have to switch their medications every few years to keep their symptoms under control.
Living with Rheumatoid Arthritis
Rheumatoid arthritis is a disease people can live with, but only if you get tested and start getting treated. Blood tests and x-rays may be necessary to find out if you have RA, and if you do have it, you will want to start treating and managing it right away to minimize permanent damage to your health. Getting treated early can help to slow the progress of this chronic illness, and reduce the risks of deformities and other complications of the disease.