Rheumatoid arthritis | Mate rumatiki

Key points

1. RA can occur at any age, but most often appears between the ages of 25 and 50 years old.
2. It occurs when your body’s immune system attacks the joints between your bones, usually affecting the hands, feet and wrists.
3. As well as pain and stiffness in the joints, RA can also make you feel unwell outside the joints, with low energy being common. 
4. RA is a common form of arthritis, affecting about 40,000 New Zealanders. It affects women 3 times more often than men; smokers have a higher rate than non-smokers.
5. Early treatment, which includes medicines and non-medication therapies, can slow the progression of rheumatoid arthritis, minimise joint damage and even lead to complete remission.

What are the symptoms of RA?

Rheumatoid arthritis usually starts quite slowly and you may first notice:

• joints of  your fingers, wrists or the balls of your feet become uncomfortable or tender
• swelling in your joints, which often comes and goes
• joints are affected symmetrically – you will notice symptoms in the same joints on both sides of the body.
• feeling stiff when you wake up in the morning.

For some people, the disease develops very rapidly and there may be a sudden onset of pain and swelling in a lot of joints.

Flare-ups

Symptoms tend to come and go with no particular pattern. You may have periods of time when your joints become more inflamed and painful (flare-ups). Sometimes these flare-ups have an obvious cause, such as physical injury, illness or emotional stress but usually, there is no obvious cause. This unpredictability is frustrating and can make it difficult to plan ahead.

Other effects

Occasionally inflammation may occur in other organs, such as your eyes (causing dry, irritable, red and painful eyes) and lungs (causing difficulty breathing).

Rheumatoid nodules (fleshy lumps) may sometimes appear, usually just below your elbows, but may also occur on your hands and feet. Anaemia (low red blood cell count) is common. Occasionally this can be a side effect of the drugs used to treat rheumatoid arthritis, but it is more often caused by the disease itself.

Long-term impact

Long-term, rheumatoid arthritis affects people differently:

• For some people, it lasts only a year or two and goes away without causing any noticeable damage.
• Other people have mild or moderate forms of the disease, with periods of worsening symptoms (flare-ups) and periods in which they feel better (remissions).
• For some people, ongoing inflammation can increase their chance of heart disease.

What causes RA?

Rheumatoid arthritis is an autoimmune disease, where your body's defence system (the immune system) is confused and attacks its own cells around the joints. The exact cause is not fully understood.

• Genes that you inherit from your parents don’t cause rheumatoid arthritis but may play a role. It can increase your chance of developing it.
• Women are affected 3 times more often than men.
• Smokers have a higher rate of getting rheumatoid arthritis than non-smokers. Smoking can increase the chances of developing rheumatoid arthritis by 40 times. It may also worsen joint damage and contribute to osteoporosis (thinning of the bones). 
• Some people find that cold, damp conditions and changes in the weather can affect their symptoms, but there is no evidence that the weather causes rheumatoid arthritis or affects its progression.

What happens in RA?

With continuous swelling and inflammation of your joints, the joint capsule remains stretched and can no longer hold the joint in its proper position. As a result, the joint may become unstable and this can lead to joint damage.

The joints affected and the extent to which this happens varies a great deal from person to person.

RA usually affects the small joints in your hands and feet, but it can affect many joints including your ankles, elbows, wrists, hips, knees, neck and shoulders.

The pain, stiffness, fatigue and whole-body (systemic) symptoms of rheumatoid arthritis can be disabling and can lead to difficulty with daily activities. 

Effective treatment by a rheumatologist can prevent joint damage and reduce other symptoms of RA.

How is RA diagnosed?

If you have painful or swollen joints, see your doctor. Early diagnosis is important as treatment does help and reduces long-term damage to your joints.

There is no single test that can make a certain diagnosis of early rheumatoid arthritis.

Doctors have to make a clinical diagnosis, where they put together all the information from listening to you and examining you, alongside with laboratory tests and sometimes x-rays.

Your doctor may suggest any of the following tests and investigations.

How is RA treated?

Starting treatment as soon as possible after a diagnosis has been made can help prevent permanent joint damage.

Although there is no cure for rheumatoid arthritis as yet, a variety of treatments are available that can slow down the disease and reduce the damage to your joints.

A combination of both medications and non-medication approaches are best. Read more about the medications used to treat RA.

Non-medication approaches

• If you are a smoker, stop smoking. There is information that shows that continuing smoking can make it less likely that you will have a good response to medications for RA.
• Physiotherapy helps preserve and improve the range of joint motion, increase your muscle strength, and reduce your pain.
• Hydrotherapy involves exercising and relaxing in warm water. Being in water reduces the weight on your joints. The warmth relaxes your muscles and helps relieve pain.
• Occupational therapy teaches you ways to use your body efficiently to reduce stress on your joints
• Self-management skills – arthritis educator clinics, seminars and self-management programmes will equip you with tools and techniques to self-manage your RA.
• Surgery is occasionally needed. Operations vary from quite minor ones such as the release of a nerve or a tendon to major surgery such as joint replacement.
• Regular medical check-ups: are an important part of managing RA, including checking blood pressure and monitoring cholesterol and other risk factors for heart disease.

Self-care

Lifestyle measures are an important part of self-management. 

• Take care of your joints. Find the balance between rest and physical activity; rest may make your inflamed joints comfortable but without movement your joints will stiffen and your muscles will weaken.
• Exercise is a very important part of a complete treatment plan for RA. It helps reduce your pain and fatigue, increases a range of joint motion and strength, and keeps you feeling better overall. Talk to your physiotherapist about the most appropriate exercise regime for you.
• Make your working life easier. You need to find a way to carry out your work tasks that allows you to manage your pain and tiredness and reduce the strain on your joints. The key to success is to do a variety of tasks, in stages, and with rest breaks.
• Both heat and cold treatments can relieve pain and reduce inflammation. Some people’s pain responds better to heat and other's to cold.
• Relaxation techniques are beneficial for releasing muscle tension, which helps relieve pain.
• Live a healthy life. Stay physically active, eat a healthy diet, stop smoking and reduce stress to help your overall health and wellbeing.
• Ask your doctor about fish oil; some studies have demonstrated beneficial effects of fish oil supplementation in decreasing pain.
  

Read more about living well with rheumatoid arthritis.

Support

Social events and meeting people with similar problems may help you to deal with day-to-day activities and provide emotional support. Arthritis New Zealand provides a range of services to all New Zealanders affected by arthritis.  

Learn more

Rheumatoid arthritis Arthritis NZ
Arthritis Information Sheet Arthritis Australia
Rheumatoid arthritis Rheumatoid Arthritis Support Network, USA

References

1. Biologic medicines for the treatment of inflammatory conditions: What does primary care need to know? BPAC 2013
2. Rheumatoid arthritis in adults: management NICE 2015
3. 2015 American College of Rheumatology guideline for the treatment of rheumatoid arthritis Arthritis Care & Research 

Reviewed by

	Associate Professor Rebecca Grainger is a senior lecturer in the Department of Medicine and Department of Pathology at the University of Otago, Wellington. She is also a consultant rheumatologist at Hutt Valley DHB. Rebecca is a subject matter expert in osteoarthritis and arthritis.