Living Well With Rheumatoid Arthritis

While doctors and researchers have yet to find a cure for this chronic inflammatory disease, new management treatments are offering hope to thousands of RA patients across the U.S.

By Julianne Hale

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Rheumatoid arthritis (RA) is a chronic inflammatory disease in which the immune system attacks the lining of the joints, resulting in chronic stiffness, swelling, pain, and loss of function.

When the immune system is functioning normally, it works to protect the body from infection and disease. But in RA, an abnormal immune system response produces destructive molecules that instead attack the synovium, the material that makes up the protective lining of the joints, causing the joints to swell and become warm, red, and painful.

Typical cases begin slowly with joint pain and tenderness in the small joints of the hands, wrists, and/or feet. Other areas of the body commonly affected include the hips, shoulders, elbows, cervical spine, ankles, and knees.

The disease usually affects joints symmetrically (on both sides of the body at the same time). It also normally affects several different areas. “With RA, it’s less common for the inflammation and resulting pain to be isolated to one area of the body,” explains Dr. Marshall Jemison, a reconstructive hand surgeon with Hayes Hand Center/The Plastic Surgery Group. “Unfortunately, that’s just the nature of its being an autoimmune disease.”

What Causes It

While there is no known cause of RA, genetics do play a role. If you have a family member with RA, you are at a higher risk for the disease. Environmental factors play a role in the development of RA as well. The disease affects 1-2% of the population, affecting upwards of 2 million people in the United States, and it is two to three times more common in women than in men. Diagnosis of the disease usually occurs between the ages of 30 and 60, and incidents of RA increase with age, approaching 5% in women over 55.

Living with the Disease

Receiving a rheumatoid arthritis diagnosis can be traumatizing and life changing, but it’s important to understand that with modern medicine, it is a very manageable condition. Early medical intervention is crucial – so the first thing you should do is find a good rheumatologist (there are lots of options in the Chattanooga area) and get started on a treatment plan. Treatment goals for rheumatoid arthritis include pain management, inflammation reduction, and the prevention of joint deformity and destruction. Effective treatment requires patients and their families to work closely with their rheumatologist, and it usually involves a combination of medications, rest, exercises, education, and joint protection. Most rheumatologists will begin treatment immediately with aggressive medications, including:

DMARDs. Some of the most common types of drugs used to treat RA are disease-modifying antirheumatic drugs, or DMARDs. These drugs promote disease remission and prevent progressive joint destruction. They became a mainstay for RA treatment in the 1970s and are a staple in the RA community now –most rheumatologists recommend starting one immediately after diagnosis. The most common DMARDs used in RA treatment is methotrexate (brand names Rheumatrex® and Trexall®) but hydroxychloroquine (Plaquenil®) and sulfasalazine (Azulfidine®) are also used. DMARDs can take several weeks to become effective and results vary drastically among RA patients. Most require use of supplementary anti-inflammatory agents, such as NSAIDs and steroids in order to get the disease under control initially. Like many drugs, patients can build up a tolerance to DMARDs and the drugs can lose their effectiveness over time. When this happens, a patient and doctor have to work together to find the right combination of medications for their particular case.

Biologics. Biologic response modifiers, often called biologics, have just come on the scene in the last decade and are transforming the lives of some RA sufferers. Often used in combination with DMARDs, biologics are still a bit of a mystery to rheumatologists because they do not help all RA patients. One-third of patients notice life-changing results when they use the injections, which halt the progression of the disease by blocking the actions of cytokines (proteins secreted by immune cells), thereby stopping joint inflammation and the destruction of cartilage; one third see some improvement; and one third of RA patients notice no change at all. Biologics are very expensive and can cause significant adverse side effects for patients, but right now, the consensus of the medical community is that the benefits of biologics outweigh the risks.

JAK Inhibitors. JAK inhibitors, also called jakinibs, are a new class of medications sometimes referred to as oral biologics. This name is misleading because, unlike biologics, jakinibs work inside the cells, blocking enzymes that affect the inflammatory and immune responses in RA. Tofacitinib (brand name Xeljanz®) was approved by the FDA in November of 2012 for the treatment of moderate-to-severe active rheumatoid arthritis in patients with an inadequate response or intolerance to methotrexate.

NSAIDs. Nonsteroidal anti-inflammatory drugs, or NSAIDs, are available over-the-counter and by prescription. They do not slow the progression of RA, but they do reduce pain and inflammation temporarily. Ibuprofen, acetaminophen, and aspirin are some well-known NSAIDs.

Corticosteroids. Oral steroids work great in the short term for making RA patients feel much better, but the adverse side effects make these drugs a poor choice in the long term. Steroid injections, which are delivered to a particular area of the body (say, an inflamed joint in the hand), are usually the preferred treatment for painful flare-ups as their side effect profile is lower.

Marshall Jemison, M.D. reconstructive hand surgeon, Hayes Hand Center/The Plastic Surgery Group

Marshall
Jemison, M.D.
reconstructive hand surgeon, Hayes Hand
Center/The Plastic Surgery Group

Procedures and Surgery

Chronic inflammation in the joints is not without consequences and some people with rheumatoid arthritis experience joint deformity and bone erosion. For these patients, surgery to repair joints may be an option – on the condition that their pain has not responded well to medications and/or lifestyle measures. Dr. Jemison explains that sometimes, certain patients aren’t able to take the newer medications—in these cases, surgical treatment can be very helpful for relieving pain. However, thanks to pharmaceutical advances made in the treatment of RA, surgeries to repair joints deformed by the disease have taken a sharp downturn in the last 20 years. “The newer medications have changed the course of this disease for many people,” says Dr. Jemison. “RA is heartbreaking because it can strike you in the prime of life. I think that’s a tragedy. But for younger patients in particular, DMARDs have made a substantial difference in preventing joint destruction.”

Chronic inflammation in the joints is not without consequences and some people with rheumatoid arthritis experience joint deformity and bone erosion. For these patients, surgery to repair joints may be an option – on the condition that their pain has not responded well to medications and/or lifestyle measures. Dr. Jemison explains that sometimes, certain patients aren’t able to take the newer medications—in these cases, surgical treatment can be very helpful for relieving pain. However, thanks to pharmaceutical advances made in the treatment of RA, surgeries to repair joints deformed by the disease have taken a sharp downturn in the last 20 years. “The newer medications have changed the course of this disease for many people,” says Dr. Jemison. “RA is heartbreaking because it can strike you in the prime of life. I think that’s a tragedy. But for younger patients in particular, DMARDs have made a substantial difference in preventing joint destruction.”

A study conducted by rheumatologists at the Mayo Clinic in Rochester, Minnesota, and published in The Journal of Rheumatology in January 2012, found that the incidence of joint surgery within 10 years of an RA diagnosis dropped from 27.3% during 1980-1994 to 19.5% during 1995-2007. Total joint replacements are also down. Yet while surgery rates have dropped, the reality is that some RA patients will still require it. The good news is that there is very little disappointment with the results. “Joint replacement can be life changing for people with constant pain,” says Dr. Jemison. “In the fingers, people almost always say it’s very helpful.”

Lifestyle Changes

Like most diseases, RA responds well to healthy lifestyle choices. If you want to slow the progression of RA and maximize your health, you can start by not smoking. If you are a smoker, quit immediately. It can also be helpful to engage in regular, low-impact exercise such as swimming, walking, elliptical machines, or yoga. Many gyms offer classes designed for people with joint pain. Take advantage of them. “Higher activity level is associated with less pain in patients with RA,” says Dr. Jemison. “Stiffness plays a role in pain, and stiffness is frequently the result of inactivity.”

If you have been diagnosed with RA, it’s normal to go through periods of anxiety, depression, and stress. But living a full and happy life with the disease is entirely possible. By working closely with a rheumatologist, learning more about the disease, receiving emotional support from family and friends, and focusing on the positive, sufferers of RA can find the strength they need to get out and enjoy life to the fullest.

 

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