What is Rheumatoid Arthritis?

Overview

Rheumatoid arthritis (RA) is the most prevalent type of inflammatory arthritis. This autoimmune disorder leads to inflammation in the joints as the body’s immune system mistakenly attacks the joint lining. This inflammation results in joint stiffness, swelling, and pain, which can significantly impair mobility. Over time, RA can cause irreversible joint damage.

Risk Factors

Several factors may increase the likelihood of developing rheumatoid arthritis, including family history, age, and gender. Individuals with a family history of RA are at a higher risk. Additionally, smoking has been identified as a contributing factor. The joints most frequently affected by RA include the wrists, fingers, shoulders, knees, and elbows.

How is Rheumatoid Arthritis Diagnosed?

A rheumatologist typically diagnoses rheumatoid arthritis through various tests. Blood tests can help identify specific antibodies and molecules associated with inflammation. Imaging techniques, such as X-rays, MRI, and ultrasounds, are also valuable in diagnosing RA, assessing disease severity, and monitoring progression.

Treatment for Rheumatoid Arthritis

Based on the diagnosis, physicians prescribe medications tailored to the patient’s specific needs, considering factors like pregnancy, other medical conditions, and concurrent medications.

Medications Overview

The primary goals of RA medications are to alleviate joint pain and swelling, prevent disease progression, and enhance the patient’s quality of life.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

NSAIDs are commonly used to treat inflammation in rheumatoid arthritis. While they do not halt disease progression, they effectively manage pain. These drugs work by blocking the production of inflammatory molecules. Common side effects include heartburn, stomach ulcers, headaches, and dizziness. Ibuprofen (Advil, Motrin) and naproxen (Aleve) are frequently prescribed NSAIDs.

Disease-Modifying Antirheumatic Drugs (DMARDs)

DMARDs aim to slow the progression of rheumatoid arthritis instead of merely alleviating symptoms. They are categorized into two types: biologic and non-biologic.

Non-Biologic DMARDs

Non-biologic DMARDs, such as methotrexate, are typically the first-line treatment for active RA. If methotrexate proves ineffective, alternative non-biologic DMARDs like hydroxychloroquine or leflunomide may be used. In some cases, combining two DMARDs can be beneficial, albeit with an increased risk of side effects. Methotrexate, originally developed for cancer treatment, is available in pill or injection form. Common side effects include mouth sores, nausea, fatigue, and liver impairment.

Biologic DMARDs

Biologic DMARDs, which include antibodies targeting inflammatory response molecules, block the processes leading to joint inflammation. These are typically not prescribed with other biologics due to potential side effects.

TNF-Inhibitors

If non-biologic DMARDs are ineffective, doctors may recommend biologic DMARDs, such as TNF inhibitors. These medications inhibit tumor necrosis factor (TNF), a molecule involved in arthritis-related inflammation. Clinical trials demonstrate significant improvements in patients using TNF inhibitors, including enhanced physical function and reduced joint damage. Common examples include adalimumab (Humira), certolizumab (Cimzia), and etanercept (Enbrel).

Interleukin-6 Receptor Inhibitors

These drugs inhibit interleukin-6 (IL-6) signaling, which plays a significant role in RA-related inflammation and pain. Serious side effects can include severe infections and gastrointestinal issues. Examples include sarilumab (Kevzara) and tocilizumab (Actemra).

T-Cell Co-Stimulation Inhibitor

Abatacept (Orencia) may be used when TNF inhibitors are ineffective, as it reduces immune cell communication and subsequently inflammation.

IL-1R Binding Antibody

Anakinra (Kineret) blocks interleukin-1 (IL-1), a cytokine involved in inflammation. Common side effects include injection site reactions, while severe effects may include low white blood cell counts.

Remission in Rheumatoid Arthritis

Some patients with rheumatoid arthritis may achieve remission, influenced by factors such as age at onset and disease duration. If remission is attained, medication adjustments can be made, and patients will be monitored to ensure stability. For those who do not reach remission and experience severe joint damage, joint replacement may be an option.

References

– American College of Rheumatology. Rheumatoid Arthritis Fact Sheet. Available at: https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Rheumatoid-Arthritis
– Bykerk VP, Akhavan P, et al. Canadian Rheumatology Association Recommendations for Pharmacological Management of Rheumatoid Arthritis. The Journal of Rheumatology. 2012;39(8):1559-1582.
– Kurkó J, Besenyei T, et al. Genetics of rheumatoid arthritis – a comprehensive review. Clin Rev Allergy Immunol. 2013;45(2):170‐179.
– Benjamin O, Bansal P, et al. Disease Modifying Anti-Rheumatic Drugs (DMARD). StatPearls [Internet]. 2020.
– Wasserman AM. Diagnosis and management of rheumatoid arthritis. Am Fam Physician. 2011;84(11):1245‐1252.
– Weinblatt ME. Methotrexate in rheumatoid arthritis: a quarter century of development. Trans Am Clin Climatol Assoc. 2013;124:16‐25.
– Additional references related to specific medications and studies are available upon request.