Rheumatoid arthritis is a severe, chronic, inflammatory disease of the connective tissue which is the most evident in the joints. In this disorder, the immune system attacks the cartilage tissue, bones and, sometimes, internal organs. Small joints of the hands, wrists, shoulders, knees and ankles are most often affected. With appropriate health measures and lifestyle changes, people can have a long and productive life.

What is rheumatoid arthritis?

In rheumatoid arthritis, the constant inflammatory process affecting the synovium gradually destroys collagen, thus reducing the joint space and eventually destroying the bone itself.

Rheumatoid arthritis is a chronic disease which causes inflammation of the joints, their swelling, pain, stiffness and loss of function. The process begins in the synovium, the membrane that wraps the wrist, forming a protective bag. This is a bag filled with fluid which lubricates the joint that is called synovial fluid. In addition to protecting the joints, this fluid supplies nutrients and oxygen to the cartilage, smooth tissue that lines the ends of bones.

Cartilage is constructed primarily of collagen, a structural protein of the body, which forms a network of fibers, thereby supporting the joints. In rheumatoid arthritis, the constant inflammatory process affecting the synovium gradually destroys collagen, thus reducing the joint space and eventually destroying the bone itself. In progressive rheumatoid arthritis cartilage destruction is accelerated when the liquid and inflammatory cells accumulate in the synovium, forming a pannus, a lump consisting of a thickened synovial tissue. Pannus produces more enzymes that destroy surrounding cartilage, worsening the condition of the affected area and attracting more inflammatory cells to the inflammatory process which is repeated constantly. This process not only affects the cartilage and bone, but damages the organs in other parts of the body.

Causes of rheumatoid arthritis

The actual causes are not known. According to the most successful theory, the "trigger" of rheumatoid arthritis is a combination of several factors, including the abnormal autoimmune response, and genetic predisposition, viral or bacterial infections. The inflammatory process is a by-product of the immune system, which fights infections, and heals wounds and injuries.

In bodily injury or infection, white blood cells which release the body of all foreign protein, such as viruses are mobilized. The accumulations of white blood cells in the area of injury or infection cause an inflammatory process in the respective areas. A healthy body controls and limits the inflammatory processes, but in rheumatoid arthritis certain defects, probably genetic, support this process. Although a lot is known, there are still some unknown factors that lead to this self-destructive state. Scientists have identified a molecule called HLA-DR4, present in many patients with autoimmune disorders.

In people with a genetic susceptibility, the immune system may attack the protein of collagen due to its similarity to a foreign antigen, such as, for example, Epstein-Barr virus. However, it is present in many people who do not have RA. Although many viruses and bacteria have been tested, it is not shown that one of them represents the primary trigger of an autoimmune response and subsequent destructive inflammatory process.

Risk group

Rheumatoid arthritis is more common in women than men in the relation 3:1. Although it usually develops between the ages of 30 to 60 years, the incidence increases with age. The risk is increased in the families with a history of rheumatoid arthritis.

Symptoms of rheumatoid arthritis

The characteristic symptom of rheumatoid arthritis is morning stiffness that lasts at least half an hour. Symptoms such as fatigue, weight loss and fever may be initial signs of rheumatoid arthritis. Some argue that they resemble the symptoms of cold or flu, except that, of course, the symptoms of rheumatoid arthritis can last for years. Swelling and pain in the joints last at least six weeks before the rheumatoid arthritis is diagnosed.

Although rheumatoid arthritis almost regularly develops in the wrists and knuckles of fingers, it often affects the knees and ankles, in fact many joints. The pain is often symmetrical, but may be more intense on one side, depending on which hand is used more often. Inflamed joints are usually swollen and often warm. In about 20% of patients, inflammation of end arteries causes subcutaneous nodules or lumps of the size of a pea or even bigger. They are located near the elbow, although they can develop anywhere else. Lumps are usually painless, and they rarely reveal the presence of rheumatoid vasculitis (inflammation of blood vessels), a condition that affects the blood vessels of the lungs, kidneys or other organs. The buildup of fluid is also possible, especially in the knees. In rare cases it occurs in the articular cartilage behind the knees and forms a Baker cyst-like tumor, and sometimes it spreads down the calf, causing pain.

Treatment / prevention of rheumatoid arthritis

The goal of most drug therapies is a long-term reduction of inflammation, preventing damage to the bones and ligaments of the joints, preservation of mobility, greater cost-effectiveness of the treatment and the absence of side effects.

Rheumatoid arthritis is treated with drugs and lifestyle changes. Many preparations are used to remove the pain and slow the progression of disease, but there is still no appropriate treatment program. The goal of most drug therapies is a long-term reduction of inflammation, preventing damage to the bones and ligaments of the joints, preservation of mobility, greater cost-effectiveness of treatment and the absence of side effects.

Initially nonsteroidal anti-inflammatory drugs (NSAIDs) that relieve pain by reducing inflammation are usually applied. NSAIDs can cause side effects such as indigestion and bleeding from the digestive tract. If, after about 4-6 weeks of use they do not prove effective, the therapy is completed by other preparations. Traditionally, antirheumatic drugs, especially slow-acting antirheumatic drugs are used. They are more effective than NSAIDs in long term and can improve the body's functions. Some of the most commonly prescribed antirheumatic drugs are hydroxychloroquine, gold salts and sulfasalazine. Some experts recommend that patients with moderate to severe rheumatoid arthritis immediately start the antirheumatic therapy, with or without the NSAID. Indicators for promptly and aggressively introduction of antirheumatic drugs are an easy progression, effect on the parts of the body with the exclusion of joints, high levels of rheumatoid factor and genetic markers.

Corticosteroids reduce inflammation and slow down joint damage. In the short term they can improve the condition, but if applied for several months or years, can lose efficiency and cause serious side effects. Other drugs that are used are immunosuppressants and blockers of tumor necrosis factor (TNF). These preparations can cause severe side effects, such as increased susceptibility to infections and diseases. General measures: regular exercise, weight control, healthy diet, the use of hot and cold therapy procedures (depending on the stage of the disease), relaxation techniques and taking the recommended medicines.

Prognosis

Treatment is more effective in terms of slowing the disease that causes disability and sometimes aggressive anti-inflammatory agents may prevent the initial damage. Therefore, it is important that a patient immediately contacts a doctor at the first onset of the symptoms.

Some experts divide the rheumatoid arthritis to Type 1 and Type 2. Type 1 is less common form which lasts at most a few months and leaves permanent disability. Type 2 is a chronic form that lasts for years, sometimes for life. Treatment is more effective in terms of slowing the disease that causes disability and sometimes aggressive anti-inflammatory agents may prevent the initial damage. Therefore, it is important that a patient immediately contacts a doctor at the first onset of the symptoms. It should be noted that the side effects of drugs often contribute to the severity of the disease. The affected joint may become deformed, and even the most common movement can be very difficult or impossible. Rheumatoid arthritis causes anemia and affects the nerves. The patients are at risk of scleritis, inflammation of the blood vessels of the eye that can cause corneal damage. The disease carries a high risk of hematological tumors which development can be affected by changes in the immune system.

Aggressive drugs that suppress the immune system may prevent the development of these tumors, but a lot of research is still necessary to exclude this feature. Although type 2 is progressive and incurable, over time the disease becomes less aggressive, and the symptoms can be alleviated. The destruction and deformation of bones and ligaments are permanent consequences. Long-term prognosis of Juvenile Rheumatoid Arthritis can be very serious. Although it usually withdraws before puberty, a study conducted on people diagnosed with juvenile rheumatoid arthritis 25 years back, found that they experienced more pain, nausea and generally disturbed physical function than people with no history of the disease.