Rheumatoid arthritis

What is rheumatic joint inflammation – known as rheumatoid arthritis?

Rheumatoid arthritis – RA for short – is the most common inflammatory joint disease.

Well over one percent of the population is affected by it. Women are affected three times more often than men. Although the first symptoms in adults usually occur between the ages of 30 and 50, rheumatoid arthritis may occur at any age. Young people, children and infants may all be affected.

Rheumatoid arthritis belongs to the group of autoimmune diseases. Autoimmune diseases are characterised by a malfunction of the body's immune system: the immune system can normally distinguish precisely between its own cells and foreign cells. Viruses and bacteria for example, are recognised and attacked by the immune system without the body’s own tissue taking any damage. In patients with an autoimmune disease the immune system incorrectly recognises the body’s own cells as foreign and attacks them.

In the case of rheumatoid arthritis, the tissue incorrectly recognised as a foreign substance is the membrane lining the joints (synovial membrane). This tissue lines every joint and protects the joint cartilage from wear and tear by producing a viscous mucus, which is called synovial fluid. The incorrect immune response triggers inflammation of the synovial membranes. They begin to proliferate wildly and destroy the surrounding cartilage, which can no longer perform its intended task of acting as a buffer to protect the bones from damage. A bud-like structure develops, pushing into the joint line and spreading over the surface of the cartilage.

As the disease progresses, this tissue proliferation may also attack the bone and destroy the ends of the bones. This may cause a loss of joint function accompanied by severe pain.

The following may be the first symptoms of rheumatoid arthritis:

  • General feeling of illness (loss of appetite, fatigue, weakness, weight loss)
  • Episodes of night sweats
  • Joints being hot
  • Joint stiffness in the morning
  • Swollen joints
  • Joint pain

The course is often episodic with symptom-free phases (remissions) alternating with severe symptoms such as the above (flare-ups). The disease is generally chronic.

It is also typical for several joints to be affected at the same time. In general, all joints may be affected but the symptoms often start in the joints of the hands and feet. The symptoms typically occur symmetrically across the axis of the body, for instance the same joints will be affected in the right and left hands.

Symptoms don’t have to be restricted exclusively to the joints. Tendon (synovial) sheaths and synovial bursae (sacs of synovial fluid) may also be inflamed, or blood vessels, eyes and internal organs may be involved.

What are the causes and risk factors of developing rheumatoid arthritis?

The exact mechanism of the inflammatory processes in the joint capsule has not yet been explained in detail. There are risk factors that may promote the development of inflammatory rheumatic disorders. These include family susceptibility, age, smoking and infectious diseases. In any case it is important to take seriously any early signs of disease and consult a GP, internal medicine specialist or rheumatologist promptly.

How is rheumatoid arthritis diagnosed?

In order to make a diagnosis, the rheumatologist will first assess the symptoms and check the mobility of the joints. Pain and swelling of the joints are indicators of the disease. The duration of morning stiffness in the joints is just as important in this context as other symptoms.

The following additional diagnostic procedures are available:

  • Laboratory blood tests
  • X-rays of the affected joints
  • Ultrasound examination

The rheumatologist will not make a diagnosis until he or she has collected all the relevant information. Other imaging procedures, such as magnetic resonance imaging, are used only in specific cases. The earliest possible diagnosis is essential to allow the rheumatologist to start effective treatment of the RA patient.

How is rheumatoid arthritis treated?

The earlier an effective treatment is started, the greater the chance of having a positive influence on the inflammatory process and stopping the destruction of the joints.

It is not possible to cure rheumatoid arthritis with the treatments currently available.

However, the progressive destruction of the joints can be prevented by appropriate treatment, and joint function can thus be preserved in most cases.

Improve quality of life for the patient is one of the most important aims of treatment. Effective alleviation of the joint pain is crucial in this context.

The following treatment procedures are available:

  • Medicinal therapy
  • Physical therapy (cold or heat applications, baths)
  • Physiotherapy
  • Occupational therapy (joint protection training)
  • Psychosocial support
  • Patient training
  • Sometimes surgical interventions

The rheumatologist selects the appropriate therapeutic options from those available, in order to offer optimal treatment.

Medicinal treatment is usually inevitable:

Nonsteroidal antirheumatic drugs (NSARs, e.g. the active substance diclofenac) and corticosteroids (e.g. the active substance prednisolone) act very rapidly to alleviate pain and have short-term anti-inflammatory effects. However, they have no influence on the actual course of the disease.

Disease-modifying antirheumatic drugs (DMARDs) are the only medicines used to influence the disease itself. These medicines, also referred to as “basic therapeutics” intervene directly in the disease process and are able to slow or stop disease progression.Therefore DMARDs should be used as early as possible.

Because rheumatoid arthritis is a chronic disease, basic therapeutics usually need to be taken for relatively long periods. If they are effective and well tolerated, the treatment is often continued for life. The basic therapeutics include methotrexate, leflunomide, sulfasalazine, azathioprine and antimalarials, for example.

Methotrexate
A relatively rapid onset of action after 4 to 8 weeks and a good efficacy/side effect ratio, even over the long term, may be reasons why methotrexate is often given as the drug of choice for basic rheumatic disease therapy all over the world.

The treatment should be continued for several months in order to assess whether methotrexate therapy is exhibiting its full effect. If the effect of methotrexate is not sufficient, the rheumatologist will increase the dosage or change the treatment.

Methotrexate was originally developed for the treatment of various cancers and is used successfully in this field. In contrast to chemotherapy for cancer, the doses of methotrexate in RA treatment are up to 1,000 times lower, so that the phrase “low-dose methotrexate therapy” is also found in antirheumatic therapy. In low doses methotrexate has anti-inflammatory effects. The dose range normally used in RA therapy is between 7.5 and 30 mg per week. It is very important that methotrexate is taken only once a week. It may be given parenterally as an injection or orally as a tablet. Parenteral administration may offer advantages in most cases because of the more rapid onset of action, better bioavailability and lower rate of gastrointestinal side effects.

Leflunomide
Leflunomide is one of the medicines known as DMARDs, which are able to slow or stop disease progression. Leflunomide is used to treat adults with active rheumatoid arthritis and psoriatic arthritis. Clinical trials have shown that leflunomide slows the bone destruction caused by the disease, reduces the inflammatory reactions and substantially improves quality of life.

A therapeutic effect can usually be expected after 4 to 6 weeks but may increase further over the following 4 to 6 months.