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  • What is the rheumatic inflammation of the joints known as rheumatoid arthritis?

    Rheumatoid arthritis (RA for short) is the inflammatory disease of the joints that occurs most frequently.

    A good one percent of the population are affected by the disease, women around three times more commonly than men. Although in adults the first symptoms usually occur between the ages of 30 and 50, rheumatoid arthritis can actually be contracted at any age, and even young people, children and infants may be affected. It is estimated that around 15,000 children and young people below the age of 18 suffer from juvenile idiopathic arthritis, or JIA for short.

    Rheumatoid arthritis belongs to the group of autoimmune diseases. These are characterised by some degree of irregularity in the control mechanism of the body’s own immune system. Normally the immune system can distinguish accurately between the body’s own cells and foreign cells or cellular tissue. Foreign bodies like viruses and bacteria, for instance, are detected and attacked by the immune system, without the body’s own tissue suffering any damage. In patients suffering from an autoimmune disorder, on the other hand,  the body’s own cells or tissues are erroneously identified as foreign bodies and so subjected to attack.  

    In the case of rheumatoid arthritis it is the the synovial membrane (see diagram 1) that is incorrectly taken by the immune system to be extraneous. The synovial membrane encloses every joint, and protects the joint cartilage against wear by forming a viscous lubricant known as the synovial fluid. The misguided immune reaction results in an inflammation of the synovial membranes. These start to proliferate, and destroy the surrounding cartilage, which is no longer able to perform its designated task of acting as a buffer to protect the bone against friction. A budlike structure develops, which penetrates the joint cavity and expands on the surface of the cartilage (see diagram 2).

    In the further course of the disease, these growths may attack the bones as well and destroy the osseous extremities. This can result in functional impairment of the joint, along with severe pain.

    Rheumatoid arthritis typically has an insidious beginning. The first symptoms of the disease may be:

    • a general feeling of sickness (loss of appetite, exhaustion, weakness, loss of weight)
    • nightly sweats
    • overheated joints
    • stiffness in the joints when waking in the morning
    • swelling of the joints
    • pain in the joints

    The disease frequently progresses spasmodically, phases of acute discomfort alternating with periods where no symptoms are felt. As a rule the progress of the condition is chronic.

    It is also characteristic that several joints are affected. Generally speaking all joints are susceptible, though in the initial phase the symptoms are generally concentrated on the joints of the hands and feet.  

    Typically the symptoms appear synchronously on the axis of the body – e.g. the same joints will be affected on the right and left hands.

    The symptoms are not necessarily restricted to the joints. Inflammation of the tendon sheaths or the bursa can also occur, or the blood vessels, eyes and inner organs may be affected.

    It has not yet been conclusively explained just how the inflammation arises in the joint capsule, though there are certainly risk factors which may encourage the development of a rheumatoid inflammation. These include a family tendency to RA, age, smoking and infectious diseases. It is important in all cases to take the first signs of the disease seriously, and to consult your GP in good time, or take the advice of an internal medicine specialist or rheumatoid consultant.

    To conduct a diagnosis, the rheumatologist will first of all check the mobility of the joints. Here swelling of the joints, and pain resulting from movement, are an indication. The duration of any stiffness in the joints felt in the mornings is just as important a factor as other symptoms that may be experienced.

    The following further diagnostic procedures are available:

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

    Only the overall picture enables the rheumatologist to arrive at a diagnosis. Other imaging procedures, like computer tomography, are used only in exceptional cases. Only an early diagnosis makes it possible for the rheumatological consultant to initiate a customised and effective therapy for the RA patient.

    The earlier an effective therapy is launched, the greater the chance of positively influencing the process of inflammation and checking the destruction of the joints.

    With the choice of therapies available today, there is no possibility of curing rheumatoid arthritis completely.

    The progressive destruction of the joints can however be prevented by suitable treatment, so preserving the functionality of the joints in most cases.  

    The improvement of life quality for the patient features among the top-level aims of treatment. Here the important thing is pain relief.

    The following therapeutic methods are available:

    • Drug-based therapy
    • Physical therapy (cold or hot treatments, baths)
    • Remedial gymnastics
    • Ergotherapy (training in joint protection)
    • Psychosocial support
    • Educating the patient
    • Surgery if appropriate

    The rheumatologist will choose the most suitable approach from the therapeutic options available, in order to offer the best possible therapy for the patient. 

    In most cases treatment with drugs is unavoidable. Non-steroid antirheumatics (NSARs, e.g. with the active substance Diclofenac) and corticoids (e.g. with the active substance Prednisolon) have a rapid effect in alleviating pain, and check the inflammation in the short term. They do not however affect the actual progression of the disease.

    Only Disease Modifying Anti-Rheumatic Drugs, known as DMARDs, affect the disease itself. These medicaments act directly on the pathology and can check the development of the disease, so it is advisable to introduce them at the earliest possible stage.

    As rheumatoid arthritis is a chronic disease, DMARDs should generally be taken over an appropriately extended period. When they prove effective and are well tolerated, they will often be used by patients for a whole lifetime. Among DMARDS commonly used are the active substances methotrexate, leflunomide, sulfasalazine, azathioprine and antimalarial drugs.

    Methotrexate
    The effects are felt relatively early (after just 4 to 8 weeks), and there is a favourable balance between the benefit and the side-effects, even when used in the long term. These are some of the reasons why methotrexate is commonly used worldwide as the DMARD of choice for the treatment of rheumatoid arthritis.

    In order to judge whether methotrexate treatment is fully effective, the treatment should be continued over several months. If the effect proves insufficient, the rheumatologist will increase the dose or switch to a different form of therapy.

    Methotrexate originated with the treatment of various kinds of tumour, and is still successfully used in this context. By contrast with chemotherapy in the treatment of cancerous diseases, methotrexate is used for RA therapy in doses that are as much as 1000 times smaller – which is why antirheumatic therapy is sometimes described as ‘low dose methotrexate therapy’. This low dosage principally acts by checking the progress of the inflammation. In RA therapy the dose is normally between 7.5 and 30 mg per week. It is very important that methotrexate be taken in just one weekly dose. The application may be given parenterally in the form of an injection, or it can be taken orally as a tablet. The parenteral application is generally found preferable, in view of the more rapid action, improved bioavailability and the low level of gastrointestinal side-effects.  

    If a patient has forgotten to take a tablet or has missed an injection, the omission must be corrected immediately. The weekly cycle will then be postponed accordingly.  

    Leflunomide
    Leflunomide belongs to the class of drugs known as DMARDs which act to check the progress of the disease. Leflunomide medac is used to treat adults with an active form of rheumatoid arthritis. Clinical studies have shown that leflunomide slows down the bone destruction resulting from the disease, reduces the inflammatory reactions and improves the patient’s life quality to a significant degree.

    The therapeutic effect can generally be expected to show after 4 to 6 weeks, but can increase further in the course of the following 4 to 6 months.

    As leflunomide’s metabolites remain in the body for a very long time, it should only be taken under strict medical supervision.  

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