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Rheumatoid Arthritis

  • An disease in which the body's immune system begins attacking the lining of the joints
  • Symptoms include pain and tenderness in the joints, stiffness especially in the morning
  • Treatments include medications that are most effective when the disease is diagnosed early
  • Involves rheumatology, center for musculoskeletal care, sports medicine

Overview

If you're one of 1.5 million people in the United States with rheumatoid arthritis (RA), you're familiar with the pain and stiffness in your joints that comes with the disease. 

Rheumatoid arthritis is an autoimmune disease where the body’s immune system begins attacking the lining of its joints, causing pain, inflammation, and eventually, cartilage and bone damage. Rheumatoid arthritis can also harm the body’s internal organs such as the heart, lungs and nervous system.

At Yale Medicine, experienced doctors commit to giving patients an early and accurate diagnosis and treatment plan to help them manage symptoms and get back to living a normal life. 

What are the symptoms of rheumatoid arthritis?

The onset of rheumatoid arthritis is often gradual, and not every person experiences the same symptoms. Symptoms can also come and go. You may feel fine for days or months and then experience a flare in pain and swelling in the joints.

The first symptoms people often notice are stiffness, and pain or tenderness in their joints. The joints in wrists, hands, fingers and feet are most commonly affected early in rheumatoid arthritis' progression.

This stiffness is usually worse in the morning but typically gets better throughout the day. Also, it’s usually present on both sides of the body.

“People tend to have joint pain symmetrically, in multiple joints—in both hands, both wrists and both knees, for example,” says Cristina Maria Brunet, MD, a Yale Medicine rheumatologist. "But that isn’t always the case. There are exceptions.”

Along with stiffness and pain, people with rheumatoid arthritis sometimes notice warmth, swelling or redness in their joints. If the disease worsens, it can eventually cause deformities and a loss of function in joints, although these problems are less common now with better and earlier treatment options.

Because of the inflammation in their bodies, people with rheumatoid arthritis often also experience related symptoms such as fatigue, loss of appetite and fever.

How is rheumatoid arthritis different from other types of arthritis?

People often confuse rheumatoid arthritis with other types of arthritis or other inflammatory diseases. In fact, there are several different types of inflammatory diseases that accompany arthritis that may or may not be rheumatoid arthritis. 

Types of inflammatory arthritis include:

  • Rheumatoid arthritis: The most common form of inflammatory arthritis in which the body’s immune system attacks its own joints.
  • Psoriatic arthritis: An inflammatory arthritis that usually develops in a person with psoriasis.
  • Ankylosing spondylitis: A type of inflammatory arthritis that primarily affects the spine and sacroiliac joints located in the back of the pelvis.
  • Juvenile idiopathic arthritis: The most common type of arthritis in children.
  • Systemic lupus erythematous:  A chronic autoimmune disease that can cause joint pain, skin rash and damage to internal organs.

The most common type of arthritis, osteoarthritis, does not usually cause the degree of inflammation found in rheumatoid arthritis and is a different disease with different treatments.

What are the risk factors for rheumatoid arthritis?

Genetics can predispose some people to rheumatoid arthritis. But researchers also say that an environmental trigger—such as an infection or some other type of physical trauma—may be necessary for someone to actually develop rheumatoid arthritis.

However, the science behind this argument is not fully understood, and doctors don’t know exactly what causes rheumatoid arthritis or who is most at risk.

Besides genetics, these factors may make a person more likely to develop rheumatoid arthritis.

Sex: Seventy percent of people with rheumatoid arthritis are women.
Age: Rheumatoid arthritis symptoms can start at any age, but they most commonly begin in people between 40 years old and 60.
Tobacco use: For people who are genetically predisposed, cigarette smoking raises their risk of developing rheumatoid arthritis or having more severe disease.
Obesity: Being overweight or obese also seems to raise a person’s risk of developing rheumatoid arthritis.

How is rheumatoid arthritis diagnosed?

If a patient has unexplained joint pain and swelling, a doctor may recommend seeing a rheumatologist. Rheumatologists specialize in inflammatory conditions and are experienced in diagnosing and treating diseases such as rheumatoid arthritis.

A rheumatologist will perform a general examination and will check the patient’s joints for warmth, swelling, tenderness and range of motion. X-rays may also be done. “They help us assess joint damage and make decisions about how aggressive we need to be with medical therapy,” says Dr. Brunet.

Blood tests can show whether a patient has elevated levels of inflammation in the body. They can also confirm the presence of two antibodies, called rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP), which are often found in the blood of people with rheumatoid arthritis.

By considering the patient’s physical symptoms, and the results of all of those tests together, a rheumatologist may rule out other conditions and make a diagnosis of rheumatoid arthritis.

What are the treatment options for rheumatoid arthritis?

Medications to treat rheumatoid arthritis can be very effective when the disease is caught early and managed properly.

“We can hope to put people in remission so they can get back to doing whatever they enjoy, without a lot of limitations,” says Dr. Brunet.

These medications include:

  • Disease-modifying antirheumatic drugs (DMARDs): These drugs can slow rheumatoid arthritis progression by suppressing the body’s immune system. They include methotrexate (Trexall, Otrexup, Rasuvo), leflunomide (Arava), hydroxychloroquine (Plaquenil) and sulfasalazine (Azulfidine).
  • Biologics: This subset of DMARDs target specific proteins in the body, so they tend to have less of an effect on the immune system as a whole. They also work by suppressing the immune system and include abatacept (Orencia), adalimumab (Humira), anakinra (Kineret), certolizumab (Cimzia), etanercept (Enbrel), golimumab Simponi, infliximab (Remicade), rituximab (Rituxan), tocilizumab (Actemra) and tofacitinib (Xeljanz).
  • Corticosteroids: These drugs, such as prednisone, reduce inflammation and may be given on a short-term basis to relieve joint pain and swelling. They usually aren’t recommended for long-term use, because they can cause side effects including high blood glucose levels and bone thinning.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs): These medicines can be given by prescription or over-the-counter to reduce pain and inflammation. Examples include ibuprofen and naproxen sodium.

Most medicines for rheumatoid arthritis have side effects and risks associated with them such as a compromised immune system. This can make a person more likely to get sick from infections or other illnesses. Before starting any medication, patients should talk to their doctors about these risks and how to stay safe while taking these drugs.

Part of a patient’s treatment for rheumatoid arthritis may also include physical or occupational therapy to learn exercises that can help keep joints flexible and muscles strong.

Sometimes, if medicine does not work to control rheumatoid arthritis symptoms or if the disease is diagnosed too late, surgery may be recommended to repair or replace damaged joints.

What makes Yale Medicine’s approach to treating rheumatoid arthritis unique?

The physicians at Yale Medicine are world-class experts at identifying and treating rheumatoid arthritis and other inflammatory diseases that are often misdiagnosed. “Inflammatory conditions may all present in similar ways, and it’s really important that the correct diagnosis is made so the right type of treatment can be used,” says Dr. Brunet. 

Our rheumatologists also have extensive experience with rheumatoid arthritis medications. Because these drugs suppress the immune system, they must be prescribed by specialists and carefully explained to patients.

“We try to individualize the approach to each patient,” Dr. Brunet says. “There’s not one way of evaluating and treating RA, so we discuss every step with patients to make sure they are comfortable with our plan.”

Patients also have access to clinical trials through Yale Medicine and may have opportunities to try promising new drugs if their current treatments aren’t working.