Rheumatoid arthritis is a condition that causes pain and swelling in the joints. Hands, feet and wrists are commonly affected, but it can also damage other parts of the body. Rheumatoid arthritis can make your joints feel stiff and can leave you feeling generally unwell and tired.
Who is affected?
The condition is estimated to affects thousands of people in Ireland and occurs more frequently in women than men. It is most common between the ages of 40 and 70, but it can affect people of any age.
Why does it happen?
Rheumatoid arthritis is an autoimmune disease. This is when your immune system, which usually fights infection, attacks the cells that line your joints, making them swollen, stiff and painful. Over time, this can damage the joint itself, the cartilage and nearby bone.
What are the symptoms?
The symptoms of rheumatoid arthritis usually vary over time. Sometimes, symptoms only cause mild discomfort. At other times, they can be very painful, making it difficult to move around and do everyday tasks.
When symptoms become worse, this is known as a flare-up or flare. A flare-up is impossible to predict, making rheumatoid arthritis difficult to live with.
For more information, see Rheumatoid arthritis - symptoms
Currently, rheumatoid arthritis cannot be prevented as the exact trigger of the condition is unknown. Although viruses and bacteria may be involved, research is not yet conclusive.
There is no known cure for rheumatoid arthritis. However, early diagnosis and treatment can control symptoms and help prevent disability. See Rheumatoid arthritis - treatment for more information.
The symptoms of rheumatoid arthritis usually develop gradually. The first symptoms are often felt in small joints, such as your fingers and toes, although shoulders and knees can be affected early, and muscle stiffness can be a prominent early feature.
The symptoms of rheumatoid arthritis vary from person to person. They can come and go, and they may change over time. You will experience flare-ups when, from time to time, your condition will worsen and your symptoms will be more intense and severe.
You can experience a flare-up at any time of the day or night. However, it is likely that your symptoms will be more painful in the morning, when you first wake up. Usually, your symptoms will begin to ease as the day progresses and you start using and flexing your joints.
The symptoms of rheumatoid arthritis are outlined below.
This is usually a throbbing and aching sort of pain. It is usually worse in the mornings and after you have been sitting still for a while. Pain is often felt while you are resting, not after activity.
Joints affected by rheumatoid arthritis can feel stiff, especially in the morning. Morning stiffness associated with a kind of arthritis called osteoarthritis usually wears off within 30 minutes of getting up in the morning. However, rheumatoid arthritis morning stiffness usually lasts longer than half an hour.
Warmth and redness
The lining of the affected joint becomes inflamed, causing the joints to swell, become hot, tender to touch and painful.
Rheumatoid arthritis can also cause inflammation around the joints, such as rheumatoid nodules, and in other parts of your body. The condition can also cause inflammation of your tear glands, salivary glands, the lining of your heart and lungs, and your blood vessels.
The exact cause of rheumatoid arthritis is unknown. We know how the condition attacks the joints, but it is not yet known what triggers the initial attack. Some theories suggest that an infection or a virus may trigger rheumatoid arthritis, but none of these theories has been proven.
Rheumatoid arthritis is an autoimmune condition. This type of condition causes the body's immune system to attack itself. Normally, your immune system makes antibodies that attack bacteria and viruses, helping protect your body against infection. If you have rheumatoid arthritis, your immune system sends antibodies to the lining of your joints, where instead of attacking harmful bacteria, they attack the tissue surrounding the joint.
The synovium is a membrane (thin layer of cells) that covers each of your joints. When antibodies attack the synovium, they leave it sore and inflamed. This inflammation causes chemicals to be released, causing the synovium to thicken. These chemicals can also damage bones, cartilage (the stretchy connective tissue between bones), tendons (tissue that connects bone to muscle) and ligaments (tissue that connects bone and cartilage). The chemicals gradually cause the joint to lose its shape and alignment and, eventually, can destroy the joint completely.
There is some evidence that rheumatoid arthritis can run in families. Your genes may be one factor in the cause of the condition. However, having a family member with rheumatoid arthritis does not necessarily mean that you will inherit the condition. Even an identical twin of someone with rheumatoid arthritis only has a one in five chance of developing it, so genes do not explain much of the risk.
Rheumatoid arthritis is three times more common in women than in men. This may be due to the effects of oestrogen (a female hormone). Research has suggested that oestrogen may be involved in the development and progression of the condition. However, this has not been conclusively proven.
Rheumatoid arthritis can be difficult to diagnose because many conditions cause joint stiffness and inflammation. Your GP will do a physical examination, checking your joints to see if they are swollen and to find out how easily they move. Your GP will also ask you about your symptoms. It is very important to tell your GP about all of your symptoms, not just the ones you think are important. This will help your GP to make the correct diagnosis.
If your GP thinks you have rheumatoid arthritis, they will refer you to a specialist (rheumatologist).
After conducting a physical examination and consulting your medical history, your GP may carry out a series of tests which may help to confirm the diagnosis, or they may refer you at the same time as requesting tests. Tests that you may have are outlined below.
No blood test can definitively diagnose rheumatoid arthritis. While a number of tests can indicate to your GP that you may have developed the condition, they will not necessarily prove or rule out the diagnosis. If you have persistent joint inflammation, you will need to see a rheumatologist.
Erythrocyte sedimentation rate (ESR)
In an ESR test, a sample of your red blood cells is placed into a test tube of liquid. The cells are then timed to see how fast they fall to the bottom of the tube (measured in millimetres per hour). If they are sinking faster than usual, you may have an inflammatory condition, such as rheumatoid arthritis.
C-reactive protein (CRP)
A CRP test can indicate if there is inflammation anywhere in the body by checking how much CRP is present in your blood. CRP is produced by the liver. If there is more CRP than usual, there is inflammation in your body.
Full blood count
The full blood count will measure your red cells to rule out anaemia. Anaemia is a condition where the blood is unable to carry enough oxygen, due to a lack of blood cells. Eight out of ten people with rheumatoid arthritis have anaemia. However, anaemia can have many causes, including a lack of iron in your diet. Therefore, having anaemia does not prove that you have rheumatoid arthritis.
This blood test checks to see if a specific antibody, known as the rheumatoid factor, is present in your blood. This antibody is present in eight out of ten people with rheumatoid arthritis. However, it cannot always be detected in the early stages of the condition. The antibody is also found in 1 in 20 people who do not have rheumatoid arthritis, so this test cannot confirm rheumatoid arthritis. If it is negative, another antibody test (for anti-CCP) may be done, which is more specific for the disease.
X-rays of your joints can help differentiate between different types of arthritis. A series of X-rays can also help show how your condition is progressing. A chest X-ray may also be taken as both the disease and certain treatments (such as methotrexate) can affect the chest.
Musculoskeletal ultrasound may be used in the clinic to confirm the presence, distribution and severity of inflammation and joint damage.
Magnetic resonance imaging (MRI) scans can help show what damage has been done to a joint.
Many different medicines are used to treat rheumatoid arthritis. Some aim to relieve symptoms and others help slow the progression of the condition. Everyone experiences rheumatoid arthritis differently, so it may take time to find the best combination of medicines for your needs. Some of the different medicines that you may be prescribed are outlined below.
Painkillers reduce pain rather than inflammation and are used to control the symptoms of rheumatoid arthritis. The most commonly prescribed painkiller is paracetamol. Codeine is another painkiller that is sometimes prescribed as a combined medicine with paracetamol (known as co-codamol).
Non-steroidal anti-inflammatory drugs (NSAIDs)
Your GP may prescribe a nonsteroidal anti-inflammatory drug (NSAID) to relieve pain and swelling in your joints. There are two types of NSAIDs and they work in slightly different ways. These are traditional NSAIDs, such as ibuprofen, naproxen or diclofenac, and COX-2 inhibitors (often called coxibs), such as celecoxib or etoricoxib. NSAIDs help relieve pain and stiffness while also reducing inflammation. However, they will not slow down the progression of rheumatoid arthritis.
Your doctor will discuss with you what type of NSAID you should take and the benefits and risks associated with each of them. NSAID tablets may not be suitable if you have asthma, a peptic ulcer, angina or if you have had a heart attack or stroke. If you are taking low-dose aspirin, discuss with your GP whether you should use an NSAID.
Taking an NSAID tablet can increase the risk of serious stomach problems, such as bleeding internally. Taking an NSAID can break down the lining that protects against damage from acids in the stomach. While the risk is serious, it is not common. According to research, if between 2,000 and 3,000 people take NSAIDs, one person is likely to have a stomach bleed. The COX-2 agents have a lower risk of serious stomach problems, but carry a risk of heart attacks and strokes.
If you are prescribed an NSAID tablet, you will almost certainly have to take another medicine, such as a proton pump inhibitor (PPI), as well. Taking a PPI reduces the amount of acid in your stomach, which greatly reduces the risk of damage to your stomach lining caused by the NSAID.
Corticosteroids help reduce pain, stiffness and swelling. They can be used as a tablet (for example, prednisolone) or an injection into the muscle (to help lots of joints). They are usually used when NSAIDs fail to provide relief. If you have a single inflamed or swollen joint, your doctor may inject the steroid into the joint. Relief is rapid and the effect can last from a few weeks to several months, depending on the severity of your condition.
Corticosteroids are usually only used on a short-term basis, as long-term use of corticosteroids can have serious side effects. These can include weight gain, osteoporosis (thinning of the bones), easy bruising, muscle weakness and thinning of the skin. They can also make diabetes and glaucoma, an eye disease, worse.
Disease-modifying anti-rheumatic drugs (DMARDs)
DMARDs help to ease symptoms and slow down the progression of rheumatoid arthritis. When antibodies attack the tissue in the joints, they produce chemicals that can cause further damage to the bones, tendons, ligaments and cartilage. DMARDs work by blocking the effects of these chemicals. The earlier you start taking a DMARD, the more effective it will be.
There are many different conventional DMARDs including methotrexate, gold, leflunomide, hydroxychloroquine and sulfasalazine.
Methotrexate is often the first drug given for rheumatoid arthritis. It is prescribed in low doses usually between 10 and 25 mgs/week and sometimes in combination with another DMARD. Side effects of methotrexate are uncommon but include sickness, diarrhoea, mouth ulcers, hair loss or hair thinning, and rashes on the skin. Sometimes, methotrexate can have an effect on your blood count and your liver, and you will have regular blood tests to monitor this. Much less commonly, it can affect the lungs, so your doctor will sometimes order a chest X-ray and possibly breathing tests if you are thought to be more at risk from this complication. However, most people tolerate methotrexate well and around half those who start it will find it effective and will have no difficulty taking it five years later.
Methotrexate may also be combined with biological treatments (see below).
It can take three to six months to notice if a DMARD working. Therefore, it is important to keep taking the medication, even if you do not notice it working at first. You may have to try two or three types of DMARD before you find the one that is most suitable for you. Once you and your doctor work out the most suitable DMARD, you will usually have to take the medicine in the long term.
Biological treatments are a newer form of treatment for rheumatoid arthritis. They include TNF-alpha inhibitors (etanercept, infliximab, adalimumab, golimumab and certolizumab), rituximab, abatacept and tocilizumab.
Biologic therapies are usually taken in combination with methotrexate or sometimes with another DMARD. They work by stopping particular chemicals in the blood from activating your immune system to attack the lining of your joints.
Biological treatments are not suitable for use by everyone and you will have some screening test performed before starting therapy.
The TNF-alpha inhibitors are usually the biologic therapies of first choice with others being considered when you have either failed to adequately respond to or are intolerant of TNF-alpha inhibitors.
Side effects from biological treatments are usually mild and include skin reactions at the site of injection, infections, nausea, fever and headaches. Some people may be at risk of getting more serious problems, including people who have had tuberculosis (TB), septicaemia and hepatitis B in the past. There is a slight risk that biological treatments can reactivate these conditions and, in rare cases, trigger new autoimmune problems.
Sometimes, despite medication, damage to your joints may occur. You may need surgery to help restore your ability to use your joint. Surgery may also reduce pain and correct deformities.
Finger and hand surgery to correct joint problems
There are different types of surgery to correct joint problems in the hand. Examples include:
- carpal tunnel release (cutting a ligament in the wrist to relieve pressure on a nerve)
- release of tendons in the fingers to treat abnormal bending
- removal of inflamed tissue that lines the finger joints
If surgery is needed on the wrist and fingers, the wrist is usually done first.
Arthroscopy removes inflamed joint tissue. A thin tube with a light source is inserted into the joint through a small cut in the skin so that the surgeon can see inside. Instruments are inserted through other small cuts in the skin to remove the damaged tissue. You usually do not have to stay overnight in hospital for this kind of surgery. The joint will need to be rested at home for several days.
Arthroplasty replaces part or all of a hip or knee joint, and may involve a long hospital stay. Depending on which joints are reshaped, it may take several weeks or months of rehabilitation to recover fully.
Replacement of hip, knee or shoulder joints is a major operation that involves 4 to 10 days in hospital followed by months of rehabilitation. The new joints have a limited lifespan of 10-20 years. They are not perfect and some function may not be restored after the damaged joint is replaced by a new one.
Your doctor may also refer you to other services that might be able to help you with your rheumatoid arthritis symptoms.
A physiotherapist may be able to help you improve your fitness and muscle strength, and make your joints more flexible. They may also be able to help with pain relief using heat or ice packs, or trancutaneous electrical nerve stimulation (TENS). A TENS machine applies a small pulse of electricity to the affected joint, which numbs the nerve endings and can help ease the pain of rheumatoid arthritis.
If rheumatoid arthritis causes you to have trouble with everyday tasks or difficulty moving around, there are many devices which could help. Your occupational health specialist can help you decide what is right for you. You may be offered some type of support for your joints or devices that can help open jars or turn on taps. You may also get help with relaxation techniques.
If you have problems with your feet, a podiatrist may be able to help. You may also be offered some type of support for your joints or shoe insoles that can ease pain.
Complementary and alternative therapies
Many people with rheumatoid arthritis try complementary therapies. In most cases, there is little or no evidence that they are effective in the treatment of the symptoms of rheumatoid arthritis. They include massage, acupuncture, osteopathy, chiropractic, hydrotherapy, electrotherapy and nutritional supplements including glucosamine sulphate, chondroitin and fish oil.
Having rheumatoid arthritis can put you at a higher risk of developing other conditions:
- Carpal tunnel syndrome - this is a common condition in people with rheumatoid arthritis. Carpal tunnel syndrome is when there is too much pressure on the nerve in the wrist. It can cause aching, numbness and tingling in your thumb, fingers and part of the hand.
- Inflammation - because rheumatoid arthritis is an inflammatory condition, it can sometimes cause inflammation to develop in other parts of your body, such as your lungs, heart, blood vessels or eyes.
- Tendon rupture - tendons are pieces of flexible tissue that attach muscle to bone. Rheumatoid arthritis can cause your tendons to be become inflamed, which in severe cases can cause them to rupture. This most commonly affects the tendons on the backs of the fingers.
- Cervical myelopathy - if you have had rheumatoid arthritis for some time, you are at increased risk of developing cervical myelopathy and you may need special assessment of your neck before any operation where you are put to sleep. This condition is caused by dislocation of joints at the top of the spine, which put pressure on the spinal cord. Although relatively uncommon, it is a serious condition that can greatly affect your mobility.
- Vasculitis - this is a rare condition that causes inflammation of the blood vessels. It can lead to the thickening, weakening, narrowing and scarring of blood vessel walls. In serious cases, it can affect blood flow to your body's organs and tissues.