Learn About Rheumatoid Arthritis
What is Rheumatoid Arthritis?
Key Symptoms
What Causes Rheumatoid Arthritis?
Conventional Treatments
Medications
Tests and Procedures
Treatment and Prevention
How Supplements Can Help
Self-Care Remedies
Alternative Therapies
When to Call a Doctor
Evidence Based Rating Scale
References
Often abbreviated RA, rheumatoid arthritis is less common and often more disabling than its everyday cousin, osteoarthritis, the "wear-and-tear" degenerative joint condition that nearly everyone develops with age. The word "rheumatoid" in itself can be confusing, because it's so similar to "rheumatism," a popular term for the aches and pains of ordinary osteoarthritis (OA). However, RA and OA are actually very different conditions.
RA is a chronic disorder that causes inflammation and eventual destruction of the cartilage and other tissues in and around the joints. Rheumatoid arthritis is classified as an autoimmune disease because it causes the immune system, which normally protects the body, to begin to attack normal tissues instead. In addition to joints, RA can affect the skin, eyes, blood vessels, heart, lungs, kidneys, and muscles. Unlike osteoarthritis, RA occurs most often in younger people, usually between the ages of 20 and 50. Women are three times more likely than men to develop the disease, which now affects 1% to 2% of Americans.
In the early stages of RA, the synovial membrane--a slippery surface that lines the joints--grows inflamed and thickened, causing pain and stiffness. More general symptoms--fatigue, weakness, fever, loss of appetite--often appear before any sign of joint pain. These are the result of a systemic RA-related inflammation that affects the body as a whole. If the disease progresses unchecked, the cartilage that lines the ends of the joints, as well as bones, tendons, and ligaments can begin to erode. The damaged tissue is slowly replaced by scar tissue, which constricts joints and limits range of motion.
In many people, rheumatoid arthritis produces only mild stiffness, the result of periodic flare-ups that come and go over many years. After an initial attack, between 50% and 75% of those with RA experience a symptom-free period (called a remission) within one or two years. Some even have a permanent remission after a couple of episodes. In other cases, however, RA worsens over time, resulting in extremely damaged, painful, deformed joints. And in very severe cases, this immune disorder can also cause inflammation of the lungs, muscles, skin, and heart.
Rheumatoid arthritis can't be prevented, nor is there one specific cure. If the disease doesn't go into permanent remission on its own, an integrative approach to treatment--using conventional medications along with a number of natural remedies and therapies--can significantly ease pain and inflammation, slow joint damage, and make regular activities easier to manage.
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Initially, general weakness, fatigue, loss of appetite, joint stiffness (usually in the morning), followed within several weeks by joint pain and inflammation.
Swollen, red, and painful joints, most often the fingers, wrists, knees, ankles, and toes, on both sides of the body.
Joints that are tender and warm to the touch.
Painless red skin lumps (rheumatoid nodules) on the elbows, ears, nose, knees, toes, or scalp.
In advanced cases: Shapeless, bent, or gnarled joints.
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With rheumatoid arthritis, the immune system goes haywire and attacks the body's own tissues, primarily the joints. What causes this reaction is unknown, although scientists believe it results from the interaction of many factors. Although no single cause has been conclusively proven, scientists are searching for answers in these areas:
Genes. A family tendency may play a part in setting the stage for RA, although some people with genetic tendencies toward RA never develop it, and others with no family associations do. Experts theorize that this may be because more than one gene is involved in determining who develops the disease.
Environment. A viral or bacterial infection may trigger RA in a person who is already genetically vulnerable, but no precise environmental agents have been identified. (Although some type of infection might be a key factor in some cases, RA is never contagious from one person to another.) Emotional stress, poor nutrition or illness may also ignite RA in someone with an underlying vulnerability.
Hormones. Another theory is that a variety of hormonal factors, including deficiencies or changes in certain natural chemicals, might activate RA in a person who is already genetically susceptible or has been exposed to an environmental trigger, such as an infection.
Leaky Gut. The GI tract may allow substances to enter the system that normally should be excreted. If they are similar to the body's own constituents, the immune system may fail to distinguish “self†from “other†and inadvertently attack its own tissues.
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Because scientists don't fully understand how immune disorders arise, there is no known way to prevent or predictably cure rheumatoid arthritis. Instead, medical and surgical therapies aim to keep the smoldering inflammation from damaging the joints too severely. They also work to repair joints where function has been lost and to encourage the body to go into remission by turning off the destructive inflammatory process mistakenly triggered by the immune system.
The biggest change in treating RA in the last decade has been to start aggressive drug treatment at the first sign of the illness, rather than to gradually increase milder medications until they begin to be effective. By using the stronger drugs first–- the so-called inverted pyramidal approach–- doctors are finding they can block inflammation at an early stage and limit long-term joint damage. If you have just begun to develop RA, this may be the best route to take. Though you may still have flare-ups, you'll have a better chance of halting the condition completely if the inflammatory cycle is stopped at the start.
In stubborn cases when joint damage is very severe, surgery may be recommended, although it should be considered only after other therapies have failed. Three types of operations may be useful for RA: joint replacement, tendon reconstruction, and synovectomy. (See Tests and Procedures, below.)
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The goal of RA medications is to help block chemical inflammation in the joints.
NSAIDs. For quick relief, aspirin or other over-the-counter or prescription painkillers known as nonsteroidal anti-inflammatory drugs (NSAIDs) can be very beneficial. Among these are ibuprofen, naproxen, and indomethacin, which are available in pill or cream form. NSAIDs can cause gastro-intestinal problems that are reduced with the newer NSAIDs, called COX-2 inhibitors; however these drugs have been found to have some increased risk of heart and circulatory problems if given over a long term. As a result, Vioxx (rofexacib) and Bextra (valdecoxib) were withdrawn from the US market in 2005. The remaining COX-2 inhibitor, celecoxib (Celebrex), is still available for use, but it should only be prescribed after you and your doctor consider risk vs. benefit.
If NSAIDs aren't working, your doctor will probably want to use more potent drugs to control the inflammation more quickly. In fact, you may be placed on a program of multiple drugs, some of which are explained below, to manage the illness more effectively. Side effects are always an issue with more powerful drugs, so close medical monitoring is crucial. Be sure to read materials from your pharmacist about any prescribed drugs, and tell your doctor about any problems that arise.
Steroids. Cortisone drugs, such as prednisone, are powerful anti-inflammatories that can quickly quell an RA flare-up. They are used orally, intravenously, or injected directly into joints for periodic relief. The injections can't be given repeatedly into the same area because they can eventually damage a joint if used too often. And high doses of oral steroids are hazardous for regular use; potential side effects include cataracts, glaucoma, gastric bleeding, thinning skin, facial swelling, weight gain, hip damage, and elevated diabetes risk.
DMARDs (disease-modifying antirheumatic drugs), also called SAARDs (slow-acting antirheumatic drugs). These are the big contenders, used in a quick-start attempt to squelch the inflammatory cycle. They include methotrexate (first developed for cancer, but used in very low doses for RA), sulfasalazine, oral or injectable gold, hydroxychloroquine (an antimalaria drug), penicillamine, and leflunomide. Immunosuppressants, such as cyclosporine, are also considered a type of DMARD.
Taken individually or in various combinations, these drugs may significantly help many people with RA, although exactly how they work is still unknown. It generally takes several months before they have a real effect. Potential side effects (depending on the drug) can include upset stomach, low red blood cell count, kidney problems, liver damage, eye damage (rare), high blood pressure, and severe toxicity.
Biologic response modifiers or TNF blockers. Based on compounds that occur naturally in the body, this new class of drugs targets specific aspects of the inflammatory process (one is called tumor necrosis factor, or TNF). They have fewer side effects than other RA drugs, and can be effective in mild to moderate cases of RA that have not responded to other medications, as well as in juvenile RA. TNF blockers include infliximab (Remicide- given every four to six weeks by IV at the doctor's office), adalimumab (Humira), abatacept (Orencia), or etanercept (Enbrel- which you can learn to self-inject twice a week at home). Potential side effects include skin reactions at the injection site, risk of serious infection, increased risk of certain cancers, and headache
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When you first visit a doctor with symptoms and signs suggestive of rheumatoid arthritis, a battery of tests known as an autoimmune profile will be ordered to verify the diagnosis. As the disease waxes and wanes, the tests may be periodically repeated to gauge the general status of your condition.
The most important tests will be part of the regular medical monitoring that all people with RA receive. Many of these screenings will be dependent on the particular medications you take. They may include blood tests to check kidney and liver function and red blood cell count, urine tests, x-rays, and eye exams. Sometimes--when you are beginning a new medication, for example--monthly tests may be required; often, twice a year will do.
In some cases, when RA has progressed and joint damage is extremely severe, surgery may be recommended. There are three primary types of procedures:
Joint replacement (arthroplasty). To relieve pain and improve or restore joint function, surgeons remove the debilitated joint and put in an artificial one. Stainless steel replaces bone and a durable plastic, such as Teflon, acts as the cartilage. Replacement joints often allow people with very severe RA to move with less pain and resume activities they've had to abandon. The downside is that some replaced joints can deteriorate with time (usually decades), and further surgery may be required.
Tendon reconstruction. The fibrous bands of tissue that connect muscles to bones and joints, tendons (particularly those in the hands), can be damaged or even ruptured by RA. A variety of operations are available to release a contracted tendon or reconstruct a new one taken from a cadaver donor. Procedures such as these help to restore hand function, particularly when the tendon is completely ruptured.
Synovectomy. This operation involves removing the inflamed synovial tissue that lines a joint. Synovectomy is often included when reconstructive procedures, such as tendon reconstruction, are being done. It is rarely performed as a separate procedure because it is difficult to remove all of the tissue and because the tissue eventually tends to grow back.
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In treating rheumatoid arthritis, the goal is to relieve pain, reduce inflammation, maintain joint function and mobility, slow damage, and prevent joint deformities from developing. Although the mainstay therapy for many patients is powerful medications, non-drug, noninvasive, and complementary approaches can also help to cope with RA. Under the right circumstances, a combination of these may allow one (with the doctor's approval and close supervision) to reduce the quantity of medications you need to take.
Physical therapy (PT) and occupational therapy (OT) can be quite helpful for RA. Physical therapists offer pain-relieving techniques, such as hot paraffin baths to ease joint pain, and can help establish a supervised or graded exercise program. Occupational therapists are expert at finding multiple ways to help people who have movement restrictions perform daily tasks more easily. Your doctor may also recommend splints, which can relieve pain by immobilizing joints during severe flare-ups. Your physical or occupational therapist can follow up the splinting prescription with you and show you how to use them safely.
Light but regular exercise that gently stretches joints and strengthens the muscles around them is effective therapy. In addition, rest is important--in fact, during periods when joints are badly inflamed, your doctor may recommend complete bed rest until the flare-up diminishes.
Many integrative medical specialists also recommend psychotherapy and counseling when a new autoimmune health problem such as rheumatoid arthritis appears. Your patterns of thinking can have a profound impact on your immune and hormonal systems. A specialist in stress management, psychosomatic medicine, or the new field of psychoneuroimmunology can help you take an inventory of your inner strengths and beliefs and find a positive response to the challenge of your illness. A 2002 analysis of multiple studies, published in the journal Arthritis and Rheumatism, concluded that a wide variety of psychological therapies can be important in helping people with RA cope with the condition. (1)
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A number of nutritional and herbal supplements can help relieve the symptoms of rheumatoid arthritis. They can be taken alone or together, and in combination with conventional medicines.
Just a reminder: If you have a serious medical condition or are taking medication, it's always a good idea to check with your doctor before beginning a supplement program.
Vitamin E levels are often found to be low in the joint fluid of RA patients. A 1997 preliminary study determined that high doses of vitamin E (1,200 I.U. a day) helped reduce joint pain and swelling in RA patients. (2) This antioxidant vitamin may also help protect joint cells from free-radical damage, protecting against the development of rheumatoid arthritis. (3)
Fish oils contain omega-3s, polyunsaturated fatty acids that act as powerful anti-inflammatory agents for joint problems. Studies show that fish oils provide relief from stiffness and joint pain. In 1998, a review of well-designed, randomized clinical trials reported that omega-3 fatty acids were more successful than a placebo in improving the condition of people with rheumatoid arthritis. The research also showed that getting more omega-3 fatty acids enabled some participants to reduce their use of NSAIDs. (4-14) (If you take anticoagulant drugs, however, check with your doctor before using fish oils.)
Borage oil is rich in GLA, an omega-6 fatty acid shown to keep inflammation in check. Good dietary sources of omega-6 fatty acids include most vegetables oils and whole-grain breads. Once processed in the body, GLA has anti-inflammatory and other healing properties. However, some research indicates the omega-6s will only maintain their status as “good†fats when they are balanced by similar amounts of omega-3s. Unfortunately, most Western diets are heavy on omega-6s, often at the expense of omega-3s. This means that omega-6 supplements are probably not necessary except as an adjunct to certain health conditions, such as rheumatoid arthritis. Evidence indicates that taking borage seed oil in combination with conventional analgesics or anti-inflammatory drugs may help decrease symptoms of RA after six weeks of treatment and for as long as 24 weeks (the duration of the study). One trial found it decreased the number of tender joints by 36 percent, the tender joint score by 45 percent, the number of swollen joints by 28 percent, and the swollen joint score by 41 percent. (15, 16) when taken in conjunction with their conventional anti-inflammatory drugs. Evening Primrose Oil (EPO) is another good source of essential fatty acids.
Zinc, an antioxidant mineral, is often low in people with RA. A small dose of a zinc supplement may restore normal levels and help reduce arthritis symptoms. Some studies have indicated zinc has a small therapeutic effect in treating RA. (17-19) However, other studies found that taking zinc orally didn't help treat RA. More research is needed to determine efficacy. Because zinc is also involved in taste, an easy test for zinc deficiency is to place a tablet on your tongue. If you sense a metallic taste, you probably don't need a supplement. Zinc and Copper need to be kept in appropriate ratio. Thus, it may be important to take copper as well if you are using zinc long term. Copper is also an anti-inflammatory agent and can enhance aspirin's anti-inflammatory effects.
Turmeric, a yellow spice whose active ingredient is curcumin, has been shown to possess potent anti-inflammatory effects comparable to both cortisone and the rheumatoid drug phenylbutazone. In a 1980 double-blind study of patients with RA where doses of 1,200 mg curcumin daily were compared with 300 mg phenylbutazone daily (a powerful old anti-inflammatory drug no longer used for humans in the U.S. because of side effects), improvements in the duration of morning stiffness, walking time, and joint swelling were comparable in both groups. (20). More recently, a 2006 study of turmeric extracts containing three of the major curcuminoids similar in composition to those available as dietary supplements found the curcuminoids prevented joint inflammation when taken before the its onset.(21) Another benefit of curcumin is that it has virtually no side effects.
Bromelain, a mixture of enzymes extracted from pineapple, possesses significant anti-inflammatory activity and has demonstrated positive results for rheumatoid arthritis. (22)
Boswellia, an Indian herb, has a long history of traditional use for arthritis. Double-blind studies have shown boswellia is as potent as many NSAIDs. Interestingly, this herb may act in a similar manner to the COX-2 inhibitors, such as Celebrex. However, results have been conflicting. (23, 24)
Ginger helps to lower the level of the body's natural pain-causing compounds called prostaglandins. Reliable studies have shown that this herb is beneficial in relieving RA symptoms because it is a natural anti-inflammatory agent. A small preliminary study of seven patients with RA whose symptoms were only temporarily or partially relieved by conventional drugs received different dosages and forms of ginger (raw, cooked, or powder). Despite the difference in dosage and preparation, all patients reported a substantial improvement, including pain relief, better joint mobility, and a decrease in swelling and morning stiffness. (25) During a follow-up study, 28 patients with RA, 18 with osteoarthritis, and 10 with muscular discomfort took powdered ginger from three months to two and a half years. Relief in pain and swelling was reported in 75 percent of arthritis patients and 100 percent of those with muscular discomfort. (26)
Glucosamine sulfate, a sugar produced in the body, plays an important role in maintaining and repairing cartilage. Although best known for treating osteoarthritis, it may also help joint pain in people with RA. In a 2007 randomized, placebo-controlled study of 51 patients with RA, who received either glucosamine or placebo, patients who received 1,500 mg glucosamine hydrochloride daily for 12 weeks along with conventional medication reported significant reduction in pain. (27) Note that glucosamine comes combined with either a hydrochloride or with a sulfate. When reading about studies that use glucosamine, it is important to note which form was used. Either form of glucosamine is also often combined with chondroitin sulfate, a natural component of cartilage, which may help block enzymes that destroy cartilage.
MSM (methylsulfonylmethane) is a sulfur compound that some experts believe is a building block for proteins in the connective tissues of joints. Numerous studies have shown that sulfur levels in arthritic joints are lower than those in healthy joints, so