Rheumatoid arthritis
The most common inflammatory joint disease
In this chapter, you will learn important facts about rheumatoid arthritis, or RA for short, which affects 0.5 to 0.8% of the population and women three times more often than men. Although the first symptoms in adults usually appear between the ages of 30 and 50, rheumatoid arthritis can develop at any age. What exactly is behind this disease and what causes it? What is the expected course of the disease? And what is a suitable treatment that can reduce the symptoms of the disease? Please read on.
What is rheumatoid arthritis?
When the immune system fights your own body
In RA, the immune system attacks the synovial membrane of the joint, causing an inflammation that results in a significant proliferation and enlargement of the synovial membrane. It penetrates into the joint space and overgrows the cartilage and bone tissue.
Without treatment, there is progressive destruction of cartilage and bone tissue in this area, which can no longer be replaced by the body. Possible consequences are pain, swelling and joint effusions. In the later course of the disease, permanent deformities and stiffening of affected joints, for example of the hand, can occur. Rheumatoid arthritis used to be called chronic polyarthritis (CP). Today, the ‘poly’ (Greek: many) does not only mean an inflammation of ‘many’ joints; vessels as well as internal organs such as the heart, lungs or eye can also be affected, although less frequently. Without appropriate treatment, there is an increased risk of inflammation-related complications in the cardiovascular system (stroke, heart attack), which also affects life expectancy.
Symptoms of rheumatoid arthritis
Do I have the autoimmune disease RA?
Rheumatoid arthritis generally progresses slowly. Without treatment, the inflammation persists and spreads. Very often, the disease progresses in episodes, which means that there are phases when you are pain-free and phases when you suffer from rheumatoid arthritis.
The first symptoms of the disease can be loss of appetite, fatigue, a feeling of weakness or even weight loss. Painful joints are typical, especially when moving – even shaking hands can hurt. Morning joint stiffness or swollen joints are also characteristic of RA. In advanced stages, persistent pain in several joints over weeks is characteristic. The pain occurs symmetrically on the right and left side of the body. Several joints on both sides of the body are involved.
Do you find the above symptoms in yourself? These could be signs of rheumatoid arthritis. Talk to your doctor about it.
How is RA diagnosed?
At the beginning of the diagnosis, as with almost every disease, there is the taking of your medical history – a detailed enquiry of medically relevant information by your doctor in order to find out e.g. a possible hereditary predisposition and any other relevant facts.
If your family doctor or general practitioner is consulted first, he or she can then initiate a referral to a specialist, i.e. a rheumatologist, if the suspicion of rheumatoid arthritis is confirmed.
This is followed by a physical examination with special attention paid to the joints. A laboratory test, imaging procedures such as X-ray, MRI or ultrasound also provide information, whereas rheumatoid arthritis at an advanced stage can be recognised with the naked eye by typical changes in the fingers.
Interesting values of the rheumatism tests are the erythrocyte sedimentation rate to clarify a suspicion of the presence of inflammation or autoimmune disease, the C-reactive protein, CRP for short, the most important blood value to detect inflammation in the body, the rheumatoid factor (RF) – a so-called autoantibody that occurs in certain autoimmune diseases, especially RA, and the CCP antibody, which also occurs in RA and is important for early diagnosis.
Treatment options for rheumatoid arthritis
Building blocks of a comprehensive therapy
DRUG THERAPY
Helps to relieve the pain and slow down the disease
PHYSIOTHERAPY & OCCUPATIONAL THERAPY
Helps to mobilise joints and counteract abnormal positions
COLD OR HEAT TREATMENT
Helps to relax, stimulates blood circulation, relieves pain
EXCHANGE & SUPPORT
Can help to clarify issues and promotes mental strength
The primary goal of treating rheumatoid arthritis is to consistently suppress the inflammation and stop the destruction of joints. This is the only way to ideally bring the disease to a halt, alleviate discomfort and prevent the deformation or functional limitation of the joints. The treatment options are many and varied. In addition to drug therapy, physiotherapy and occupational therapy, joint protection training that improves mobility and corrects abnormal postures have proven effective. Cold or heat treatment as part of physical therapy also has a positive effect by stimulating blood circulation and muscle and nerve fibres and thus providing pain relief and relaxation. Heat therapy can also activate or suppress the immune system1.
Sharing with others can also be beneficial – psychosocial support or training is useful here. Ultimately, surgical intervention can be considered if it is deemed necessary by the specialist.
Several substances are available for the drug therapy of RA, which can be used alone or in combination.
Non-steroidal anti-inflammatory drugs (NSAIDs) reduce pain but do not have a disease-fighting effect. Glucocorticoids – colloquially known as cortisone – have a very rapid pain-relieving and anti-inflammatory effect and can delay joint destruction. The dosage should be as low as possible and the duration of use as short as necessary. The recommendation is that cortisone should not be used for longer than three to six months.
The effect of basic therapeutics, the so-called disease-modifying anti-rheumatic drugs – DMARDs for short – is delayed, but best case, they can even bring the course of the disease to a complete halt.
Since rheumatoid arthritis is a chronic disease, the basic therapeutics usually have to be administered over correspondingly long periods of time. With good efficacy and tolerability, treatment is often continued for life.
Biologics are used when treatment with basic therapeutics does not work sufficiently. Biologics are medicines that target the body's own messenger substances, which play an important role in the development and maintenance of rheumatic diseases. Since patent protection has been removed for some biologics, they are now available in generic forms called biosimilars.
Targeted synthetic disease-modifying antirheumatic drugs (tsDMARDs), so-called ‘small molecules’, can also be used for therapy. These medicines act inside the cells and interrupt signalling pathways that promote inflammatory reactions in the body.
What is the most commonly used rheumatism medication?
Conventional DMARDs are probably the most commonly used long-acting anti-rheumatic agents. They come in different forms of administration: as a tablet, syringe or by self-injection – in the form of a ready-made pen that makes injection easier. Sometimes the injection form can be useful for patients who have difficulty swallowing the medicine. It may also be the case that the medicine is not well tolerated in tablet form or is not sufficiently effective.
Source
1 Gottwalt J, Gottfried T: Physical therapy in rheumatic diseases. OUP 2019; 8: 262-272, www.online-oup.de/media/article/2019/05/D937A198-276F-45D3-AFB4-554253A36FD6/D937A198276F45D3AFB4554253A36FD6_gottwalt_1_original.pdf, last accessed 03 Apr 2023.
