Rheumatoid arthritis

Rheumatoid arthritis is a systemic disease of unknown cause which is mainly manifested by chronic inflammation of synovial membranes leads to a deforming arthropathy. It affects 1-3% of the population, and is twice as common in women as in men. The peak age at onset is 20-40 years.

Clinical Features

This condition usually has an insidious onset. Patients initially describe stiffness of the joints, mainly affecting the small joints of the hands but also affecting the toes and larger joints, such as the wrists, elbows and knees. The patient then goes on to develop a symmetrical polyarthritis with pain and stiffness, which is worse in the morning. They may also have constitutional symptoms, such as fatigue, reduced appetite and general malaise. On clinical examination during the acute inflammatory phase, the joints are swollen, hot to the touch, tender, and have limitation of movement. As the disease progresses there is destruction of the synovial structures, the ligaments and the tendons around the joint, and a deforming arthritis results, with atrophy of the muscles surrounding the inflamed joints. Extra-articular features include skin ulcers, digital ischaemia, pleural effusions, pulmonary fibrosis and splenomegaly. Patients often develop rheumatoid nodules, which are most commonly found on the extensor aspects of the elbow joints over the olecranon process, but may also be found around the wrist joint or on the dorsum of the hand. The presence of rheumatoid nodules indicates that the patient has a rheumatoid factor-positive condition, and is associated with a poor prognosis.

Investigations

There is often a mild normochromic normocytic anaemia. The erythrocyte sedimentation rate (ESR) is elevated, as is the level of C-reactive protein, during acute acute episodes of inflammation of the joints. The main diagnostic test is the detection of rheumatoid factor in the blood. Aspiration of synovial fluid shows the presence of increased levels of protein, a slight reduction in glucose concentration, and polymorphonuclear leucocytes present in the fluid.

The diagnosis is based on the presence of four or more of the following criteria:

1. hand involvement in an inflammatory arthritis

2. symmetrical joint involvement

3. arthritis of three or more joints that lasts for six or more weeks

4. morning stiffness

5. the presence of rheumatoid factor

6. the presence of rheumatoid nodules

7. The presence of erosions on X-ray of the small joints of the hands and/or feet.

Treatment

In the early stages, during the acute inflammatory process, the patient should be advised to rest their joints, and this sometimes involves splinting the joints. The specific drug therapy is described below.

Analgesics

Analgesics are given in the form of either simple paracetamol or more commonly non-steroidal anti-inflammatory drugs, which not only reduce the pain and discomfort but are also effective in reducing the inflammatory process.

Disease-modifying drugs

These drugs are designed to suppress or modulate the autoimmune process. They do not have an immediate therapeutic effect, and up to 4-6 months of treatment may be necessary to obtain a full response. Drug in this group include D-Penicillamine, gold and antimalarial drugs such as hydroxyxhloroquine.

Steroid Drugs

These drugs have a potent anti-inflammatory action, and are generally used for patients whose condition is not well controlled by non-steroidal anti-inflammatory drugs, or in whom there is evidence of extra-articullar involvement, such as neuropathy, renal disease or lung disease. Initially, hogh does of steroids are used. These does are then gradually reduced while monitoring the activity of the disease process and inflammatory markers as ESR and C-reactive protein.

Immunosuppressive drugs

These drugs are used to suppress rheumatoid factor production and thus reduce the circulating levels of the immune complexes that cause the inflammatory reaction to occur. This group of drug includes methotrexate, azathioprine and cyclophosphamide.

Specific anticytokine drugs

'With the development of agents that can inhibit the actions of interleukins and tumor necrosis factor, a number of drugs now available necrosis factor, a number of drugs b hat inhibit the cytokines which trigger inflammatory reaction in this condition Monoclonal antibodies and recombinant DNA technology have resulted in the development of a whole range of drugs which can inhibit the action of cytokines or block the receptors to which they normally attach. The potential for the use of these drugs in suppressing the disease activity of rheumatoid arthritis has been demonstrated. However, the potential for increasing the risk of infection and the development of malignancy as a consequence of long-term therapy must also be considered.

Complications

Rheumatoid arthritis can affect nearly every part of the body. Complications may include:

• Damage to the lung tissue (rheumatoid lung)

• Increased risk of hardenign of the arteries

• Spinal injury when the neck bones become damaged

• Inflammation of the blood vessels (rheumatoid vasculitis), which can lead to skin, nerve, heart, and brain problems

• Swelling and inflammation of the outer lining of the heart (pericarditis) and of the heart muscle (myocarditis), which can lead to congestive heart failure

Prevention

There is no known prevention. Proper early treatment can help prevent further joint damage.

"It is possible that yoga may have important physical and psychological benefits for patients with rheumatoid arthritis."