Rheumatoid arthritis is a relatively common disease in Singapore. It is one of many different types of arthritis, each with its own particular characteristics. With proper treatment, rheumatoid arthritis can be controlled and severe deformities of the joints may be prevented. Some patients when told that they have the disease may feel depressed, anxious or frustrated. Misconceptions about the disease and the desire for a rapid cure may lead the patient to seek unproven therapy, resulting in delay in appropriate treatment and dire consequences.This booklet is written for people who have rheumatoid arthritis, and their family. It aims to explain some of the facts about rheumatoid arthritis and help you understand the disease so that you can take a positive role in keeping it under control.
Rheumatoid arthritis is an inflammatory disease characterised by pain, swelling and stiffness in the joints. The disease causes inflammation in the lining of the joints (“arth” means joint, “itis” means inflammation). Inflammation is the body’s reaction to injury. In an inflamed area, the flow of blood increases, resulting in heat and redness; fluid and cells leak into the tissue, causing swelling and pain. Most inflammatory reactions are short-lasting responses to injury but in rheumatoid arthritis the inflammation is persistent and abnormal. Fluid may accumulate in the joint as a result of the inflammation and this contributes to the joint swelling. If the inflammation continues uncontrolled for a long time, it may cause damage to the joints or tendons. This inflammation distinguishes rheumatoid arthritis from other more common forms of arthritis like osteoarthritis.
Apart from the joints, the disease can also affect other parts of the body like the eyes, lungs, nervous system and the skin. In its mild form, it may cause no more than minor discomfort and does not lead to serious joint deformity. In its severe form, rheumatoid arthritis can give rise to painful and badly damaged joints. The disease is thus different from patient to patient. It is a chronic disease and there may periods of remission (no symptoms) between periods of active disease.
It can occur at any age but most commonly it appears between the ages of 25 and 50. A similar form of arthritis affects children. Both sexes may be affected although it is three times more common in women than in men.As other types of arthritis may sometimes mimic rheumatoid arthritis, it is difficult to be sure how common it is. In the USA, approximately one percent of the population have rheumatoid arthritis. The figure in Singapore is not yet known.
It is not yet known what causes rheumatoid arthritis. It is thought that the inflammation in the joint is due to a disorder of the body’s immune system and that a triggering agent causes the disease only in those with a genetic or inherited susceptibility. The result is an immune reaction to the body’s own cells and tissue especially in the joints leading to inflammation in the joints. The persistent inflammation causes damage to the joints.The “triggering agent” may well be a virus or bacteria but it has yet to be identified. The disease is however not contagious.There is no scientific evidence that rheumatoid arthritis is caused by changes in weather, lack of vitamins or excess dietary intake of certain food stuff.
The diagnosis of rheumatoid arthritis is based on the overall finding of the characteristic symptoms the patient experiences and signs of arthritis on examination, together with the help of laboratory tests and X’rays. The pattern of joint involvement is one useful way of differentiating rheumatoid arthritis from other types of arthritis. For example, the wrists and many of the joints of the hands may be affected but usually not the joints closest to the finger nails (except for the thumb). In contrast, another common type of arthritis called osteoarthritis affects the joints closest to the fingernails more often than other joints of the hands. Rheumatoid arthritis may also involve other joints like the elbows, shoulders, neck, jaw, hips, knees, ankles, and the feet. Apart from the neck, rheumatoid arthritis usually does not affect the spine.
Another type of arthritis which predominantly affects the spine but can also involve the joints of the limbs, is called spondyloarthropathy. Spondyloarthropathy more often afflicts young male adults.The joints tend to be symmetrically affected in rheumatoid arthritis, meaning that if the knuckles of the left hand are inflamd, is likely that those on the right will be similarly affected.Rheumatoid arthritis tends to persist for more than a few weeks to months. Some other forms of arthritis like those associated with a viral infection come in shorter spells and often resolves completely. The presence of lumps or nodules under the skin and along tendons is another feature of rheumatoid arthritis which is not usually found in other types of arthritis.
A blood test which identifies the presence of a substance called the rheumatoid factor, which is present in about 70% of helps in the diagnosis. However the presence of rheumatoid factor in the absence of other characteristic features of the arthritis, does not allow the diagnosis of rheumatoid arthritis to be made because it may occur in other conditions and even in normal people. The activity of the disease may be assessed with the help of some blood tests such as the “erythrocyte sedimentation rate” or ESR. Anaemia or low red blood cell counts may be present especially when the disease is active.
X’rays are usually normal early in the disease They may later show
typical pattern of joint damage or “erosions” of the bones. Serial X’ray
may help to assess the degree of joint damage , and the response to treatment.
The disease is not passed directly from parents to children. A tendency or susceptibility to develop the disease may be inherited but the presence of other yet unknown factors are also important for it to occur. Rarely, there are some families where the arthritis affects more than one member.
How does Rheumatoid Arthritis affects the patient?
About 10% of patients have a single attack of arthritis and a long lasting remission after that. However, in the majority of patients with the disease, the arthritis will persist for a long time if left untreated. The course of the disease varies from person to person.. There will be some whose disease will be mild with periods of exacerbation (worsening of the arthritis called “flares”). In others, the disease may be continuously active and progress relentlessly.
When the disease starts, the patient may feel generally unwell with
fatigue, loss of appetite and weight, and develop joint stiffness and aches. The stiffness
in the muscles and joints often occurs in the morning and it may be a few hours before it
gets better. The inflamed joints will become swollen, warm, tender to touch and difficult
to move. If the inflammation in the joints is prolonged, the joint may be damaged and the
muscles around the joints may become weak and wasted. The joints may become deformed and
occasionally the tendons may rupture causing the fingers to “drop” and unable to
move.The disease may strike the patient suddenly and severely. Those afflicted with
disease may find that they are unable to perform the activities of daily living that they
used to take for granted, like dressing, bathing and doing simple household chores.
Depression, denial, frustration and anxiety are sometimes experienced by patients who will
benefit from counselling and education about their disease.
Understanding the disease will make it easier to cope with it. It is useful to learn more about the disease by talking to your doctor, physiotherapist, other patients and by joining a support group.No single standard treatment is suitable for all patients. Therapy is tailored to the severity of the disease and involves a combination of medication, rest, physiotherapy and knowing how to protect the joints.
REST is one of the best way to treat the inflamed joint and reduce
fatigue. Splints may be used to restrict movement to rest the joint and prevent joint
deformity. However too much rest may allow the joint to stiffen and the surrounding
muscles to be weak. Therefore, once the inflammation has subsided, mobilisation of the
joint and physiotherapy may be required.
MEDICATION is often required to control the disease. Many patients are afraid about taking
drugs because of the possible side effects. Whilst the drugs may have occasional side
effects, for most patients the benefits of the drugs far weigh the potential risks and
they provide a great relief to many sufferers. There are two major groups of drugs used to
treat rheumatoid arthritis; one group is the “anti-inflammatory” agents and the
other is the so-called “disease-modifying” agents which induces remission of the
disease over a long period of time.
Anti-inflammatory drugs have more immediate effect and reduces the pain, swelling and stiffness associated with the arthritis within hours and days. They are called non-steroidal anti-inflammatory drugs or NSAID and there are many different types available with varying dosing intervals. Some examples of NSAIDs are aspirin, indomethacin, diclofenac, naproxen, ibuprofen, mefenamic acid and piroxicam. NSAIDs may cause gastric upset which may be reduced by taking them after food or with another drug to relieve the abdominal symptoms. Different patients respond to different NSAIDs, and it may require some time to find the best one that suits them.
Disease-modifying drugs are used to control the arthritis and hopefully prevent the disease from progressing. In contrast to NSAIDs, these drugs tend to act more slowly and may take months to produce maximal benefit. There are possible side effects which may require regular monitoring of blood and urine test.. There are many drugs in this group such as methotrexate, gold, sulphasalazine, hydroxychloroquine, chloroquine and penicillamine. Some patients respond so well to the drugs that the disease seems to disappear and they do not require the NSAID. However the arthritis may flare if the drug is stopped and patients are usually required to take it on a long term basis.
Corticosteroids have strong anti-inflammatory properties but should be used only sparingly and in very severe disease. When used in the appropriate conditions, steroids can be of great benefit. However, it may have many side effects especially when used in large doses and for long period of time. Injection of steroids into the joints is occasionally used to help control the arthritis in one or two troublesome joints.
HEAT AND COLD treatment is a simple and effective therapy for relieving joint pain and muscle spasm. Hot pads, a hot shower, paraffin wax and cold compress may be used.
EXERCISE AND PHYSIOTHERAPY are also important in the overall treatment of the disease. It is important that the muscles are kept strong and that the joints maintain as full a range of movement as possible when the inflammation in the joints is sufficiently controlled.
DIET has no special effect on the arthritis. A well-balanced and healthy
diet is beneficial. It is logical that you should diet if you are overweight to reduce the
stress on the joints in your lower limbs.
SURGERY may be recommended for patients with severe disease to correct or prevent joint
deformity. In the badly damaged joints like the hips and the knees, joint replacement may
provide the patient pain relief, increased mobility and a better quality of life. Lupus
is an unpredictable disease but in most cases it can be successfully treated. Once an
effective treatment program has been started, it is important for the patient to keep to
it faithfully and to inform the doctor of any change in symptoms so that t he medications
can be modified.
The treatment program for lupus includes medications, getting enough rest when the disease is active and avoiding sun exposure.
No, there is no cure yet for this disease at present. However there are effective treatment which can control the disease. The aims of therapy are to relieve pain, reduce joint inflammation, halt the progression of joint damage and improve the patient’s function and well-being.
If your disease is well controlled, there is no reason to avoid pregnancy. However, please consult your doctor before you get pregnant as some of your drugs may need to be stopped. In about 70% of patients, the arthritis improves during pregnancy but may flare up again after delivery.
It is important to continue the fight against the disease. This disease has a spectrum of severity ranging from mild to very severe. Only a small minority of patients will develop crippling deformities. Many patients, with proper treatment and self care, can cope well with the disease and can look forward to a full and productive life. Continuing research on this disease will allow us to understand it more and enable us to better treat the disease. New therapies like biological agents (eg. monoclonal antibodies) are been evaluated. Thus the outlook for patients with this disease is bright.
If you like further information please write to the
Rheumatoid Arthritis Society (Singapore), Towner Post Office, PO Box 1578, Singapore
913240.
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