Could I have Rheumatoid Arthritis?
What is Rheumatoid Arthritis?
Rheumatoid arthritis (RA) is an autoimmune disease which affects the joints, causing pain, swelling, stiffness and joint damage. The inflammation associated with RA can cause other systemic symptoms such as fatigue, weight loss, skin, eye, nerve, vascular, bone and lung problems.
The early diagnosis of RA is vital to prevent the disease progressing, and to reduce the risk of long-term joint damage.
We don’t fully understand what causes the immune system to mistakenly attack the cells that line joints, but we do know that RA is more common in:
Increasing age (RA occurs most frequently in people in their 60’s)
People who have family history of RA
People who are significantly overweight
People who have recently had an infection (e.g. a urinary tract caused by proteus mirabilis, and after an infection with Epstein-Barr virus).
In addition, there is a growing body of research to link high levels certain kinds of gut bacteria as being a trigger for the development of RA, and a diet high in red meat.
What are the symptoms of Rheumatoid Arthritis?
Dr Arti Mahto, LIPS Consultant Rheumatologist describes that many patients talk about their joints in terms of “tightness”, particularly affecting their hands and wrists, which starts in the early morning, and then improves as the day goes on. The stiffness may come and go or appear to “flit” between joints. Many patients will dismiss these early symptoms, even brushing it off as being a part of “getting old”. This is known as the first stage.
In the second stage of RA, the joints may become visibly swollen, and in around 20% of people with RA, small firm lumps can develop under the skin, known as rheumatoid nodules. In the second stage rheumatoid and other antibodies be produced, which can be detected in blood tests, and characteristic “erosions” may become evidence on imaging of the joints.
By the time RA has advanced to the third stage, the joints are becoming misshapen and deformed. As the immune system attacks the joint lining, a fibrous layer of tissue called “pannus” develops which releases proteins that cause damage to the surrounding tissues, cartilage surfaces, and ligaments. Joints become unstable and bent, giving the classic RA clinical signs of “swan-neck deformity”, “Boutonniere deformity” and “hitchhiker’s thumb”.
In fourth and final stage of RA, the affected joints are so damaged that no joint surface remains, and the joints fuse.
Thankfully, early detection and treatment of RA can significantly limit the progression of the disease and joint damage.
Rheumatoid Arthritis in the hands
How can Rheumatoid Arthritis (RA) be diagnosed early?
There isn’t a single test that definitively proves if you have rheumatoid arthritis, but the diagnosis is made using a combination of the story of your symptoms, a physical examination, blood tests and imaging, one of which is ultrasound scanning.
It’s also important to remember that some conditions can mimic RA, such as Psoriatic Arthritis, Lupus, Lyme Disease, Viral Arthritis and Reactive Arthritis.
What do I need to know about blood tests?
Blood tests are just part of the assessment. More often than not, a person who has RA will have high levels of Rheumatoid Factor antibodies, or Anti-CPP (anti-citrullinated peptides) antibodies in their blood, and this is known as being “seropositive”. It’s thought that 65-80% of patients with RA have Rheumatoid Factor antibodies, and 50-70% of patients with RA will have Anti-CPP antibodies. However, this also means that there may be a significant proportion of patients who have RA who are “seronegative”, and who won’t exhibit either of these antibodies in their blood. In addition, there are many people who have no symptoms of signs of Rheumatoid Arthritis, who may test positive for these antibodies.
This is why it’s so important not to ignore the symptoms of joint pains and morning stiffness, and why early seeing a rheumatologist soon will ensure you have the correct diagnosis.
High resolution musculoskeletal ultrasound can play important role in the early diagnosis of RA, particularly in the first stage of the disease. It’s a highly sensitive tool, often used to assess the small joints of the hand and wrist, and it can spot early synovitis (inflammation of the lining of joints), as well as looking for signs of increased blood vessel activity, tendon changes, joint swelling, and early joint “erosions”. Ultrasound scanning can also be used as a prognostic tool, and a way of monitoring the disease.
How is Rheumatoid Arthritis treated?
Many patients fear that a diagnosis of rheumatoid arthritis means they can expect a lifetime of pain, severe difficulty with their joints, and other medical complications, such as heart disease. Thankfully, early intervention with prompt treatment can mean a really positive future, and these days, the goal is early, robust treatment, to swiftly halt the disease progression. Much can be done, and it’s important to understand that a wide range of treatments are now available.
The mainstay of rheumatoid arthritis treatment are DMARDs – Disease Modifying Anti-Rheumatic Drugs. These act to suppress the body’s abnormal immune and inflammatory responses, essentially controlling white blood cell over-activity, blocking the inflammation that damages joints. DMARDs, such as Methotrexate, take a few weeks to gain their effect, so it’s important to be patient if you’re commenced on treatment. During that time, regular blood tests are needed to monitor your progression, and to ensure your liver and kidneys are tolerating the treatment well.
Your rheumatologist might also recommend steroid or non-steroidal anti-inflammatories to help with your symptoms, whilst the DMARDs are taking effect. There are other DMARDs available, such as Hydroxychloroquine, Sulphasalazine and Leflunomide, if Methotrexate isn’t very well tolerated.
If a traditional DMARD medication doesn’t produce the desired response, then your rheumatologist may advise adding in, or switching to, a “biologic” DMARD, such as Etanercept or Infliximab. These are medications which block the action of an inflammation-generating protein called “TNF”.
Some patients fear taking DMARDs, as they’ve been told that they are “strong” drugs, or “chemotherapy” drugs, but they are a highly effective tool in limiting the impact of the disease, and your rheumatologist will work with you, to find the treatment that best suits your needs.
Dr Arti Mahto, Consultant Rheumatologist, is an expert in early inflammatory arthritis diagnosis, and she is one of the very few rheumatologists who is also trained in the ultrasonographic assessment of joints. If you would like to book a consultation with Dr Mahto, please contact the LIPS team at: