Rheumatoid Arthritis
Herni Suprapti dr MKes
Rheumatoid arthritis (RA) is a chronic (long-
standing) disease that damages the joints of
the body.
Rheumatoid arthritis (RA) is an autoimmune disease that causes
chronic inflammation of the joints.
Autoimmune diseases are illnesses that occur when the body is
mistakenly attacked by its own immune system.
Rheumatoid arthritis can also cause inflammation of the tissue
around the joints, as well as in other organs in the body.
Because it can affect multiple organs of the body, rheumatoid
arthritis is referred to as a systemic illness and is sometimes called
rheumatoid disease.
While rheumatoid arthritis is a chronic illness, meaning it can last
for years, patients may experience long periods without symptoms.
Typically, however, rheumatoid arthritis is a progressive illness that
has the potential to cause joint destruction and functional disability.
What Is Rheumatoid Arthritis?
RA affects approximately 1.3 million people in the
United States, with women developing the condition
three times more often than men.
Rheumatoid arthritis is a common rheumatic
disease, affecting approximately 1.3 million people
in the United States, according to current census
data.
The disease is three times more common in women
as in men.
It afflicts people of all races equally.
The disease can begin at any age, but it most often
starts after age 40 and before 60.
In some families, multiple members can be affected,
suggesting a genetic basis for the disorder.
Who Is at Risk for Rheumatoid
Arthritis?
Juvenile rheumatoid arthritis (JRA) is arthritis that
causes joint inflammation and stiffness for more than
six weeks in a child 16 years of age or younger.
Juvenile rheumatoid arthritis (JRA) is arthritis that
causes joint inflammation and stiffness for more
than six weeks in a child 16 years of age or
younger.
It affects approximately 50,000 children in the
United States.
Inflammation causes redness, swelling, warmth,
and soreness in the joints, although many children
with JRA do not complain of joint pain.
Any joint can be affected, and inflammation may
limit the mobility of affected joints.
What Is Juvenile Rheumatoid
Arthritis?
This illustration shows the differences between a
normal, healthy joint, a joint affected by osteoarthritis,
and one affected by rheumatoid arthritis.
A joint is where two bones meet to allow movement of body
parts.
Arthritis means joint inflammation.
The joint inflammation of rheumatoid arthritis causes
swelling, pain, stiffness, and redness in the joints.
The inflammation of rheumatoid disease can also occur in
tissues around the joints, such as the tendons, ligaments,
and muscles.
In some patients with rheumatoid arthritis, chronic
inflammation leads to the destruction of the cartilage, bone,
and ligaments, causing deformity of the joints.
Damage to the joints can occur early in the disease and
progress as the individual ages.
What Is the Difference Between Normal,
Healthy Joints and Arthritic Joints?
The cause of rheumatoid arthritis is a
very active area of worldwide research.
The cause of rheumatoid arthritis is unknown.
Even though infectious agents such as viruses, bacteria, and fungi
have long been suspected, none has been proven as the cause.
The cause of rheumatoid arthritis is a very active area of worldwide
research.
Some scientists believe that the tendency to develop rheumatoid
arthritis may be genetically inherited.
It is suspected that certain infections or factors in the environment
might trigger the immune system to attack the body's own tissues in
susceptible individuals, resulting in inflammation in various organs of
the body including the joints.
Environmental factors also seem to play some role in causing
rheumatoid arthritis.
Recently, scientists have reported that smoking tobacco increases the
risk of developing rheumatoid arthritis.
What causes rheumatoid arthritis?
The symptoms of rheumatoid arthritis come
and go, depending on the degree of tissue
inflammation.
The symptoms of rheumatoid arthritis come and go,
depending on the degree of tissue inflammation.
When body tissues are inflamed, the disease is active. When
tissue inflammation subsides, the disease is inactive (in
remission).
Remissions can occur spontaneously or with treatment and
can last weeks, months, or years.
During remissions, symptoms of the disease disappear and
patients generally feel well. When the disease becomes active
again (relapse), symptoms return.
The return of disease activity and symptoms is called a flare.
The course of rheumatoid arthritis varies from patient to
patient, and periods of flares and remissions are typical.
Remission, Relapse, and Flares
Rheumatoid arthritis symptoms can include
fatigue, lack of appetite, low-grade fever,
muscle and joint aches, and stiffness.
When the disease is active, symptoms can include:
fatigue,
lack of appetite,
low-grade fever,
muscle and joint aches, and
stiffness.
Muscle and joint stiffness are usually most notable in the morning
and after periods of inactivity.
Arthritis is common during disease flares.
Also during flares, joints frequently become red, swollen, painful,
and tender.
This occurs because the lining tissue of the joint (synovium)
becomes inflamed, resulting in the production of excessive joint
fluid (synovial fluid). The synovium also thickens with inflammation
(synovitis).
What Are the Symptoms of
Rheumatoid Arthritis?
In rheumatoid arthritis, multiple joints are
usually inflamed in a symmetrical pattern
(both sides of the body are affected).
In rheumatoid arthritis, multiple joints are usually inflamed
in a symmetrical pattern (both sides of the body affected).
The small joints of both the hands and wrists are often
involved.
Simple tasks of daily living, such as turning door knobs and
opening jars can become difficult during flares.
The small joints of the feet are also commonly involved.
Chronic inflammation can cause damage to body tissues,
cartilage, and bone. This leads to a loss of cartilage and
erosion and weakness of the bones as well as the muscles,
resulting in joint deformity, destruction, and loss of
function.
What Are the Symptoms of
Rheumatoid Arthritis? (cont.)
Rheumatoid arthritis is a systemic disease and
its inflammation can affect organs and areas
of the body other than the joints.
Since rheumatoid arthritis is a systemic disease, its inflammation can affect organs
and areas of the body other than the joints. Examples of other areas that may be
affected include the following:
Sjgrens syndrome is the result of inflammation of the glands of the eyes and mouth
and causes dryness of these areas.
Rheumatoid inflammation of the lung lining (pleuritis) causes chest pain with deep
breathing or coughing.
Tissue inflammation surrounding the heart, called pericarditis, can cause chest pain
that typically changes in intensity when lying down or leaning forward.
Rheumatoid disease can reduce the number of red blood cells (anemia) and white
blood cells.
Decreased white cells can be associated with an enlarged spleen (Feltys syndrome)
and can increase the risk of infections.
Firm lumps under the skin (rheumatoid nodules) can occur around the elbows and
fingers where there is frequent pressure.
A rare and serious complication is blood-vessel inflammation (vasculitis). Vasculitis
can impair blood supply to tissues and lead to tissue death. This is most often initially
visible as tiny black areas around the nail beds or as leg ulcers.
Rheumatoid Arthritis and
Inflammation of Organs
A rheumatologist is a medical doctor who
specializes in the nonsurgical treatment of
rheumatic illnesses, especially arthritis.
A rheumatologist is a medical doctor who specializes in the nonsurgical
treatment of rheumatic illnesses, especially arthritis.
Rheumatologists have special interests in unexplained rash, fever,
arthritis, anemia, weakness, weight loss, fatigue, joint or muscle pain,
autoimmune disease, and anorexia.
They often serve as consultants, acting like detectives for other doctors.
Rheumatologists have particular skills in the evaluation of the over 100
forms of arthritis and have special interest in rheumatoid arthritis,
spondylitis, psoriatic arthritis, systemic lupus erythematosus,
antiphospholipid syndrome, Still disease, dermatomyositis, Sjogren's
syndrome, vasculitis, scleroderma, mixed connective tissue disease,
sarcoidosis, Lyme disease, osteomyelitis, osteoarthritis, back pain, gout,
pseudogout, relapsing polychondritis, Henoch-Schonlein purpura, serum
sickness, reactive arthritis, Kawasaki disease, fibromyalgia,
erythromelalgia, Raynaud's disease, growing pains, iritis, osteoporosis,
reflex sympathetic dystrophy, and others.
Who is a rheumatologist?
The first step in the diagnosis of
rheumatoid arthritis is a meeting
between the doctor and the patient.
The first step in the diagnosis of rheumatoid arthritis is a meeting between the doctor
and patient.
A doctor with special training in arthritis and related diseases is called a
rheumatologist.
The doctor reviews the history of symptoms, examines the joints for inflammation
and deformity, the skin for rheumatoid nodules, and other parts of the body for
inflammation.
Certain blood and X-ray tests are often obtained.
The diagnosis will be based on the pattern of symptoms, the distribution of the
inflamed joints, and the blood and X-ray findings.
Several visits may be necessary before the doctor can be certain of the diagnosis.
The distribution of joint inflammation is important to the doctor in making a
diagnosis.
In rheumatoid arthritis, the small joints of the hands, wrists, feet, and knees are
typically inflamed in a symmetrical distribution (affecting both sides of the body).
When only one or two joints are inflamed, the diagnosis of rheumatoid arthritis
becomes more difficult. The doctor may then perform other tests which 'are described
on the next slides.
How Is Rheumatoid Arthritis
Diagnosed?
A newer, more specific blood test for
rheumatoid arthritis is the citrulline antibody
test.
Abnormal blood antibodies can be found in patients with rheumatoid
arthritis.
A blood antibody called rheumatoid factor can be found in 80% of
patients.
Citrulline antibody is present in most patients with rheumatoid
arthritis.
It is useful in the diagnosis of rheumatoid arthritis when evaluating patients
with unexplained joint inflammation.
A test for citrulline antibodies is most helpful in detecting the cause of
previously undiagnosed inflammatory arthritis when the traditional blood test
for rheumatoid arthritis, rheumatoid factor, is not present.
Citrulline antibodies are also indicators of potentially more aggressive disease.
Citrulline antibodies have been felt to represent the earlier stages of
rheumatoid arthritis in this setting.
Another antibody called "the antinuclear antibody" (ANA) is also
frequently found in patients with rheumatoid arthritis.
RA Diagnostic Test: Citrulline
Antibody Test
The sedimentation rate (sed rate), another
blood test for RA, is a measure of how fast red
blood cells fall to the bottom of a test tube.
A blood test called the sedimentation rate (sed rate) is a measure of
how fast red blood cells fall to the bottom of a test tube.
The sed rate is used as a crude measure of inflammation of the joints.
The sed rate is usually faster from inflammation such as during
disease flares and slower during remissions.
Anotherblood test that is used to measure the degree of
inflammation present in the body is the C-reactive protein.
The rheumatoid factor, ANA, sed rate, and C-reactive protein tests can
also be abnormal in other systemic autoimmune and inflammatory
conditions.
Therefore, abnormalities in these blood tests alone are not sufficient
for a firm diagnosis of rheumatoid arthritis
RA Diagnostic Test: Sedimentation
Rate (Sed Rate)
Joint X-rays can also be helpful in monitoring
the progression of rheumatoid disease and
joint damage over time.
Joint X-rays may be normal or only show swelling
of soft tissues early in the disease.
As the disease progresses, X-rays can show bony
erosions typical of rheumatoid arthritis in the
joints.
Joint X-rays can also be helpful in monitoring the
progression of disease and joint damage over time.
Bone scanning, a radioactive test procedure, and
MRI scanning can demonstrate inflamed or eroded
joints.
RA Diagnostic Test: Joint X-rays
In arthrocentesis, a sterile needle and syringe
are used to drain joint fluid out of the joint for
study in the laboratory.
The doctor may elect to perform an office procedure
called arthrocentesis.
In this procedure, a sterile needle and syringe are used
to drain fluid out of the joint for study in the laboratory.
Analysis of the joint fluid can help to exclude other
causes of arthritis, such as infection and gout.
Arthrocentesis can also be helpful in relieving joint
swelling and pain.
Occasionally, cortisone medications are injected into the
joint during the arthrocentesis in order to rapidly relieve
joint inflammation and further reduce symptoms.
RA Diagnostic Test: Arthrocentesis
There is no known cure for rheumatoid arthritis;
however, early medical intervention has been shown to
be important in improving outcomes.
There is no known cure for rheumatoid arthritis.
To date, the goal of treatment in rheumatoid arthritis is to reduce joint
inflammation and pain, maximize joint function, and prevent joint
destruction and deformity.
Early medical intervention has been shown to be important in improving
outcomes.
Aggressive management can improve function, stop damage to joints as
seen on X-rays, and prevent work disability.
Optimal treatment for the disease involves a combination of medications,
rest, joint-strengthening exercises, joint protection, and patient (and
family) education.
Treatment is customized according to many factors such as disease activity,
types of joints involved, general health, age, and patient occupation.
Treatment is most successful when there is close cooperation between the
doctor, patient, and family members.
How Is Rheumatoid Arthritis
Treated?
Two classes of medications are used in treating
rheumatoid arthritis: fast-acting first-line drugs and
slow-acting second-line drugs.
Two classes of medications are used in treating rheumatoid arthritis:
fast-acting first-line drugs and slow-acting second-line drugs (also
referred to as disease-modifying antirheumatic drugs or DMARDs).
The first-line drugs, such as aspirin and cortisone (corticosteroids), are
used to reduce pain and inflammation.
The slow-acting second-line drugs, such as methotrexate (Rheumatrex,
Trexall), and hydroxychloroquine (Plaquenil), promote disease
remission and prevent progressive joint destruction, but they are not
anti-inflammatory agents.
Some newer second-line drugs for the treatment of rheumatoid
arthritis include leflunomide (Arava) and the biologic medications
etanercept (Enbrel), infliximab (Remicade), anakinra (Kineret),
adalimumab (Humira), rituximab (Rituxan), and abatacept (Orencia).
What Medications Are Used to
Treat Rheumatoid Arthritis?
Symptomatic pain relief can often be achieved
with oral acetaminophen (Tylenol and others)
or OTC topical preparations.
There is no special diet for rheumatoid
arthritis.
Fish oil may have anti-inflammatory beneficial
effects.
Likewise, the benefits of cartilage preparations
remain unproven.
Symptomatic pain relief can often be achieved
with oral acetaminophen (Tylenol and others)
or over-the-counter topical preparations,
which are rubbed into the skin.
Other Treatments for Rheumatoid
Arthritis
The areas of the body, other than the joints,
that are affected by rheumatoid inflammation
are treated individually.
The areas of the body, other than the joints, that are
affected by rheumatoid inflammation are treated
individually.
Sjogrens syndrome can be helped by artificial tears and
humidifying rooms in your home or office. Medicated
eyedrops, cortisporine ophthalmic drops (Restasis), are also
available to help the dry eyes in those affected. Regular eye
check-ups and early antibiotic treatment for infection of the
eyes are important.
Inflammation of the tendons (tendinitis), bursae (bursitis),
and rheumatoid nodules can be injected with cortisone.
Inflammation of the lining of the heart and/or lungs may
require high doses of oral cortisone.
Other Treatments for Rheumatoid
Arthritis (cont.)
A balance of rest and exercise is important in
treating rheumatoid arthritis.
A balance of rest and exercise is important in treating rheumatoid arthritis.
During flare-ups (worsening of joint inflammation), it is best to rest joints
that are inflamed. When joint inflammation is decreased, guided exercise
programs can be helpful to maintain flexibility of the joints and to
strengthen the muscles that surround the joints.
Range-of-motion exercises should be done regularly to maintain joint
mobility.
Swimming is particularly helpful because it allows exercise with minimal
stress on the joints.
Physical and occupational therapists are trained to provide specific exercise
instructions and can offer splinting supports. For example, wrist and finger
splints can be helpful in reducing inflammation and maintaining joint
alignment.
Devices, such as canes, toilet seat raisers, and jar grippers can assist daily
living.
Heat and cold applications can ease symptoms before and after exercise.
Why Are Rest and Exercise
Important?
Surgery may be an option to restore joint mobility and
repair damaged joints. In worst-case scenarios, total
artificial joint replacement may be needed.
Surgery may be recommended to restore joint mobility or
repair damaged joints.
Doctors who specialize in joint surgery are orthopedic
surgeons.
The types of joint surgery range from arthroscopy (insertion
of a tubelike instrument into the joint to see and repair
abnormal tissues) to partial and complete replacement of
the joint.
Total joint replacement is a surgical procedure whereby a
destroyed joint is replaced with artificial materials.
For example, the small joints of the hand can be replaced
with plastic material. Large joints, such as the hips or
knees, are replaced with metals.
Is Surgery an Option for
Rheumatoid Arthritis?
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