Rheumatoid arthritis is an autoimmune disease of unknown cause that results in chronic systemic inflammation affecting many parts of the body, but primarily the joints. The clinical course is highly variable. The disease can fluctuate and may sometimes go into remission for months or years, either spontaneously or with the use of various medications. After 10 years, about 20% of those affected will have no disability or joint deformities. Most however experience a progressive course with exacerbations and remissions associated with some loss of functioning. About 5-15% of affected individuals will have persistent disease activity throughout the course of this illness.
The disease process causes inflammation of the capsule around the joints, eventually leading in some cases to destruction of articular cartillage and fusion of the joints. While it usually involves smaller joints on both sides of the body, resulting in painful swelling and stiffness, it can also affect the larger joints. Likewise, in about 15-25% of cases the diffuse inflammation can involve the lungs, heart, kidneys, eyes, skin, nerves and blood vessels. About 1% of the population has rheumatoid arthritis, and women are two to three times more likely to have the disease than men. The onset can occur at any age, but it usually presents between the ages of 25 and 50. Rheumatoid arthritis becomes more prevalent at older ages.
Diagnosis & Treatment
Diagnosis is clinical and based on symptoms, physical exam, X-rays and serologic testing. There is no cure for rheumatoid arthritis, but many different treatments can improve symptoms and slow progression of the disease. Disease-modifying anti-rheumatic drugs (DMARDs) are the primary treatment. Started early in the course of the disease, these drugs produce remissions in about 50% of individuals. They generally improve symptoms, decrease joint damage and improve overall functional capacity.
Examples include methotrexate, sulfasalazine, leflunomide and hydroxychloroquine. Biologic agents may be part of the regimen. Examples include TNF blockers, interleukin 1 blockers and monoclonal antibodies. Non-steroidal anti-inflammatory agents can relieve symptoms but do not impact the course of the disease. Steroids can provide short term relief, but are generally avoided for long term use due to side effects.
Rheumatoid arthritis can reduce expectation of life by approximately 3 to 12 years. Higher mortality risk is associated with a younger age at onset, a longer duration of disease, concurrent presence of other health problems, and characteristics of more severe and progressive disease. The most common causes of death are cardiovascular disease, cancer and infection. Again, the underlying unifying pathology is generalized severe ongoing inflammation. Some of the more effective treatments for this disease may also have serious side-effects that contribute to its mortality.
A 62 year old woman who was diagnosed with rheumatoid arthritis about 10 years ago. She is currently working full-time and plays golf once a week. She has occasional joint discomfort that responds to ibuprofen, and has required no other treatment. This can be Standard Plus.
A 55 year old year old woman who has had rhematoid arthritis for several years. She is active in her community and participates in several volunteer organizations. She is limited by occasional diffuse joint pain and stiffness that have improved considerably with the use of methotrexate and a biologic agent. This can be Table 2.
A 58 year old man who has been unable to work for the past three years due to severely deformed joints resulting from rheumatoid arthritis that began in his early 20s. He has undergone several joint replacements as well as cervical spine surgery for instability due to rheumatic involvement. He has recently experienced increasing shortness of breath, and his physician has been unable to determine whether his lungs have been affected by rheumatoid arthritis, its treatment with methotrexate, or perhaps both. This would be a decline.