Rheumatoid Arthritis (RA) is a chronic, progressive, autoimmune disease characterised by inflammation of the peripheral joints of the hands, wrists, elbows, shoulders, hips, knees and feet, usually on both sides of the body.

Damage is caused by persistent inflammation of the synovium, the membrane lining the joint, with subsequent damage or destruction of the cartilage, bone erosion and joint deformities. Unfortunately, once cartilage and joints have been damaged by inflammation, they don’t heal well, so much of the treatment of RA is aimed at suppressing the inflammation so typical of the condition.

Although normally confined to the joints, rheumatoid arthritis may affect other systems such as the lungs, heart and nervous system, but this is rare. It’s now understood that there’s an immune reaction against the body's own synovial tissue, called an autoimmune reaction.

As is often the case with diseases of which the exact cause isn’t known, there’s no sure-fire way of preventing rheumatoid arthritis (RA).

Smoking has been shown to be a risk factor for the development of RA, and persistent smoking in people suffering from RA may predict a poorer outcome.

But with early diagnosis of RA, aggressive treatment is possible, by means of which the disease can be stopped or slowed down. This could prevent increased joint damage over a long period of time.

A healthy diet, the right kind of exercise, no excessive drinking, no smoking and trying to reduce your stress levels will all contribute to your general health, whether you have RA, or no

Treatment of rheumatoid arthritis

There are several treatment options available for rheumatoid arthritis.

It’s important to realise that theumatoid arthritis (RA) is a treatable condition, requiring urgent intervention at the earliest possible moment. It’s a medical problem and the specialist of choice is a rheumatologist.

Although alternative treatments such as omega-3 and omega-6 fatty acids may help to alleviate pain, there’s no scientific evidence to prove that they in any way modify the outcome of the disease.

Disease-modifying anti-rheumatic drugs (DMARDs) are the cornerstone of all therapy for RA and should be introduced as soon as possible in order to achieve remission. Remission is defined as the absence of any tender or swollen joints, or laboratory indicators of inflammation if you’re on treatment.

The goals of rheumatoid arthritis therapy are to:

Relieve symptoms such as pain
Reduce inflammation
Control the disease with early induction of remission to prevent joint damage
Preserve quality of life and your ability to function

Non-pharmocological therapies

Education, counselling and lifestyle changes

Education and counselling is important to help you understand your illness and how to cope with it. Your doctor will advise you to eat healthily, but that there’s no diet or supplement that can cure RA. You’ll be advised to stop smoking completely (if you do). Alcohol isn’t harmfull to RA, but it may increase your risk of liver problems when you’re using medications such as methotrexate.

Exercise and physiotherapy

Exercise and physiotherapy can help you to become more active. Exercises are aimed at maintaining muscle strength and joint mobility without exacerbating the joint inflammation.

Several kinds of exercise are used in managing RA, including range-of-motion exercise to improve joint motion, exercises to increase muscle strength, as well as exercises to build endurance (walking, swimming). A physiotherapist could assist you in designing an exercise programme that’s tailored to your specific needs. Foot orthotics and supportive footwear, made by a podiatrist, could also be very helpful.

Medications

(a) Relief of symptoms and reduction of inflammation

Painkillers (analgesics) such as paracetamol and tramadol are often used to relieve pain symptoms.

Non-steroidal anti-inflammatories (NSAIDs) such as diclofenac or naproxen are used to decrease pain and minor inflammation in RA. These should be used with caution due to possible side effects, including gatro-intestinal bleeding and an increased risk of kidney and heart problems.

Cox 2 selective anti-inflammatories (COXIBs) are effective, and they have fewer gastro-intestinal side-effects. These include celebrex and arcoxia. Note that these drugs should also be used with caution, especially if you have cardiovascular disease. It’s important to realise that these drugs don’t influence the effects of RA on the joints.

(b) Conventional disease-modifying anti-rheumatic drugs (DMARDs)

Early aggressive treatment with DMARDs is essential. These drugs reduce the amount of joint destruction and X-ray damage. Methotrexate is the most commonly used DMARD. Although developed as a chemotherapy drug, it’s extremely effective in treating RA and remains the backbone of most treatment programmes.

Chloroquine (Nivaquin), an anti-malarial drug, and sulphasalazine (Salazopyrine) are older drugs that are commonly used alone or in combination with methotrexate. Leflunomide (Arava) is a more expensive but powerful DMARD that’s often used when methotrexate fails to produce remission. These drugs all need several weeks to show improvement.

(c) Biological DMARDs

These are the most recent disease-modifying treatments for RA. Biologics, unlike traditional medicines made from chemicals, are derived from living organisms. They’re targeted against molecules on the cells of the immunological system and their inflammatory products, secreted in the joints.

Biologic therapies have revolutionised the treatment of many chronic diseases, such as RA. To manufacture these drugs is a very complicated and expensive process, hence the high cost of these medicines. There are several of these medicines available, targeting specific types of molecules, including the anti-TNF-alpha agents, tocilizumab, anakinra, abatacept, rituximab and tofacitinib. Discuss the options with your rheumatologist. These medications are often reserved for people who don’t respond or tolerate conventional DMARDs.

(d) Steroids (glucocorticoids)

Glucocorticoids have strong anti-inflammatory effects and are very useful for treatment of the symptoms while waiting for the disease-modifying drugs to work.

The steroids work rapidly to counter all aspects of the disease. Side effects are dose-dependent and it isn’t a good idea to use these medications on an ongoing, long-term basis. Persistent need for oral cortisone indicates incomplete control of the underlying disease and the need for more aggressive DMARD therapy.

Judicious injection of glucocorticoids either intramuscularly or directly into joints is helpful in controlling flare-ups of the disease. High doses of intravenous glucocorticoids are restricted for the potential life-threatening situation where there is systemic disease and organ involvement. In these cases, the drugs may be life-saving.

Surgery

Surgery can be helpful if there’s persistent inflammation of a single large joint such as the knee or wrist without severe joint damage. Performing a synovectomy can produce prolonged relief of symptoms.

Joint replacement surgery is reserved for individuals with severely damaged joints. The most successful procedures are carried out on hips and knees. Shoulder replacements are becoming more common, and even though they’re fairly rare, elbow replacements and replacements of the base of the thumb and the base of the big toe can be done to provide relief and restore functionality.

Rheumatoid arthritis is primarily a medical problem and surgery should be reserved for patients who are under the care of an experienced rheumatologist or physician.

Reviewed by Dr Stella Botha, rheumatologist at Groote Schuur Hospital, Cape Town (MBChB, MRCP, PhD).