Definition
Rheumatoid arthritis is a generalized disease which makes the joints of the body become inflamed and painful. It is a chronic disease and may also affect other parts of the body. It affects up to 2% of the population and is more common in females than males. It can start at any age from children to old age. However the most common age for the disease is between 30 and 50.

Causes
The cause of rheumatoid arthritis is unknown. However genetic factors involving tissue types is important. It has also been found that female hormones have some protective factor as the symptoms are improved in pregnancy and also when on the contraceptive pill.

The inflammation in rheumatoid arthritis is produced by the body’s own defence cells and unlike the inflammation in infection it does not stop of its own accord. The main inflammation is the lining of the joints called synovium. Once the joint is inflamed the cartilage and bone in the joint may be destroyed by the inflammation. This results in the joint becoming less stable and resulting in deformity.

Symptoms and Signs
The main symptoms are related to the changes in the joint in that the joints become swollen, tender and warm. The joints that are most commonly affected are in the hands, wrists, knees and feet. Often only one joint may be affected. The involved joint tends to have a decreased range of movement. Other signs of involvement are inflammation of the tendons, so-called tenosynovitis. There may be skin nodules and occasionally the rheumatoid arthritis affects other parts of the body. If the eyes are affected tear production is decreased resulting in the so-called dry eyes syndrome (Sicca syndrome). If the lung is affected it may cause interstitial lung disease (link) and fluid may accumulate between the pleura of the lung resulting in pleurisy.

Complications of the Disorder
Occasionally the disease may progress to involve the majority of the joints of the body leading to widespread acute arthritis which is very debilitating. If the inflammation continues this may result in an actual bacterial infection, so-called septic arthritis of the joint involved. Very rarely a rheumatoid arthritis will affect the kidneys leading to renal failure. Long term bone disorders such as instability of joints both in the long bones and in the spine can occur. Drug treatment of the condition itself may well lead to the development of inflammation of the stomach leading to active ulceration and blood loss, as well as occasional damage to the kidneys.

Tests
There is no test that is diagnostic of rheumatoid arthritis however doctors normally make the clinical diagnosis following a detailed examination and test. Blood tests may show that you are anaemic which affects around 80% of patients. There may also be changes suggesting inflammation in that the erythrosedimentation rate (ESR) is raised or indeed the C-reactive protein CRP. Specific blood tests of the immune system may be performed. The rheumatoid factor which is found in the blood is raised in 80% of cases. However, in early cases only 50% of patients will have a raised rheumatoid factor.

X-rays
X-rays will only show damage caused to the joints by the rheumatoid arthritis. However, one of the earliest changes detected are those affecting the joints of the feet.

Treatment
Treatment is primarily medical, the aim of which is to decrease the pain and symptoms and signs of inflammation and therefore hopefully prevent the progression of joint damage. This is also supplemented by physiotherapy and occupational therapy. Surgery is occasionally needed to correct any deformities in the joints.

Medication
Four types of drugs are normally used; analgesics, non-steroidal anti-inflammatories and disease modifying anti-rheumatic drugs, as well as steroids.

Analgesics
These are pain killers such as paracetamol related medication. These are primarily used to control the pain.

Non-steroidal anti-inflammatory drugs
NSAIDs are specifically given to reduce the pain and swelling and normally start working within a few hours. Side effects of these drugs are quite common in that they affect the stomach resulting in inflammation and occasional bleeding.

Disease modifying anti-rheumatic drugs
These are aimed specifically at reducing the effects of the disease themselves. They may well slow down the deterioration and the disruption of the joints. They may take many weeks to have an effect and not everyone with rheumatoid arthritis will require the medication. As these drugs can have significant side effects careful monitoring by doctors, including blood and urine tests are important. The more commonly used drugs are listed below.

• Gold
  Gold injections have been used for many years and are normally given weekly reducing in frequency as symptoms improve. Side effects do occur in that it may well affect the kidneys and therefore regular blood tests and urine tests are essential.
• Sulphasalazine
  This is normally taken by mouth. However side effects such as sickness may be short lasting.
• Penicillamine
  Once again this is taken by mouth. Side effects are very similar to that of gold, as well as occasionally affecting taste sensation.
• Methotrexate
  This drug was initially designed to attack cancer cells. It is normally taken in weekly doses and is normally reserved for the elderly or those that do not wish to have a family as it has a direct effect on the reproductive system.
• Azathioprine
  This suppresses the immunity and therefore as such care must be taken to see that the blood count does not decrease whilst on this treatment.

Steroids or corticosteroids
These are commonly used. They have a very powerful affect on inflammation. However when used for a long time they can have significant side effects in high dosage, the major one being osteoporosis. Steroids may be used in 3 ways. They may be given by mouth in low dosages to keep the inflammation under control. They may be injected into the inflamed joint. However, this can only be used a certain number of times. In extreme cases corticosteroids may be given by intramuscular or intravenous injection (pulses to damp down severe exacerbations of the disease).

Physiotherapy
Regular physiotherapy is aimed at increasing joint flexibility and therefore decreasing the pain. Swimming is an ideal form of exercise for rheumatoid arthritis as there is less strain on the joints. Many people find that the pain is worse first thing in the morning when the joints are stiff but once they have started to loosen up by exercise the pain and discomfort lessens. Regular exercise helps to retain movement and stops the muscles wasting away. It must be avoided if more joints become warm and swollen and associated with increased pain.

Outcome
Out of 100 people 75% continue to have some joint pain, swelling and flare-ups, 20% have very mild rheumatoid arthritis and 5% develop severe disease with extensive disability. Those who are greatly affected are normally female, with a high level of rheumatoid factor and persistently elevated blood tests such as the ESR and CRP, as well as those in whom the rheumatoid arthritis also affects other parts of the body apart from the joints. In severe cases joint replacement of the affected joints may be undertaken.