Rheumatoid Arthritis

What is it?

Overview

What Is It?
Rheumatoid arthritis (RA) is an autoimmune disease that occurs when the body's immune system attacks and damages the joints and, sometimes, other organs.

Rheumatoid arthritis (RA) is a chronic and potentially debilitating inflammatory disease that causes pain, swelling, stiffness and loss of function in the joints.

According to the Arthritis Foundation, RA affects about 1.3 million Americans, mostly women; two to three times more women have RA than men, and the number of women with the disease appears to be increasing. The age of onset can vary, but it typically occurs between ages 30 and 50, with the risk increasing as a person ages. The good news is that new advancements in treatment that have made it possible to slow or stop the progression of RA.

Unlike the more common osteoarthritis, which is mainly a disease of the cartilage in joints, RA occurs when the body's immune system attacks and damages the joints and, sometimes, other organs. RA often occurs in a symmetrical pattern, meaning that if one knee or hand is involved, the other one is, too.

The condition is considered an autoimmune disease. Such diseases are characterized by an immune-system attack on the body's healthy tissues. In RA, white blood cells travel to the synovium (the membranes that surround joints) and cause inflammation, or synovitis. The ensuing warmth, redness, swelling and pain are typical symptoms of rheumatoid arthritis, which usually affects the wrists, fingers, knees, feet, and ankles.

The continuous inflammation associated with RA gradually destroys cartilage, which coats the end of the bones. This narrows the joint space and eventually damages bone. The surrounding muscles, ligaments and tendons that support and stabilize the joint also become weak and unable to work normally.

Symptoms can include fatigue, occasional fever, morning stiffness, difficulty moving a joint or several joints, pain and inflammation in or around a joint and a general sense of malaise.

Rheumatoid arthritis varies from person to person, but most cases are chronic, meaning they never go away. Some people have mild or moderate disease, with flares (periods of worsening symptoms) and remissions. For others, the disease is active most of the time. The resulting joint damage can be disabling.

The disease can affect more than just the joints, bones and surrounding muscle. About one-quarter of those with RA develop rheumatoid nodules. These are bumps under the skin that often form close to the joints. Many people with rheumatoid arthritis develop anemia. Other effects, which occur less often, include neck pain and dry eyes and mouth. Very rarely, RA results in inflammation of the blood vessels, the lining of the lungs, or the sac enclosing the heart. If you have RA, you may also be at increased risk for infections and gastrointestinal ailments.

Although no one knows the causes of rheumatoid arthritis, it seems to develop as a result of an interaction of several factors, including genetics, environment and hormones.

Diagnosing and treating rheumatoid arthritis can sometimes be difficult. It may require a team effort between you and several types of health care professionals, including a rheumatologist, a physician who specializes in arthritis and other diseases of the joints, bones and muscles. Physical therapists, psychologists and social workers can also play a role.

Rheumatoid arthritis can be devastating, but current treatment strategies can help you cope and possibly reduce the impact of the disease. These strategies can include pain relievers and other medications, rest, appropriate exercise, education and support programs.

The psychological element is important: Some studies indicate that if you are well informed about your condition and participate in your own treatment plan, you will probably have less pain and make fewer visits to your health care professional than otherwise. You can find treatment support groups in many cities.

Diagnosis

Diagnosis

Rheumatoid arthritis (RA) can be difficult to diagnose in its initial stages, but an early diagnosis can be crucial to limiting its progress and severity. Some studies indicate that rheumatoid arthritis causes the most joint damage in the first two years.

There is no single test to determine if you have RA. The symptoms often are similar to those of other types of arthritis and joint conditions. The types of symptoms you experience—and the severity—may differ markedly from those of another person with RA. To make matters more confusing, symptoms can vary in the same person: Symptoms develop over time, and only a few may be present in the early stages of RA.

Often, RA is diagnosed by recognizing the type and pattern of joint involvement; it is a hallmark of RA, for example, if the same areas are affected symmetrically on both sides of the body.

The typical symptoms of RA include:

• tender, warm and swollen joints

• symmetrical pattern

• joint inflammation often affecting the wrists, fingers, knees, feet and ankles

• fatigue

• occasional fever

• a general sense of malaise

• pain and stiffness lasting for more than 30 minutes in the morning or after a long rest

• rheumatoid nodules (bumps under the skin—often formed close to the joints—that affect about a quarter of those with RA)

Less common symptoms can include neck pain and dry eyes and mouth. Very rarely, RA may cause inflammation of the blood vessels, the lining of the lungs or the sac enclosing the heart.

If you have any of these symptoms, you should visit a health care professional. He or she will take several elements into consideration before rendering a diagnosis:

• Medical history. Your description of the symptoms—including their duration and intensity—can help with the diagnosis.

• Physical examination. Your health care professional will do a physical exam and pay particular attention to your joints, skin, reflexes and muscle strength.

• Laboratory tests. Some lab tests can help establish the presence of RA. Your health care professional will probably order a test to detect rheumatoid factor (an antibody eventually present in the blood of most people with rheumatoid arthritis). It's inconclusive, however, since not all people with RA test positive for rheumatoid factor, especially in the early stages. Some people with other types of rheumatic disease and a small number of healthy individuals also have a positive rheumatoid factor test, so you could test positive and never develop the disease. A test called anti-cyclic citrullinated peptide, or anti-CCP, is now available and might be somewhat more specific than rheumatoid factors. Specificity is much higher when both tests are positive. Other common tests include one that indicates the presence of inflammation in the body (the erythrocyte sedimentation rate and the C-reactive protein), a white blood cell count and a blood test for anemia.

• X-rays. These can help determine the extent of joint destruction. If you identify RA in its early stages, X-rays may not be helpful in diagnosis. However, they can be used to monitor the disease's progress. Other imaging techniques, such as MRI and ultrasound, also may be used to assess inflammation and joint damage.

Treatment

Treatment

Treating rheumatoid arthritis means, for the most part, relieving symptoms and slowing the disease's progress. Although there is no cure, you and your health care professional can develop strategies for managing the disease. You'll probably use a variety of approaches, but all have the same basic goals: relieve pain, reduce inflammation, slow (or even stop) joint damage and improve your ability to function.

In addition to the guidance of your primary health care professional, you may need care from a physical therapist, a rheumatologist (a physician who specializes in diagnosing and treating disorders that affect the joints, muscles, tendons, ligaments and bones) or an orthopedist.

When symptoms occur, you can take steps to lessen their severity. Protecting your joints from undue stress can help. You may find that using a splint around a painful joint (generally wrists and hands) helps reduce pain and swelling. The splint supports the joint and lets it rest. Your health care professional can help you obtain a properly fitting splint. You may want to talk to him or her about self-help devices that can reduce stress on the joints while you participate in everyday activities. Zipper pullers, long-handled shoehorns and products that help you get on and off chairs, toilet seats and beds can all ease the strain on your joints.

Most likely, your treatment plan will include medications to relieve pain and/or reduce inflammation. Although there is no cure, disease-modifying antirheumatic drugs (DMARDs) may slow or stop the course of the disease. In the past, health care professionals often hesitated to prescribe these strong drugs until the disease had become relatively advanced. However, this approach has changed, especially for those who suffer from severe, rapidly progressing rheumatoid arthritis. Many health care professionals believe that early treatment with more powerful drugs and the use of drug combinations is the best way to halt RA's progression and reduce or prevent joint damage.

The following are commonly used rheumatoid arthritis medications:

• Analgesics. Analgesics are drugs that provide pain relief, and they can be used either orally or topically in people with RA. Analgesics include topical capsaicin (Capsagel), oral acetaminophen (Tylenol), tramadol (Ultram), and the more potent narcotics oxycodone (OxyContin) and hydrocodone (Vicodin). Narcotics are usually discouraged in the treatment of rheumatoid arthritis, however, because of the long-term nature of the condition and the danger of dependence.

• Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs such as aspirin, ibuprofen, ketoprofen and naproxen help diminish pain, swelling and inflammation. However, each NSAID is a different chemical and can have different effects in the body.
  
  NSAIDs may cause side effects including ringing in your ears, bruising, heart problems, gastric ulcers, stomach irritation, and liver and kidney damage. The longer you use NSAIDs, the more likely you are to have side effects, and the more serious those effects can be. Many other drugs cannot be taken with NSAIDs—in particular, the blood thinner warfarin (Coumadin. NSAIDS should be used with caution in people over 65 and in those with any history of ulcers or gastrointestinal bleeding, congestive heart failure, renal insufficiency and hypertension. Even the nonprescription, over-the-counter forms of these medications have the same risks. It's important to ask your health care professional for safety information associated with pain relievers with your personal health history in mind.
  
  A newer NSAID (called a COX-2 specific inhibitor) inhibits an enzyme (COX-2), which triggers pain and inflammation, while sparing an enzyme called COX-1, which helps maintain the normal stomach lining. The COX-2 inhibitor celecoxib (Celebrex) is sometimes prescribed for rheumatoid arthritis, osteoarthritis and other pain-causing conditions, such as acute pain and menstrual cramps. Celebrex is currently the only COX-2 inhibitor on the market. Celebrex may increase the risk of heart attack and stroke; discuss these risks with your health care professional. And if you are currently taking Celebrex and think you are having an allergic reaction or have other severe or unusual symptoms while taking any NSAID, call your health care professional immediately. For more information on the risks associated with Celebrex, visit www.fda.gov.

• Disease-modifying antirheumatic drugs (DMARDs). Also called slow-acting antirheumatic drugs or second-line drugs, DMARDS help alter the course of the disease and prevent joint and cartilage destruction. They can produce significant results. You may need to wait weeks—even months—before seeing any effect, and you may use some or all of these, depending on the specifics of your condition. In some cases, one DMARD is used by itself. In other cases, more than one DMARD may be prescribed at the same time. You may have to try different medicines or combinations to find one that works best with the fewest side effects.
  
  The most common DMARDs are: methotrexate (Rheumatrex, Trexall), sulfasalazine (Azulfidine), hydroxychloroquine (Plaquenil), leflunomide (Arava), cyclosporine (Sandimmune, Neoral) and minocycline (Dynacin, Minocin). Less commonly used is azathioprine (Imuran, Azasan). People taking methotrexate and most other DMARDs need periodic monitoring to make sure that toxicity to the liver or bone marrow does not occur. Although there is clearly a potential for toxicity of a powerful drug like methotrexate, it actually has a remarkable safety profile in RA and can be taken continuously for many years. Side effects of DMARDS vary greatly but may include nausea or vomiting, diarrhea, heartburn, high blood pressure, sun sensitivity, rash, temporary hair loss, damage to the retina, liver or kidney damage, lung infections and bone marrow suppression.
  
  Pay attention to how your body responds to these drugs. Not only do you need to make sure the medications are effective (since efficacy can occasionally diminish over time), you also need to be alert to any problems arising from the drugs.

• Immunosuppressants. These drugs help restrain the overly active immune system that causes RA. This class of drugs includes azathioprine (Imuran, Azasan), cyclosporine (Neoral, Sandimmune, Gengraf) and cyclophosphamide (Cytoxan). These drugs can be effective, but they also can prove extremely toxic and often have severe side effects including an increased risk of infection and even a possible increased risk of cancer. Again, close monitoring and lab tests, including liver-function tests, are advisable.

• Corticosteroids. Also known as glucocorticoids, corticosteroids such as prednisone and methylprednisolone (Medrol) reduce inflammation and pain and may slow joint damage from RA. Because they can cause dramatic improvements in a very short time, health care professionals often use them while waiting for DMARDs to kick in, and then may gradually discontinue use. They may be an option if your RA doesn't respond to NSAIDs and DMARDs. These medications also have serious side effects, especially at high doses, including increased bruising, thinning of bones, weight gain, onset or worsening of diabetes, cataracts and a round face.
  
  Rheumatoid arthritis can increase bone loss, leading to osteoporosis. This bone loss is more likely in people who use corticosteroids. To keep your bones as strong as possible, use the lowest possible dose of corticosteroids for the shortest amount of time, consume at least 1,000 to 1,200 milligrams of calcium and 400 to 1,000 IUs of vitamin D a day and talk to your doctor about medications called bisphosphonates, such as alendronate sodium (Fosamax) and ibandronate sodium (Boniva), that can help reduce bone loss.

• Biologic response modifiers. These are proteins that must be administered by injection. These drugs are designed to prevent or reduce joint-damaging inflammation, and they have demonstrated remarkable efficacy in some cases. The most commonly used agents block and inactivate a protein called tumor necrosis factor, or TNF-alpha, that is involved in the cascade of immune responses that cause inflammation in people with RA. Other biologic response modifiers target different molecules involved in the inflammation process—interleukin-1 (IL-1) and cell surface molecules on T and B lymphocytes.
  
  There have been very rare reports of serious nervous system disorders such as multiple sclerosis, seizures or inflammation of the nerves of the eyes, and serious infections, including sepsis and tuberculosis, with the TNF-inhibitors. The risk of tuberculosis has been greatly decreased with pre-therapy screening of TB skin tests and/or chest x-rays and treating with anti-TB drugs if these tests are positive.
  
  Additionally, there is some evidence that people treated with TNF inhibitors might have a somewhat higher risk of lymphomas. Although you need to be aware of these risks, it is equally important to recognize that the benefits can be substantial. The following TNF inhibitors have been approved for use in the United States:

  • Etanercept (Enbrel) is a genetically engineered protein that helps reduce symptoms and inhibits the progression of structural damage in people with moderate to severe RA who have not responded well to other treatments. It can also be used in combination with methotrexate if methotrexate alone isn't doing the job. The usual side effects are injection site reactions that include redness, itching, bruising or pain, upper respiratory infections and allergic reactions.

  • Infliximab (Remicade) is an antibody-based TNF therapeutic that is often used in combination with methotrexate. It is effective for the symptoms as well as for inhibiting the progression of structural damage in people with moderately to severely active rheumatoid arthritis who have not responded well to methotrexate. The drug is given intravenously at intervals of two to eight weeks. Side effects include allergic reactions, upper respiratory infections and reactivation of tuberculosis.

  • Adalimumab (Humira) also reduces symptoms and inhibits the progression of structural damage in adults with moderately to severely active RA. Humira is administered every one to two weeks by subcutaneous injection and can be used by itself or with methotrexate. Side effects are similar to those associated with etanercept.

  • Certolizumab pegol (Cimzia) is a drug developed for the treatment of Crohn's disease that is also approved for people with moderate to severe RA that hasn't responded to conventional treatments. It can ease pain, stiffness and fatigue in people with RA within two weeks. Cimzia works by targeting the inflammatory compound TNF-alpha. It is given via injection every two to four weeks, either alone or together with methotrexate.

  • Golimumab (Simponi) is an anti-TNF drug given as a once-monthly injection. Together with methotrexate, it helps ease symptoms in people with moderate to severe RA.

  Tocilizumab (Actemra) is a biologic response modifier that inhibits interleukin-6. It was recently approved for the treatment of RA in patients who haven't responded to one or more TNF-inhibitors.
  
  Abatacept (Orencia) is another biologic response modifier used in the treatment of RA. It works similarly to Rituxan but targets T-cells instead of B-cells. Similarly to Rituxan, it is usually only recommended for people with moderate to severe RA who haven't responded to methotrexate or anti-TNF drugs.

• Rituximab (Rituxan) is a cancer drug that works by targeting immune cells involved in inflammation known as CD20-positive B-cells, which are believed to contribute to RA. Rituxan is recommended for people with RA who haven't responded to TNF-inhibitors and is usually given along with methotrexate. Side effects include flu-like symptoms, such as fever, nausea, chills and infections.

• Anakinra (Kineret) is a drug in a class called human recombinant IL-1 receptor antagonists, and it works by blocking interleukin-1 (IL-1), a protein present in excess in people with RA. By blocking IL-1, anakinra modestly inhibits the inflammatory response, reducing pain. It is significantly less potent than TNF inhibitors in most people with RA and is rarely used. Anakinra is given as a daily self-administered injection under the skin. Potential side effects include decreased white blood cell count, an injection site reaction, headache and an increase in upper respiratory infections, especially in people who have asthma or chronic obstructive pulmonary disease. Anakinra may be used with DMARDs, but it cannot be used at the same time as anti-TNF agents due to the risk of infection.

If you are taking a biologic response modifier and have an infection severe enough to require antibiotics, the biologic should not be given until the infection is gone.

If you are using DMARDs or biologics, you should not receive live-virus vaccinations. Discuss how to handle live-virus vaccinations with your health care provider.

Surgery may be an option if you have severe joint damage. In the right circumstance, it can help reduce pain, improve the affected joint's function and appearance and enhance your ability to perform daily activities. However, surgery is not right for everyone, and you and your health care professional need to discuss the best approach. Factors to consider include your overall health, the condition of the joint or tendon that will be operated on and cost of the surgery.

A common type of surgery prescribed for people with RA is joint replacement, which replaces your damaged joint with an artificial one. One thing to consider is that the artificial joints can wear out, necessitating additional surgery.

Tendon repair, most frequently performed on the hands, is a surgery that repairs overly loose or tight tendons around a joint.

In synovectomy, the inflamed synovial tissue is removed. Synovectomy is performed if the lining around your joint (synovium) is inflamed and causing pain.

RA may also require joint fusion (arthrodesis) or the surgical fusion of a joint to stabilize or realign it for pain relief in cases where joint replacement isn't possible.

ClinicalTrials.gov, a service of the National Institute of Health, provides easy access to information on clinical trials for a wide range of diseases and conditions, including rheumatoid arthritis. The Web site is located at www.clinicaltrials.gov.

What You Can Do to Combat RA Symptoms

While health care professionals must be involved in your care, there are a number of lifestyle changes you can make to help manage RA. Experts suggest that eating a healthy diet can enhance your overall health and thus help you better manage your RA. Although drinking has no known impact on the disease itself, you may need to avoid alcoholic beverages, depending on the RA medications you are taking, especially the often-prescribed methotrexate. Check with your health care professional. Stress reduction is also important, since your stress level may affect the amount of pain you feel.

Rest and exercise—seemingly opposite ends of the spectrum—are important to your health. When your RA is active, you will want more rest. But exercise is critical to healthy muscles, joint mobility and flexibility. (Note: Discuss any exercise program with your health care professional before starting.)

While exercise may seem unappealing if you're experiencing frequent pain, there are a number of techniques to help you get through a program:

• Moist heat supplied by warm towels, hot packs, a bath or a shower can be used at home for 15 to 20 minutes three times a day to relieve symptoms. Applying heat before exercise can be a good way to start. A health care professional can apply deep heat using short waves, microwaves and ultrasound to relieve pain.
• Cold supplied by a bag of ice or frozen vegetables wrapped in a towel helps stop pain and reduce swelling when used for 10 to 15 minutes at a time. This treatment often is recommended for acutely inflamed joints. Do not use cold treatments if you have numbness or poor circulation.
• Hydrotherapy (water therapy) can decrease pain and stiffness. Exercising in a large pool may be easier because water takes some weight off painful joints. Many community centers, YMCAs and YWCAs have water exercise classes developed for people with arthritis. You may also find relief from the heat and movement of a whirlpool.
• When performed by a trained professional, massage and manipulation (using the hands to restore normal movement to stiff joints) can help control pain and increase joint motion and muscle and tendon flexibility.

Although these types of physical therapy can temporarily relieve symptoms, none have documented anti-inflammatory effects or affect the rate of joint damage that can occur in RA.

Alternative Therapies for RA Pain Relief

• Relaxation techniques: Deep breathing, guided imagery and visualization (where you focus on "seeing" pleasant pain-free scenes or activities in your mind) and stress reduction help provide some pain relief. Physical therapists can teach relaxation techniques. The Arthritis Foundation has a self-help course that includes relaxation therapy; find out more about the Arthritis Foundation Self-Help Program at www.arthritis.org/self-help-program.php.
• Acupuncture: Acupuncture is an important component of traditional Chinese medicine that involves the insertion of thin needles at specific points, which are mostly along the body's nerve pathways, to improve health. A handful of small studies have been conducted on the use of acupuncture in RA, and the findings do not clearly answer the question of whether or not it works. Individuals who want to use acupuncture should discuss their interest with their health care team and only a licensed acupuncturist should be used.
• Thunder god vine: Studies indicate that preparations made from the peeled root of this plant, used in traditional Chinese medicine to treat inflammatory and autoimmune disorders, may be helpful in the treatment of RA. Possible side effects include menstrual changes, hair loss and diarrhea.
• Nutritional supplements: A few studies have shown that the nutritional supplement gamma-linolenic acid (GLA) and the fish oils eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) may help reduce some of the symptoms of RA. Discuss your interest or questions about such products and reports with your health care professional.
• Biofeedback: Biofeedback is a way to enhance an awareness of your body so that you become focused on how your body functions; usually this enhanced focus is turned toward something—such as muscle control—that typically occurs at a subconscious level. During biofeedback, an electronic device provides information about a body function (such as heart rate) so you can learn to control that function. Biofeedback may help people with arthritis learn to relax their muscles. In this case, an electronic device amplifies the sound of a muscle contracting, so you know that the muscle is not relaxed. The therapy is typically learned with the help of a health care professional and then may be practiced at home once you have mastered the technique, either with a biofeedback machine or without one.
• Some additional techniques under investigation include tai chi (a movement- based form of meditation) and cognitive behavioral therapy (a method of anticipating and preparing yourself for situations and bodily sensations that will cause pain).

With all of these treatments—lifestyle, medical and surgical—monitoring which treatments work and which don't and watching for side effects is critical. Monitoring can involve regular consultations with your health care professional as well as blood, urine and other laboratory tests and x-rays.

Prevention

Prevention

Genetic, environmental and hormonal factors probably all play a role in the development of rheumatoid arthritis (RA). However, there is no known way to prevent RA. Cigarette smoking is one environmental risk factor for RA that you can avoid.

Certain genes involved in immune system responses are associated with a predisposition for developing RA, although there is no single "rheumatoid arthritis gene." People with RA are more likely to have human leukocyte antigen (HLA) genes than people without the disease, and other genes also play roles in the development of RA. Having any of these genes is no guarantee that you'll develop RA (in fact, many individuals with this common gene do not develop the disease); likewise, the absence of these genes doesn't rule out the possibility of developing the disease. It appears that a person's genetic make-up is an important part of the story, but not the whole answer.

Facts to Know

Facts to Know

1. According to the Arthritis Foundation, rheumatoid arthritis affects approximately 1.3 million Americans, and two to three times more women have RA than men.

2. RA is considered an autoimmune disease. Such diseases are characterized by the immune system attacking the body's healthy tissues. Although RA affects other parts of the body, joint inflammation is the hallmark of this disease.

3. Although no one knows the precise causes of rheumatoid arthritis, it seems to develop as a result of an interaction of several factors, including genetics, environmental factors and hormones. A virus or bacterium could serve as the environmental trigger in people genetically susceptible to the disease.

4. Many researchers think a viral or bacterial infection may help trigger the development of RA. However, this remains unproven.

5. Rheumatoid arthritis appears to cause considerable joint damage in the first two years. An early diagnosis can be crucial in preventing the worst effects of the disease, especially since there are more effective treatment options today.

6. Common RA symptoms can include fatigue, occasional fever, morning stiffness, difficulty moving a joint or several joints, pain and inflammation in or around a joint and a general sense of malaise.

7. There is no single test you can take to find out if you have RA, although tests are used as part of the diagnosis.

8. Arthritis literally means joint inflammation, but the term often is used to refer to more than 100 rheumatic diseases that can affect children and adults. Osteoarthritis is the most common form.

Questions to Ask

Questions to Ask

Review the following Questions to Ask about rheumatoid arthritis (RA) so you're prepared to discuss this important health issue with your health care professional.

1. Do I have rheumatoid arthritis (RA)? How can you tell?

2. Can you rule out similar diseases, like osteoarthritis and lupus?

3. What are my treatment options?

4. How can I recognize a flare? What should I do when one occurs?

5. What drugs are available to help me? What are their benefits and side effects? Will these drugs interact with any other medications I am taking?

6. Can you recommend an exercise plan that is compatible with my stage of RA?

7. Should I try nutritional supplements like green tea and fish oils?

8. How far has my RA progressed? How does that affect the management plan you're recommending?

9. Can I benefit from starting therapy with disease-modifying anti-rheumatic drugs (DMARDs) early?

10. Are there any RA support groups in my area?

11. Are there any special devices that can help me stay as independent and active as possible?

12. What is methotrexate and how can it help me? How should I take methotrexate, and what are its risks? Are there any alternative drugs similar to methotrexate that I can try?

13. Should I take the selective COX-2 inhibitor Celebrex or one of the standard NSAIDs? What are the risks and benefits of both?

Key Q&A

Key Q&A

1. Why is rheumatoid arthritis (RA) sometimes called an autoimmune disease?

   Autoimmune diseases are characterized by an immune system attack on healthy tissues. In RA, white blood cells travel to the synovium (the membranes that surround joints) and cause inflammation, or synovitis. The ensuing warmth, redness, swelling and pain are typical symptoms of rheumatoid arthritis, which usually affects the wrists, fingers, knees, feet and ankles.

2. What causes rheumatoid arthritis?

   A combination of factors—genetic, environmental and hormonal—probably play a role in the onset of the disease. Those with a genetic susceptibility may develop RA when it is triggered by an environmental agent, perhaps a virus or bacterium, although no pathogenic agent has yet been identified. Hormones also appear to have a role.

3. Is RA preventable?

   No one has found a course of action that can prevent RA.

4. What can be done to reduce the pain or slow the disease?

   The symptoms of RA are highly treatable in most cases, and new research shows that the long-term outcome can be affected by how quickly the disease is diagnosed and treatment initiated. Consulting with your health care professional, you will find that there is a wide range of options—medical, surgical and lifestyle—available for modifying the disease and treating pain, swelling and other symptoms.

5. How can I find out if I have RA?

   The symptoms you describe to a health care professional are the foundation of an RA diagnosis. The most common symptoms are tender, warm, swollen joints; symmetrical pattern of pain; joint inflammation; fatigue; occasional fever; a general sense of malaise; pain and stiffness lasting for more than 30 minutes in the morning or after a long rest; and rheumatoid nodules (bumps under the skin). Because many of these symptoms are also indicative of other diseases (for example, lupus), your health care professional may recommend lab tests for those diseases or for confirmation of an RA diagnosis, as well as x-rays to detect any joint damage. A full medical history and physical exam are also part of a typical diagnostic workup for RA.

6. Is it safe to exercise if I have RA?

   Yes, although you should consult with a health care professional before beginning any new exercise regimen. Moist heat applied before an exercise session and a cold pack applied afterward can help alleviate pain. Exercising in a pool is also a good option for preventing joint stress during a workout.

7. Can diet make a difference in preventing or managing RA?

   There is no scientific evidence that any specific food or nutrient helps or harms most people with rheumatoid arthritis. However, an overall nutritious diet with enough—but not an excess of—calories, protein and calcium is important. Some studies have shown that the omega-3 fatty acids in certain fish or plant seed oils also may reduce rheumatoid arthritis inflammation. However, many people are not able to tolerate the large amounts of oil necessary for any benefit, and both fish oils and plant oils have side effects, including risk of bleeding and interactions with certain medications, including blood pressure medications and psychiatric drugs. More research is necessary to find the optimal dosage of fish and plant seed oils for the management of RA.

8. If I have the "RA gene," does that mean I will develop the disease?

   There is no single RA gene. People with specific human leukocyte antigen (HLA) genes are more likely to develop RA than people without them, and other genes also play a role in the onset of disease. Having any of these genes is no guarantee that you'll develop RA, and their absence doesn't rule out the possibility of developing the disease. It appears that a person's genetic makeup is an important part of the story, but not the whole answer.

Organizations and Support

Organizations and Support

For information and support on coping with Rheumatoid Arthritis, please see the recommended organizations, books and Spanish-language resources listed below.

American Autoimmune Related Diseases Association (AARDA)
Website: http://www.aarda.org
Address: 22100 Gratiot Avenue
East Detroit, MI 48021
Hotline: 1-800-598-4668
Phone: 586-776-3900
Email: aarda@aarda.org

American Chronic Pain Association
Website: http://www.theacpa.org
Address: P.O. Box 850
Rocklin, CA 95677
Hotline: 1-800-533-3231
Email: acpa@pacbell.net

American College of Rheumatology
Website: http://www.rheumatology.org
Address: 1800 Century Place, Suite 250
Atlanta, GA 30345
Phone: 404-633-3777

Arthritis Foundation
Website: http://www.arthritis.org
Address: P.O. Box 7669
Atlanta, GA 30357
Hotline: 1-800-283-7800

Bone and Joint Decade
Website: http://www.usbjd.org/index.cfm
Address: 6300 North River Road
Rosemont, IL 60018
Phone: 847-384-4010
Email: usbjd@usbjd.org

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)
Website: http://www.niams.nih.gov
Address: National Institutes of Health
Bldg. 31, Room 4C02 31 Center Dr. - MSC 2350
Bethesda, MD 20892
Hotline: 1-877-22-NIAMS (1-877-226-4267)
Phone: 301-496-8190
Email: niamsinfo@mail.nih.gov

250 Tips for Making Life With Arthritis Easier
by Shelley Peterman Schwarz

Arthritis 101: Questions You Have. Answers You Need
by The Arthritis Foundation

Arthritis Bible: A Comprehensive Guide to Alternative Therapies and Conventional Treatments for Arthritic Diseases
by Craig Weatherby and Leonid Gordin M.D.

Arthritis Sourcebook
by Amy L. Sutton

Autoimmune Connection: Essential Information for Women on Diagnosis, Treatment, and Getting On with Your Life
by Rita Baron-Faust and Jill Buyon

Exercise Beats Arthritis: An Easy-to-Follow Program of Exercises
by Valerie Sayce and Ian Fraser

Pain-Free Arthritis: A 7-Step Plan for Feeling Better Again
by Harris H. McIlwain and Debra Fulghum Bruce

Walk with Ease: Your Guide to Walking for Better Health, Improved Fitness and Less Pain
by Arthritis Foundation

American Academy of Family Physicians
Website: http://familydoctor.org/online/famdoces/home/articles/876.html
Email: http://familydoctor.org/online/famdoces/home/about/contact.html

National Institute of Arthritis and Musculoskeletal and Skin Diseases
Website: http://www.niams.nih.gov/Portal_en_espanol/Informacion_de_salud/Artritis/rheumatoid_artritis_ff_espanol.asp
Address: National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) / National Intitutes of Health
1 AMS Circle
Bethesda, MD 20892
Hotline: 1-877-226-4267
Email: NIAMSinfo@mail.nih.gov