RA is a chronic autoimmune disorder that affects nearly 1.3 million Americans. It occurs worldwide and affects all racial and ethnic groups.¹ RA can develop in early childhood in the form of juvenile rheumatoid arthritis; however, the disease usually affects those in the prime of life — young to middle-aged adults like Sally Hirsch (see Clinical Vignette). RA is two to three times more common in women.^1-3 Hormonal factors are thought to play a role in RA. For example, RA symptoms may abate during pregnancy but flare again after pregnancy and during breastfeeding.^2,3

Although the severity of RA varies over time and from person to person, progressive development of joint destruction, deformity and disability are common outcomes. If untreated, 20% to 30% of people with RA are permanently unable to work within two to three years of diagnosis, and increasing joint destruction may eventually impair their ability to do basic activities of daily living.⁴ Once established, loss of joint function is generally irreversible except by surgery.⁴ Early recognition and appropriate treatment is key to preventing these consequences. The prognosis for people with RA has improved dramatically for newly diagnosed patients.⁴ The focus of this module is to help us understand how RA develops, characteristic symptoms, treatment strategies and interventions.

Joint Destruction, Systemic Involvement

A joint, formed where two bones meet, is enclosed by a joint capsule that protects and supports it. This joint capsule is lined with synovial tissue that produces fluid to lubricate and nourish the joint. The primary site of inflammation in RA is the synovium.¹ RA develops in three stages. In the first stage, the synovial lining becomes inflamed, causing pain, stiffness, redness and joint swelling. Next, granulation tissue begins to cover the entire joint surface, leading to the formation of pannus, a scar tissue that continues to erode and destroy joint structures.^1,3 In the third stage, the inflamed cells release enzymes that can destroy bone and cartilage, causing joints to lose their shape, which results in more pain and restricted joint movement.^1,2,3

RA is a rapidly developing disease that without appropriate intervention and aggressive therapy can quickly lead to irreversible joint destruction.4 Joint damage in RA is caused by the action of cytokines — biologically active proteins that are thought to cause joint inflammation and damage. Research has focused on specific cytokines, including tumor necrosis factor (TNF-alpha) and interleukin-6 (IL-6).³ Cell destruction results when these and other cytokines bind to cell receptors and activate the inflammatory process. These findings led to new pathophysiologically-based treatments, early intervention and a more encouraging outlook for people with RA.^1,3

RA is an autoimmune disease in which the immune system that normally serves a protective function attacks joint tissues. A person’s genetic makeup may increase RA susceptibility. The genetic marker HLA-DR4 is found in more than two-thirds of Caucasians with RA.³ Some scientists believe that environmental factors such as a viral or bacterial infection sets the disease process in motion.^2,3

RA can be differentiated from other forms of arthritis by several features. (Refer to the sidebar on RA classification criteria.) The most characteristic feature of RA is bilateral pain and swelling in the fingers and joints closest to the hands. With progression, the ankles, cervical spine, elbows, hips, knees and shoulders can be involved.^1,3 RA stiffness is typically worse in the morning, often lasting several hours. This is an important diagnostic clue as the pattern of a lengthy period of joint stiffness with rest is not characteristic of other forms of arthritis.¹

In addition to its effects on joints, RA is a systemic disease that can affect almost every body system. People with RA may experience fatigue, sporadic episodes of fever, general malaise, weight loss, anemia and lymph node enlargement. Common extra-articular, or outside the joint, manifestations of RA include Sjögren’s syndrome and rheumatoid nodules, which are small lumps of tissue under the skin that are seen in about 20% of people with RA.^2,3 People with Sjögren’s syndrome have a form of conjunctivitis that produces a gritty or burning feeling in the eyes, decreased tearing, itching and photosensitivity. Other systemic problems associated with RA include inflammatory eye disorders, pulmonary disease, vasculitis and cardiac abnormalities.^2,3 People with RA, especially those whose disease is not well controlled, may have an increased risk of cardiovascular disease and stroke.¹

The course of RA varies and is unpredictable. The uncertainty of knowing how one will feel from day to day is a significant challenge for people with RA. On one day patients with RA may feel well and the next day may have so much joint pain and swelling that they are unable to get out of bed.³ Disease exacerbations are known as flares and are followed by remissions, when disease activity is quiescent.^2,3 The diagnosis is made on the basis of the patient’s history and physical examination, together with laboratory and radiographic findings.

Although lab tests and imaging studies can help confirm the diagnosis and monitor disease progress, RA is primarily a clinical diagnosis, and no single laboratory test is specific for a diagnosis. Rheumatoid factor, an antibody that helps regulate normal immune system response, is elevated in about 70% to 80% of people with RA.⁴ The erythrocyte sedimentation rate (ESR) is significantly elevated. The red blood cell count and C4 complement component are often decreased. In addition, C-reactive protein may be elevated and the anti-nuclear antibody may also be positive.⁴ A low functional score early in the disease, lower socioeconomic status, rapid involvement of many joints, a high CRP level, a positive RF and early radiographic changes are associated with a poorer outcome.⁴

RA Treatment Goals

During the past 25 years, RA treatment has improved significantly.¹ Today’s treatment is directed at relieving pain, reducing inflammation, slowing down or stopping joint damage and improving a person’s sense of well-being and ability to function.^1,3 It is particularly important that patients with RA eat enough protein and calcium to prevent anemia. Eating small frequent meals, taking vitamins and consuming nutritious snacks can help provide the nutrients patients with RA need. People who take some types of arthritis medications may need to abstain from drinking alcoholic beverages to prevent liver damage.

People with RA can improve their health and maintain independence through appropriate exercises that protect joints.^2,3 A home program of joint range of motion and joint strengthening exercises are important in maintaining joint function. Therapeutic exercise that moves joints through their normal ROM and exercises to promote strengthening and endurance are important modalities for the treatment of RA.

The purpose of ROM exercises is to improve joint mobility. Many people with RA keep painful joints in a bent position because it feels more comfortable; however, joint contractures can develop quickly. Passive ROM exercises, done without any effort by the patient, can preserve joint mobility and prevent contractures. As joint inflammation decreases, the patient can perform active ROM exercises under the direction of a therapist.

Isotonic and isometric strengthening exercises preserve or improve the ability of muscles to do work. An isometric exercise, such as quadriceps setting, isolates and contracts the muscles without moving joints. Because they require repetitive joint motion, isotonic exercises in which the joint is moved are done carefully in people with RA.

For severely inflamed joints, splints can help resolve inflammation and keep joints in a functional position. In addition to keeping joints flexible, improving muscle strength and increasing the patient’s ability to do daily activities, regular exercise improves overall health by decreasing the risk of osteoporosis, increasing energy level, promoting sleep, helping with weight control, reducing depression and improving self-esteem and well-being.² The Arthritis Foundation sponsors the PACE (People with Arthritis Can Exercise) program; patients participate by attending classes or doing video exercises at home.

Medications and RA

Medications are an important part of RA management; they both relieve symptoms and modify the course of the disease. In the past, patients diagnosed with RA were treated conservatively. It is now known that potentially irreversible damage occurs early in the course of RA. Therefore, early treatment of RA with aggressive drug therapy is used to slow the process that leads to joint damage.^1,3

Analgesic drugs are used specifically to relieve pain. Rheumatogists recommend acetaminophen as a first-line drug for RA pain because it is safe when taken in limited doses, effective and inexpensive.⁵ Physicians may also prescribe products that contain acetaminophen with opioid analgesics, such as oxycodone with acetaminophen (Percocet), or propoxyphene with acetaminophen (Darvocet). Long-acting opioids, such as oxycodone (OxyContin) or transdermal fentanyl (Duragesic), may be used to treat severe RA pain.

Non-steroidal anti-inflammatory drugs are widely used to treat RA symptoms. The three types of NSAIDs — traditional NSAIDs, salicylates and COX-2 inhibitors — work by blocking prostaglandins, substances that produce pain and inflammation. Traditional NSAIDs include about 20 drugs; three are available in reduced strength nonprescription forms. All traditional NSAIDs, including prescription and over-the-counter (OTC) formulations, can cause gastrointestinal distress and bleeding. NSAIDs, including COX-2 inhibitors, reduce pain and inflammation quickly, but don’t prevent progressive joint damage.

Acetylated salicylates such as aspirin, when taken in large doses to control RA symptoms, can also cause gastrointestinal damage. Nonacetylated salicylates are formulated to have fewer adverse effects than aspirin. Patients who take more than 3,600 mg of any form of salicylates should have their salicylate levels monitored regularly.^2,3

RA patients should talk to their physicians about how to relieve joint pain and inflammation while minimizing the risk of cardiovascular or gastrointestinal adverse effects. Disease-modifying antirheumatic drugs relieve RA symptoms and modify the disease process by suppressing the immune system. As part of an aggressive treatment approach, the American College of Rheumatology recommends that DMARDs be started within three months of an RA diagnosis.¹ DMARDs include drugs such as cyclophosphamide (Cytoxan), hydroxychloroquine sulfate (Plaquenil), methotrexate (Rheumatrex, Folex), leflunomide (Arava), sulfasalazine (Azulfidine), azathioprine (Imuran), oral gold (Auranofin), intramuscular gold (Myochrysine), minocycline (Minocin Dynacin) and cyclosporine (Sandimmune, Neoral).^1,2,3

Drugs known as biologic response modifiers target parts of the immune system that lead to inflammation and joint and tissue damage.¹ These drugs can stop the RA disease progress and produce a long-lasting remission. The BRMs adalimumab (Humira), etanercept (Enbrel) and infliximab (Remicade) block TNF. Rituximab (Rituxan) is a selective B-cell inhibitor. Anakinra (Kineret) and Abatacept (Orencia) inhibit IL-1.^2,3 Combination drug treatment with the DMARD methotrexate and a BRM shows promise in controlling RA symptoms.²

Because BRMs must be given by muscular injection or intravenous infusion, research is under way to find medications that can be given orally. Corticosteroids, such as betamethasone (Celestone), dexamethasone (Decadron) and prednisone (Deltasone), are some of the most effective and fast-acting drugs to treat RA symptoms. They may be used as bridge or interim therapy while slower-acting DMARDs take effect.³ To maximize the benefits and reduce the risk of the adverse effects of corticosteroids, such as cataracts, diabetes, hypertension, immunosuppression and osteoporosis, they are prescribed in doses as low as possible for short periods of time and gradually tapered before being discontinued.³ The American College of Rheumatology regularly publishes recommendations for the use of nonbiologic and biologic disease-modifying drugs for RA treatment.

When medications can’t prevent unacceptable pain levels, loss of ROM or functional limitations caused by joint destruction, surgery may be performed. Surgical procedures such as joint replacement, tendon reconstruction and synovectomy can reduce pain and improve a person’s ability to perform daily functional activities.³

Drugs Used to Treat RA^1,2,3

• Analgesics
• NSAIDs
• DMARDs
• BRMs
• Corticosteroids

Our Focus

Based on our knowledge about the RA disease process, we identify and manage health issues for our patients with RA such as pain management, stiffness fatigue, self-care abilities and decisions, physical mobility, patient and family coping skills and alterations in self-concept.⁷ We should also be aware of how personal characteristics, family dynamics and ethnocultural diversity affect our patients’ perception of their illness.^6,7

RA treatment and management depends on collaboration between patients and their healthcare team, which usually includes the primary physician, nurse, occupational therapist, physical therapist, psychologist, rheumatologist and social worker.⁷ Our focus is to help patients live a healthy and satisfying life with RA. Through education, we can help patients and families understand the RA disease process and its effects on the family and to appreciate the chronic and unpredictable nature of the disease.⁷

Patient education is the foundation of RA management. We play a key role in helping people learn important self-care and self-advocacy skills. We can assess learning readiness, prioritize learning needs as well as design, implement and evaluate the effectiveness of a comprehensive educational plan.⁶ Pain is often a primary patient concern; fortunately, a number of strategies can be used to help manage pain. RA pain is caused by several factors, including the inflammatory process that causes joint swelling, damage to joint tissues from the disease process and stiffness, particularly upon waking.

Fatigue and sleep deprivation may make pain seem worse and more difficult to control.^2,3 OTC topical creams containing capsaicin may temporarily relieve pain. Capsaicin is an alkaloid derived from plants and is the active ingredient in hot peppers. Capsaicin decreases substance “P,” interrupting the transmission of pain signals from peripheral neurons to the brain.² Using heat and cold can reduce RA pain and stiffness. Cold packs used during a flare can help reduce inflammation and swelling. Dry or moist heat can relax muscles and stimulate circulation.² The disabling effects of early morning stiffness can be relieved by taking NSAIDs, using an electric blanket before getting out of bed or taking a warm bath to loosen joints.

A chronic disease such as RA may produce feelings of powerlessness. Patients who can learn to view their relationship with RA as an evolving partnership have better physical and psychological outcomes than those who view RA as the “enemy.”⁷ An important intervention for powerlessness is to increase patients’ participation in decision-making by allowing them as many choices as possible. Knowing about RA, its typical course, the appropriate treatment and ways to promote well-being helps prevent feelings of powerlessness.⁷ We can also help patients exercise control by suggesting that they keep a medication notebook to record essential medication information that can be given to other healthcare providers, such as dentists, other medical specialists if they are hospitalized.⁷

Encouraging patients to use positive coping strategies — such as seeking out information and support, finding strength through spiritual practices, verbalizing feelings and concerns, setting realistic goals and expressing positive thoughts — is a therapeutic intervention.⁷ We should encourage patients considering complementary and alternative medicine strategies to inform their physicians and advise them about how to evaluate claims about arthritis remedies.

An important, but often overlooked, aspect of coping is sexual expression for patients with a chronic disability such as RA. We can help patients by exploring with them broader expressions of sexuality, such as open communication and touch, and suggesting strategies such as taking a warm bath and pain medication before engaging in sexual activity, using positions that enhance comfort and timing sexual activity after rest.⁷

The Arthritis Foundation provides useful material for people with RA, including its award-winning Arthritis Today magazine, which contains consumer-oriented information about alternative therapies, exercise, nutrition, research and treatments. It’s important for people with RA to know that although there is no cure for RA, it can be controlled by exercise, joint protection, medications and self-management. The Arthritis Self-Help Course, offered by the Arthritis Foundation, is a self-management program that provides information about RA and its treatment, exercise and relaxation, problem-solving strategies and effective communication between patients and healthcare providers. This program has helped people with RA understand the disease process, reduce their pain while remaining active, increase their coping skills and gain a sense of confidence in their ability to lead full, active and independent lives.³ The American College of Rheumatology offers a number of Patient Facts Sheets and other valuable information about RA and its treatment.

The future of RA treatment depends on developing biomarkers that can identify which medication regimen will be most effective for individual patients.8 To achieve this goal, researchers are developing patient registries that provide data about biological and treatment information for large numbers of patients. The National Institutes of Health sponsors the Treatment Efficacy and Toxicity in Rheumatoid Arthritis Database and Repository (TETRAD). This initiative is in 10 centers across the country where data and genetic information are collected. The Arthritis Foundation funds the Arthritis Internet Registry. The goal of AIR is to enter data from thousands of people with RA.⁸ We can encourage people with RA to consider participating in these projects, the goals of which are to improve understanding of RA and, potentially, to realize a more effective treatment.

Gannett Education guarantees this educational activity is free from bias.