Rheumatoid arthritis

You may feel stiff when you wake up in the morning. Many people only seek help from the doctor when the symptoms become more severe or more frequent.

For about 1 in 5 of those with rheumatoid arthritis the disease develops very rapidly, with pain and swelling in a lot of joints, severe morning stiffness and great difficulty doing everyday tasks.   

Although arthritis means inflammation of the joints, it's not just the joints that are affected. Along with pain and swelling in the joints you may feel tired, depressed or irritable, even with mild arthritis. Fatigue can be one of the most difficult aspects of rheumatoid arthritis for people to deal with.

A lack of red blood cells (anaemia) is very common – occasionally this can be a side-effect of drug treatments, but it's more often caused by the disease itself. Some people with uncontrolled rheumatoid arthritis lose weight, and many complain of hotness and sweating brought on by the inflammation. There may be inflammation in the eyes, and they can become dry and irritable.

Rheumatoid nodules may appear. These are fleshy lumps that usually occur just below the elbows, but may appear on hands and feet as well. If there is any doubt about the cause of the lumps, the doctor can remove a piece for examination under a microscope (this is known as a biopsy).

The genes we inherit from our parents may affect the likelihood of developing the disease, but genetic factors alone do not cause rheumatoid arthritis. Even the identical twin of somebody with rheumatoid arthritis, who shares all the same genetic material, only has a 1 in 5 chance of developing the disease. And even where members of the same family have rheumatoid arthritis the severity of the disease can be very different.

There is some evidence that lifestyle factors may affect the risk of developing the disease. For example, rheumatoid arthritis is more common in people who smoke, who eat a lot of red meat or who drink a lot of caffeine.

Rheumatoid arthritis is less common in people who have a high vitamin C intake.

While 'normal' inflammation dies down once the 'bug' that triggered it has been destroyed, in rheumatoid arthritis the inflammation becomes a long-term (chronic) process. We don't yet know exactly what sets off the inflammation in rheumatoid arthritis.

Inflammation causes the tough capsules that surround joints to stretch. When the swelling goes down the capsule remains stretched and can no longer hold the joint in its proper position. As a result the joint becomes unstable and this can lead to deformities of the joints. Some damage is done every time the joints are inflamed and once joints are damaged they don't heal properly. This is why most treatment aims to prevent joint damage by minimizing inflammation as early as possible in the disease.

Inflammation can sometimes affect the blood vessels, the lungs and, rarely, the membrane around the heart. People with rheumatoid arthritis are also more at risk of heart attack and strokes. This seems to be caused by the inflammation and the risk is probably reduced by controlling the disease.

Although the risk isn't very great, it needs to be taken into account along with any other risk factors such as high cholesterol and smoking. We would strongly recommend that you don't smoke if you develop rheumatoid arthritis.

Some people, maybe as many as 1 in 5, always have very mild rheumatoid arthritis that causes few problems. People in this group will usually have only minor damage to a small number of joints.

A few people, no more than 1 in 20, will have rheumatoid arthritis that becomes progressively worse, often quite quickly. These individuals are likely to have severe damage to many of their joints, and are also more likely to have inflammation in other parts of the body besides their joints.

Most people follow a pattern of flare-ups with periods of months or even years when there is little inflammation. There's likely to be some damage in a number of joints. People whose disease follows this pattern are likely to have some problems with their joints and may have to change their activities a little, but overall probably won't notice too great an impact on their lives.

Because rheumatoid arthritis can affect other parts of the body besides the joints it's important to tell your doctor about all the symptoms you've had even if they don't seem to be related.

Blood tests

Blood tests may show you are anaemic, a problem that affects about 8 out of 10 people with rheumatoid arthritis. They may also detect changes in your blood that are produced by inflammation. There are three tests to measure inflammation:

• erythrocyte sedimentation rate (ESR)
• plasma viscosity (PV)
• C-reactive protein (CRP).

Each of these may show a high value when inflammation is present. Which test is used depends on the laboratory your doctor uses.

Rheumatoid factor is a blood protein produced by a reaction in the immune system. About 8 out of 10 people with rheumatoid arthritis have positive tests for this protein. But the presence of rheumatoid factor can't confirm the diagnosis because some people who don't have rheumatoid arthritis also test positive for this protein. And only about half of all people with rheumatoid arthritis have a positive rheumatoid factor when the disease starts.

X-rays and other imaging techniques

X-rays will show any damage caused to the joints by the inflammation in rheumatoid arthritis. The changes caused by rheumatoid arthritis often show up in x-rays of the feet before they appear in other joints, so your doctor may want to x-ray your feet even if they aren't causing you any problems.

Early diagnosis is known to be an important factor in the successful treatment of rheumatoid arthritis, so doctors are evaluating imaging techniques such as magnetic resonance imaging (MRI) and ultrasound scanning to see how useful they are for diagnosing early disease and for monitoring its progress (see Figure 4).

Blood tests and x-rays are likely to be repeated at intervals to help your doctor assess how quickly your arthritis is developing, and whether you need any changes to your medication.

Rheumatoid arthritis drugs

Many people are worried about the possible side-effects of drugs. We have to accept that all drugs have side-effects, but for most people with rheumatoid arthritis, the benefits of drug treatment far outweigh any possible side-effects. 

Four main groups of drugs are used to treat rheumatoid arthritis:

• painkillers (analgesics)
• non-steroidal anti-inflammatory drugs (NSAIDs)
• disease-modifying anti-rheumatic drugs (DMARDs)
• corticosteroids.

Analgesics

These drugs are painkillers. They are not sufficient by themselves as a treatment for rheumatoid arthritis, but they are useful to 'top up' the pain-relieving effects of other, more specific, drugs. Paracetamol is most often used. It may be given by itself, or alongside codeine tablets, or as combination tablets.

Non-steroidal anti-inflammatory drugs (NSAIDs)

There are now about 20 drugs of this kind available. They reduce pain and swelling and start working within a few hours. The effect of some will only last a few hours but others are effective all day. Your doctor will help you to find the preparation and the dose that are right for you.

Disease-modifying anti-rheumatic drugs (DMARDs)

These drugs don't treat the symptoms directly and it takes longer, often weeks or months, before the benefits start to be felt. The drugs alter the way the disease progresses and slow down the damaging effects of inflammation on the joints, especially if they are started early on in the disease. Over a period of time this should bring improvements in the symptoms.

This group of drugs includes sulfasalazine, gold injections, penicillamine, methotrexate, azathioprine and leflunomide.

The newest DMARDs for rheumatoid arthritis are known as biological therapies. They target specific molecules involved in the processes of inflammation and joint damage.

Infliximab, certolizumab pegol, etanercept and adalimumab all target a substance called tumour necrosis factor (TNF). Anakinra inhibits one of the body's messenger substances called interleukin-1 (IL-1), and rituximab attacks a specific molecule on the surface of B-cells (which produce antibodies including rheumatoid factors).

Because biological therapies are relatively new drugs they are all monitored both for safety and to assess how well they are working. And we are still learning about the best ways of combining them with other treatments to give the most benefit.

Corticosteroids

Corticosteroids are often called steroids for short. They are not the same as the steroids used by athletes to build up their bodies (anabolic steroids). Corticosteroids have a very powerful effect in reducing inflammation. They can be given as injections into a joint, a vein or a muscle, or as tablets.

Surgery

This is occasionally needed to repair the damage caused by rheumatoid arthritis. Operations vary from quite minor ones such as the release of a nerve or a tendon to major surgery such as joint replacement.

The symptoms of rheumatoid arthritis tend to come and go with no particular pattern. Sometimes flare-ups have an obvious cause – either physical causes, such as unaccustomed physical exertion or another illness, or emotional trauma. Usually, though, there is no obvious trigger and this unpredictability makes it difficult to plan ahead.

Because of this unpredictability it's tempting to do all your jobs when you're having a good day. But overdoing things on the good days can be counter-productive, causing a flare-up of symptoms the next day. Pacing yourself is an important aspect of learning to live with rheumatoid arthritis. Make it clear to your family and friends that not all days are the same. It's important they realize that activities you enjoy on a good day may be impossible on a bad one.

Exercise

It's important to strike a balance between rest and exercise. Rest will make inflamed joints feel more comfortable, but without movement your joints will stiffen and your muscles will become weaker. You'll need to find out for yourself what the right balance is for you.

Exercise is good for your general health, so use your muscles and joints as much as you can without harming them. If a particular activity causes one or more of your joints to become warm and swollen, or if it causes severe pain then stop and rest. If not, you should be fine to continue. If a particular activity always causes a flare-up of symptoms then it’s probably best to avoid it and find an alternative.

Contact sports should be avoided, as should other vigorous types of exercise. Take great care choosing footwear for any sports you take part in. Good shoes with shock-absorbing soles are essential. And make sure you always warm up properly.

Swimming is particularly recommended – it exercises the whole body but with minimal strain on the joints because the water supports your weight.

If you go to a gym or health club, tell the fitness instructor about your disease so that an appropriate exercise plan can be developed for you. Your physiotherapist can advise you about this too. In general it’s best to avoid exercises involving hard impacts, such as step exercises. Aquaerobics (aerobics in a swimming pool) is suitable for most people. Click here for general advice and specific exercises that will help you keep active.

Diet and nutrition

There is a lot of publicity for diets that claim to cure rheumatoid arthritis. Unfortunately none do, although there is some scientific evidence that diets may help the symptoms in some people.

The diets most likely to help are low in saturated fats and high in unsaturated fats, especially fish oils. We recommend 3 grams of fish oil (i.e. fish body oil, not fish liver oil) daily. You can achieve this by eating oily fish, taking fish oil supplements, or a combination of the two.

Increasing your intake of vitamin C may also help.

There is some evidence that a very strict vegetarian diet can help, although the reasons for this aren’t clear. And there may be a small increase in the risk of rheumatoid arthritis among people who eat a lot of red meat. Speak to your doctor or a dietician before starting any strict diet as the disadvantages may outweigh the advantages.

Keeping to a healthy weight is strongly recommended. You put the equivalent of four times your body weight through your joints just walking, so keeping your weight down will help reduce the strain on your joints.

Occasionally some people with arthritis find that a specific type of food upsets them, but this is quite unusual. If you think you may have an intolerance to a particular food try removing it from your diet for about 3–4 weeks and then reintroducing it. If you do have an intolerance you will notice a flare-up in your arthritis within a few days. Click here for more information about elimination diets, as well as more general advice on diet, nutrition and nutritional supplements.

Complementary therapies

Many people with rheumatoid arthritis try herbal or complementary therapies . Unfortunately, the promises made by many of these remedies aren’t always realistic. Certainly none of them offers either a cure or a reduction in joint damage.

Herbal remedies are usually safe to use, but some may interfere with your anti-rheumatic medication. A good herbal practitioner will be able to advise you about this. Remember also that some herbal remedies can also have unpleasant side-effects. Be careful what you buy, as unfortunately some ‘traditional’ medications, especially Chinese remedies, sold in this country have been found to contain large quantities of steroids and other drugs.

Arthritis Research UK's review of the evidence on complementary therapies suggests that fish body oils (not fish liver oils) are the most likely to have a beneficial effect on the symptoms of rheumatoid arthritis. Evening primrose oil and borage seed oil may also offer some benefit, although the evidence for these is more limited.

More and more health professionals offer various kinds of complementary and alternative medicine, including acupuncture, homoeopathy, manipulation and aromatherapy. Many people find acupuncture helpful, and massage is often very soothing and relaxing, although there is little evidence that specific oils add any particular benefit.

Supports, aids and gadgets

It’s very important to protect your joints from unnecessary strain. An occupational therapist can give you detailed advice about adapting your technique to reduce strain, and also about ways of avoiding some tasks or using simple aids or adaptations to make them easier. A huge variety of gadgets are available to help with daily tasks whether at work, around the home or in the garden.

Sleep

Tiredness (fatigue) is an important aspect of this disease, and people with rheumatoid arthritis are also much more likely to suffer disturbed sleep than people who don’t have arthritis. Lack of restful sleep can make it all the more difficult to cope with the pain of arthritis. If you are not sleeping well the first thing to do is to work out why.

• Is it pain and stiffness during the night?
• Are you having difficulty winding down?

If it’s pain or stiffness, painkillers or a warm bath before going to bed may help. Check that your bed is supportive and comfortable, and if your neck and shoulders are stiff or painful try experimenting with different pillows.

If you’re having trouble winding down try to establish a relaxing bedtime routine. Avoid eating, drinking tea, coffee or alcohol, and smoking close to bedtime. Regular exercise should help you to sleep but don’t exercise within three hours of going to bed. Discuss your sleep problems with your doctor or a specialist nurse. Although doctors are reluctant to prescribe sleeping tablets for long-term use, they can be useful for short spells when lack of sleep is a serious problem.

Read more about the most common sleep problems and what can be done to help.

Sex and pregnancy

There’s no reason why you should stop having sex. You may find that some positions are more comfortable than others, so do experiment. And you may find that tiredness affects your desire for sex. Good communication with your partner is the key to resolving any difficulties.

Find out more on how arthritis and related conditions can affect relationships and sex.

It’s fine to take the contraceptive pill if you have rheumatoid arthritis. It will make no difference to your arthritis or its treatment. And with some rheumatoid arthritis treatments, such as methotrexate and leflunomide, it’s important to use reliable contraception.

There is no reason why you should not have a baby if you have rheumatoid arthritis, but it’s important to make sure you are not taking any drugs that could harm the baby. Discuss your plans with your doctor well in advance as you may need to change your medications some time before you start trying for a baby.

Most mothers with rheumatoid arthritis feel better during pregnancy – though symptoms are likely to return once the baby is born. This isn’t fully understood, but it seems that the mother’s immune system is partially suppressed to ‘tolerate’ the growing baby. As the immune system is suppressed so is the inflammation in the joints. Any flare-up of symptoms after the birth can usually be quickly dealt with.

Find out more about how arthritis and related conditions may affect your pregnancy.

Work and rheumatoid arthritis

With modern treatments it’s usually possible to keep on working, unless it involves a lot of manual effort. Help is available if your workplace needs to be adapted because of your condition. Your local Jobcentre Plus office can put you in touch with a Disability Employment Adviser who will be able to advise on this. If necessary they can also advise on retraining for alternative work.

Read more if your rheumatoid arthritis is causing difficulties at work.