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Rheumatoid arthritis

 


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Condition
Rheumatoid arthritis
Class
Musculoskeletal system
Description
Rheumatoid arthritis is an inflammatory type of arthritis that normally affects the joints and tendons of the wrists, hands and feet. It is the second most common form of arthritis; osteoarthritis being the most common form. (See separate article on osteoarthritis)

Rheumatoid arthritis usually affects those between the age of 30 and 50, although it can affect people of all ages, including children and the elderly. It is estimated that about 1 in 100 people are affected by rheumatoid arthritis, equivalent to nearly half a million people in the UK. Women are 3 times more likely to suffer from rheumatoid arthritis than men. Approximately 12,000 children in the UK are affected by the juvenile form of the condition, known as juvenile rheumatoid arthritis.

Although rheumatoid arthritis usually starts in the wrists, hands and feet, it can affect other parts of the body including the lungs, heart and eyes.
Causes
Rheumatoid arthritis is known as an autoimmune disease. This means that the body’s immune system that normally protects against infections, turns against itself and starts to attack the joints. It is not known what triggers this autoimmune disease. There is a genetic link but the link is not straightforward as some people who have the genes do not develop rheumatoid arthritis, while others with rheumatoid arthritis do not have the genes. It is likely that other factors such as stress, viral infection or hormonal changes may trigger the start of the disease in those people who have a genetic tendency to develop it.

Although the exact cause of rheumatoid arthritis is not known, much is known about the progress of the disease. To understand how rheumatoid arthritis develops, it is necessary to understand the structure and function of joints.

Joints permit movement. Without them, the bones that make up the skeleton would be fixed in a rigid position. Each joint is surrounded by a capsule, within which there is a layer called the synovial membrane that produces a fluid called synovial fluid. At the end of each bone, there is a layer made of a tissue called cartilage. Cartilage protects the ends of the bones and allows the joint to move easily. Muscles are attached to a bone by means of a band of tough, inelastic fibrous tissue called tendons which are encased in a sheath. When the muscle contracts, it creates a pull on the tendon that moves the bone. Small, fluid-filled sacs called bursae are located at the points where the muscles or tendons slide across the bone to reduce the friction between the two moving surfaces. A sheet or band of tough, fibrous tissue called ligaments connects bones or cartilages at a joint and determines the range of movement of the bone when the muscle contracts.

In rheumatoid arthritis, the immune system reacts abnormally to the lining of the joints that starts an inflammatory response. Inflammation particularly affects the synovial membrane, the tendon sheaths and the bursae. As a result, the joint capsule swells and the joint becomes swollen, and movement becomes painful and stiff. If the inflammatory response continues, the cartilage, ligaments and tendons within the joint will be damaged. The more damage that occurs, the longer and more difficult it is for the joint to recover and it may end up being deformed and unable to work properly.

Proteins (amyloids) released from the damaged joints may be carried to other parts of the body to affect the circulation, heart, lungs, eye and brain.
Symptoms
Rheumatoid arthritis normally affects the wrists, hands and feet but may also affect joints in the neck, shoulders, hips, knees, ankles and elsewhere in the body. Symptoms include joint stiffness and joint pain. Pain is usually worse in the morning and gradually eases during the day. Flu-like symptoms and an overwhelming feeling of tiredness are common. Symptoms may develop suddenly, almost overnight, or may come on so gradually that it is hard to pinpoint exactly when they began. There may be times when the disease is inactive and other times when it becomes suddenly active or flares up.

Rheumatoid arthritis is a chronic long-term condition. About 20% of people who are affected will develop severe joint deformity, but for the majority of people the symptoms of rheumatoid arthritis can be controlled so that it need not have a devastating effect on their life.
Treatment
Treatment of rheumatoid arthritis depends upon the location and severity of the symptoms. In general, different types of product are used to ease pain, reduce inflammation and slow the progression of the disease. Combinations of drugs will frequently be used.

Drugs used to ease pain include analgesics such as paracetamol and codeine, either used alone or in combination. If pain is severe and accompanied by inflammation, drugs known as NSAIDs (non-steroid anti-inflammatory drugs may be used). The earlier NSAIDs include drugs such as ibuprofen, diclofenac and naproxen. The later NSAIDs are usually referred to as COX-2 inhibitors, for example celecoxib and etoricoxib. These drugs inhibit the enzyme cyclo-oxygenase (COX-2) and are thought to have less risk of causing severe upper gastrointestinal disturbances than the earlier NSAIDs. However, they may carry an increased risk of causing stroke and heart attacks.

Corticosteroids, taken orally or injected into the joint may also be used to reduce inflammation. Drugs that slow the progression of the disease are known as DMARDs (disease-modifying anti-rheumatic drugs). There are a large number available, including methotrexate, azathioprine, ciclosporin, cyclophosphamide, leflunomide, penicillamine, gold,  chloroquine, hydroxychloroquine and sulfasalazine. These drugs may suppress the immune response and suppress the disease process. They are also effective in reducing symptoms in other parts of the body away from the joints. Biological compounds are also used to suppress the immune response and limit disease progression. These compounds include adalimumab, anakinra, certolizumab, etanercept, infliximab, rituximab and tocilizumab. They work by interfering with the chemicals that are released during an inflammatory response. Most are used in conjunction with methotrexate when the response to DMARDs is inadequate.

As joint damage occurs in the early stages of rheumatoid arthritis, DMARDs and/or biological agents should be started as soon as possible after the diagnosis of rheumatoid arthritis has been confirmed by a specialist.
When to see your pharmacist
Rheumatoid arthritis is a long term condition that may require treatment for years. In such circumstances it is worth registering with your pharmacist for the repeat dispensing of your prescriptions. By doing so, your pharmacist will get to know you and the medicines that you are taking and is always available to offer advice. It also provides an opportunity for you to discuss any questions about your medicine and how it should be used.

When purchasing over the counter medicines for other illnesses, it is important always to ask your pharmacist which medicines are safe to take, as they may interfere with your prescribed medicines.

If you have poor grip strength and find it difficult to open medicine bottles, tell your pharmacist. When dispensing your medicines your pharmacist will fit special caps on the bottles that will make them easier to open.
When to see your doctor
It is very important to be diagnosed and get treatment started for rheumatoid arthritis as soon as possible to minimise joint damage and maintain a good quality of life. Anyone with symptoms such as joint stiffness - particularly in the morning, joint pain, flu-like symptoms and feeling generally tired should see their doctor promptly.

Rheumatoid arthritis can be a difficult disease to diagnose, partly because some signs and symptoms of rheumatoid arthritis can have other, more common explanations. For example, swollen and painful joints may be caused by viral infections. If your doctor thinks you may have rheumatoid arthritis, he or she will refer you to a rheumatologist who will use blood tests or X-rays of your joints to confirm the diagnosis.
Living with rheumatoid arthritis
It can come as a shock to hear that you have rheumatoid arthritis. However, most people are able to carry on as normal by making some adjustments to their lifestyle. If you suspect that you may have rheumatoid arthritis see your doctor and ask for a referral to a rheumatologist. The earlier your condition is diagnosed and treated, the lower the risk of joint injury. Do not be afraid to ask your doctor and specialist questions. The more you understand about the condition and the medicines that you are taking, the better the outcome will be. In some cases a referral to a physiotherapist or an occupational therapist will help. The therapists can give you special exercises to help overcome mobility problems and avoid joint strain, and show techniques that will help you relax.

Look after your joints. Keep your weight under control. Excess body weight exerts a heavy toll on load-bearing joints such as the knees and hips. Eat a balanced diet, rich in fresh fruit and vegetables. Limit your consumption of red meat, fatty foods, alcohol, tea and coffee and increase the amount of oily fish (mackerel, herring, sardines) in your diet. If you smoke, make every effort to give up. Ask your doctor, practice nurse or pharmacist for help.

Maintain a balance between rest and activity. Regular exercise strengthens muscles that will help support joints, but rest when you get tired. Avoid high impact activities. If you enjoy walking, get yourself a pair of good trainers with cushioned soles or quality walking boots that provide support to the feet and ankles. A ski-pole or walking stick will also help ease the load on the hips and knees. Swimming is a great way to keep the heart and circulation in good order without putting too great a strain on joints.

Maintain an upright posture when sitting, standing or moving around to keep joints in alignment. Avoid repetitive tasks and if your joints start to ache, rest for a while. Organise your work area, to make things accessible. If you spend long times in front of a computer, make sure that your screen and chair are appropriately adjusted to avoid strain to the neck, back, hips and knees.
Useful Tips
  • If you smoke, giving up smoking is one of the most important things to do – people with rheumatoid arthritis who do not smoke do better over time.
  • Aim for a healthy weight as this helps reduce the stresses on joints
  • Try to rest and try to exercise – get the balance right
Further information
National Rheumatoid Arthritis Society (NRAS) - NRAS is the only UK patient-led charity exclusively dedicated to supporting people in Britain with rheumatoid arthritis, as well as their families, carers and the healthcare professionals who treat them.

National Rheumatoid Arthritis Society
Unit B4 Westacott Business Centre
Westacott Way
Littlewick Green
Maidenhead
SL6 3RT

Helpline 0800 298 7650
Email: helpline@nras.org.uk
www.nras.org.uk

Arthritis Care  - Arthritis Care is the UK’s largest charity working with and for all people who have arthritis. The website provides useful information about the various forms of arthritis and makes available a series of guides that contain practical advice to help you take control of your symptoms and to live and work with the condition.

Arthritis Care
18 Stephenson Way
London NW1 2HD

Helpline: 0808 800 4050
www.arthritiscare.org.uk

Arthritis Research UK - Arthritis Research UK is the charity leading the fight against arthritis by funding high class research, providing information and campaigning.

Arthritis Research Campaign
Copeman House
St Mary’s Court
St Mary’s Gate
Chesterfield
Derbyshire
S41 7TD

Helpline 0870 850 5000
www.arc.org.uk


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