DID YOU KNOW?
- Arthritis is a leading cause of disability in Canada.
- About one out of every 100 Canadians has rheumatoid arthritis (RA). That's about 300,000 Canadians.
- Anyone can get RA at any age, but it most often appears between the ages of 25 and 50.
- RA affects women three times more often than men.
There is no cure for RA, but when you are diagnosed early and start the right treatment, you can take better control of your disease and often avoid severe damage to your joints. Most people with RA can lead active and productive lives with the help of the right medication, surgery (in some cases), exercise, rest and joint protection techniques.
WHAT IS RHEUMATOID ARTHRITIS?
Rheumatoid arthritis (RA) is a type of inflammatory arthritis and an autoimmune disease. An autoimmune disease is one where the body's immune system becomes confused and begins to "attack" the body.
In RA, the target of the immune attack is tissue in the lining of the joints and, sometimes, in other internal organs (such as the eyes, lungs or heart). This causes swelling, pain, inflammation and joint destruction.
RA usually begins slowly, starting in a few joints and then spreading to other joints over a few weeks to a few months. As time goes on, RA involves more and more joints on both sides of the body often in a "symmetrical" pattern. This means if joints in your right hand are swollen, then joints in your left hand will probably be swollen.
The symptoms of RA vary from person to person. Some people have only a few joints involved or mild inflammation, whereas others have many joints involved or severe inflammation. The symptoms of RA also vary from times when the joints feel good to other times (often for no reason at all) when the joints become more stiff, sore and swollen.
WHAT ARE THE WARNING SIGNS OF RA?
RA usually starts over a period of weeks to months, with more joints affected over time. You should see your doctor if you experience any of the following symptoms for more than two weeks:
- You start to feel unusual pain and stiffness in your joints. Look for swelling of the wrists, knuckles or small joints of the fingers or toes, including the ball of the foot.
- You feel pain and stiffness in the morning, typically lasting more than 30-60 minutes before you "loosen up" and start feeling better.
- Some people notice that they feel more tired when RA starts. Some will occasionally lose weight or develop a low-grade fever.
HOW DOES YOUR DOCTOR DIAGNOSE RA?
There is no single test for RA. If you have signs and symptoms of RA, your doctor will likely examine your joints and perform blood tests and X-rays to help with the diagnosis.
Your doctor may order blood tests, such as the ESR (Erythrocyte Sedimentation Rate) and the CRP (CReactive Protein), to look for inflammation in the blood. Other blood tests, including the Rheumatoid Factor (RF) and the Cyclic Citrullinated Peptide (CCP) Antibody, can be helpful, but it's not possible to diagnose RA with a simple blood test. You should remember the following about special blood tests for diagnosing RA:
- Having a positive test result does not mean that you have RA.
- Some people with RA may have negative or normal test results, especially early on in the disease.
- Establishing an accurate diagnosis is very important because there are many treatment options to manage the symptoms of RA.
WHAT DO YOU DO IF YOUR FAMILY DOCTOR THINKS YOU HAVE RA?
If your family doctor believes you have RA, you should be referred to a rheumatologist as soon as possible and begin treatment immediately. A rheumatologist is a doctor who is an expert in arthritis.
WHY IS EARLY TREATMENT FOR RA SO IMPORTANT?
RA causes inflammation (swelling, pain and warmth) in the affected joints. You can think of this inflammation like a "fire" burning in the joints. If the fire of inflammation is left "burning," it can permanently damage the joint. Once a joint is damaged, it cannot be fixed with medicine. Just as you would try to put out a fire in your home with a fire extinguisher before it spreads, you want to put out the fire in your joints as quickly and as safely as possible with the help of your rheumatologist.
To emphasize, RA can cause permanent joint damage quickly when it is not treated and controlled. This damage can occur even when the pain is not severe. Once damage occurs, it is not reversible and can cause significant pain and disability. Fortunately, we know that much research has confirmed that treating RA early and aggressively often improves the long-term outcome and significantly reduces damage.
WHY DO PEOPLE GET RA?
No one knows what causes RA. To simplify things, let's again think of the inflammation of RA like a fire. This time, imagine you're outdoors and you want to start a campfire. You first gather and arrange enough wood and paper for the fire. If you gather lots of dry wood and newspaper, chances are the fire will light. If you gather soaking wet wood, chances are you won't be able to get the fire started. People who develop RA have genes (DNA) that "set them up" to get the disease. They have the dry wood and paper that are ideal for lighting the "fire" of RA. If they have genes like the wet wood, the fire of RA will not be lit.
However, having genes that are conducive to RA does not necessarily mean you will develop this disease. Something is always needed to light a fire. Just like many things can be used to light a fire (matches, flint, lightning, etc.), there are many "triggers" that can lead to RA.
Unfortunately, we don't know what that "trigger" is. It could be a viral infection or something else in our environment. There may be more than one trigger.
Most people who develop RA have no history of the disease in their family. However, if a relative has RA, you are at a small increased risk. It is unusual to see RA in many family members, but it is possible.
HOW CAN I MANAGE RA?
Once your diagnosis is confirmed, there are many treatments that can help decrease your pain and increase your movement. Non-medication therapies, such as physiotherapy, occupational therapy, education, physical activity, healthy eating and relaxation techniques, are a very important part of the treatment of RA. While you can perform them on your own, it's best that you first ask a health-care professional for guidance.
Physical activity protects joints by strengthening the muscles around them. Strong muscles and tissues support those joints that have been weakened and damaged by arthritis. A properly designed program of physical activity reduces pain and fatigue, improves mobility and overall fitness, and alleviates depression. Physical activity allows someone with arthritis to have a more productive, enjoyable life.
There are different types of exercises that you can do to lessen your pain and stiffness:
- Range of motion exercises reduce pain and stiffness and keep your joints moving. To achieve the most benefit, these exercises should be done daily.
- Strengthening exercises maintain or increase muscle tone and protect your joints.
- Moderate stretching exercises help relieve the pain and keep the muscles and tendons around an affected joint flexible.
- Endurance exercises strengthen your heart, give you energy, control your weight and help you feel better overall. These exercises include things like walking, swimming and cycling. It is best to avoid high-impact exercises like step aerobics, jogging or kickboxing.
For more information, refer to The Arthritis Society's Physical Activity & Arthritis Guide [PDF].
HEAT AND COLD
Heat: Taking a warm shower and using warm packs are great ways to help reduce pain and stiffness. Always use a protective barrier, such as a towel, between the warm pack and the skin. Heat is ideal for:
- Relieving pain.
- Relieving muscle spasms and tightness.
- Enhancing range of motion.
To avoid making symptoms worse, heat should not be applied to an already inflamed joint.
Cold: Using a commercial cold pack or a homemade one (from crushed ice, ice cubes or a bag of frozen vegetables) can be helpful. Always use a protective barrier, such as a towel, between the cold pack and the skin. Cold is ideal for:
- Decreasing swelling.
- Decreasing pain.
- Constricting blood flow to an inflamed joint.
For further details on using heat and cold to manage your arthritis, speak with your health-care team.
PROTECTING YOUR JOINTS
You should always use your joints in ways that avoid excess stress. This allows you to experience less pain, perform tasks more easily and protect your joints from damage. Techniques to protect your joints include:
- Pacing by alternating heavy or repeated tasks with lighter tasks. Taking a break reduces the stress on painful joints and conserves energy by allowing weakened muscles to rest.
- Positioning joints wisely promotes proper alignment and decreases excess stress. For example, squatting and kneeling may put extra stress on your hips or knees. When lifting or carrying heavy items, keep items at waist height and avoid carrying them up and down stairs.
- Talk to your doctor about seeing an occupational therapist or physiotherapist, who may prescribe splints, braces or orthotics (shoe inserts) to help align and support your joints.
- Using assistive devices conserves energy and makes daily tasks easier. Raise seat levels to decrease stress on hip and knee joints. Use a reacher to pick up items from the ground. Use a cane to decrease stress on hip and knee joints. Enlarge grips on utensils, such as spoons or peelers, to decrease stress on delicate hand joints. Other devices to consider include carts for carrying objects and jar/tap openers.
RELAXATION & COPING SKILLS
Developing good relaxation and coping skills can help you maintain balance in your life, giving you a greater feeling of control over your arthritis and a more positive outlook. Relaxing the muscles around a sore joint reduces pain. There are many ways to relax. Try deep breathing exercises. Listen to music or relaxation tapes. Imagine or visualize a pleasant activity, such as lying on a beach.
The most important link between your diet and arthritis is your weight. Being overweight puts an extra burden on your weight-bearing joints (back, hips, knees, ankles and feet). Maintaining an appropriate weight will help you more than any food supplements. If you have arthritis, consider a balanced diet as a way to help you achieve and maintain a healthy weight. For others, healthy eating may give you the energy to complete your daily activities. Proper nutrition is vital to controlling body weight and managing arthritis symptoms.
For more information, read The Arthritis Society's Nutrition & Arthritis Guide [PDF] and watch the Nutrition and Arthritis video.
WHAT MEDICATIONS ARE USED FOR RA?
The general approach to treating RA is to reduce joint inflammation and prevent long-term damage to the joints. The cornerstone of therapy is Disease-Modifying Anti-Rheumatic Drugs (DMARDs).You can think of DMARDs like your local fire trucks with their hoses on the fire.
DMARDs are often used in combination with Non- Steroidal Anti-Inflammatory Drugs (NSAIDs) and/or Corticosteroids (steroids). Although NSAIDs and steroids slow down the day-to-day inflammation, they don't affect the long-term outcome of the disease.
A newer class of medications called biologics has revolutionized the treatment of RA. These medications, which can be used in combination with DMARDs, also suppress inflammation and help prevent damage to the joint. You should discuss the use of any arthritis medication with your doctor.
For more detailed information on arthritis medications see Arthritis Medications: A Consumer's Guide [PDF].
Disease-Modifying Anti-Rheumatic Drugs (DMARDs)
DMARDs are a class of medications used to treat inflammatory types of arthritis, such as rheumatoid arthritis. DMARDs slow down the biologic processes that are the driving force behind the persistent inflammation (pain, swelling and stiffness) in the joints. DMARDs are important because they help to prevent damage to the joint. Doctors know that prescribing a DMARD early on is important to slow or even stop the progression of joint damage, but it cannot fix joint damage that has already occurred.
DMARDs generally work well in most people; however, they do take some time to work. Most DMARDs will start to work in about six to 12 weeks; however, some may take longer – up to three or four months. While you are waiting for the DMARD to work, your doctor might prescribe an additional medication, such as a steroid or an NSAID, to help control the symptoms.
Although DMARDs can be used one at a time, many studies show that for some people two or three DMARDs taken together are of greater benefit than one medication alone. Your doctor will recommend a therapy that is best suited to your type and stage of arthritis, other medical problems and medications.
Taking DMARDs carries some risk, which must be balanced against the potential benefits. In general, the risk of joint damage and permanent disability is much greater than the risk of side effects from DMARDs used to control the disease. When properly monitored, the vast majority of side effects are rare and most are reversible by adjusting the dose or switching medications.
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
Non-steroidal anti-inflammatory drugs (NSAIDs) are a class of medications used to treat the pain and inflammation of arthritis. They do not contain steroids, hence the name "non-steroidal." It is important to remember that these medications work to improve symptoms and have no proven long-term benefits. As such, these medications can be taken on an as-needed basis and do not need to be taken regularly. That being said, some patients may find it helpful to take their NSAID on a regular basis to control their symptoms. Your doctor will advise you on what is best for you. Some patients will notice the effects of an NSAID within the first few hours of taking a dose. In other patients, the effects may not be evident for a few days and even up to a week or two after the medicine has been started. If it hasn't helped within two to three weeks, it is unlikely to be of much benefit. Your doctor might ask you to try a few different NSAIDs, as some may work better for you than others; what works varies from person to person.
Indigestion, heartburn, stomach cramps and nausea are the most common side effects of NSAIDs. NSAIDs can affect the protective lining of the stomach, making you more susceptible to ulcers and bleeding. COXIBs are a class of NSAIDs that have been developed to reduce the risk of gastrointestinal ulcers and bleeding. Although COXIBs are safer on the stomach, they have all of the other side effects of NSAIDs and may still cause indigestion, nausea, stomach cramps and heartburn.
Cortisone is a hormone produced naturally by the body's adrenal glands that regulates routine inflammation from minor injuries. Major traumas, such as broken bones or surgery, depend upon the adrenal gland to produce even more cortisone. But the adrenal gland cannot produce enough cortisone to meet the challenge of inflammatory arthritis. In the 1950s, physicians found that giving extra cortisone to patients with rheumatoid arthritis dramatically improved their symptoms.
From this discovery, corticosteroids, also known as steroids, were developed and are some of the oldest, most effective and fastest working medications for inflammatory arthritis. Steroids can be given by mouth, injected into the joint, injected into a muscle ('IM') or administered through an intravenous drip ('IV').
Steroids are often used as interim measures to get control of inflammation while waiting for the slower acting DMARDs to take effect. Steroids work quickly (usually within a few days) and some patients start to feel better within hours of taking the first dose. To maximize benefits and minimize side effects, doctors prescribe corticosteroids in doses as low as possible and for as short a time as possible. Dosages vary widely and are based on your disease and the goals of treatment.
Biologics are a class of medications specially designed to treat inflammatory types of arthritis, such as rheumatoid arthritis. There are a number of biologics available that work by acting on the body in different ways. Like DMARDs, biologics are used to suppress inflammation and help prevent damage to the joint.
Biologics are administered in two ways: infusion and injection. Your doctor can provide you with information on the way in which different medications are administered and help make the right choice for you. An infusion means that the medication will be given to you through a needle placed in a vein in your arm. An injection means that the medication will be given by a needle under the skin of your abdomen or thigh.
Biologics are generally successful with most people; however, they can take some time to work. Some people may notice the effects of the medication quite quickly (within days to weeks), while others may take three to six months to feel the effects. Biologics can be combined with DMARDs.
Your doctor will recommend a therapy that is best suited to your type of arthritis, other medical problems and other medications. Your doctor will discuss the benefits of each biologic, how the medication is given and its potential side effects. Biologics work by suppressing your immune system, which can make it slightly harder for you to fight off infections. Please inform your doctor if you are prone to frequent infections. It is advisable to stop your medication and call your doctor immediately if you develop a fever, if you have or think you have an infection or if you have been prescribed antibiotics. Any woman who is pregnant or may become pregnant should not take a biologic.
Living with a chronic disease like arthritis can be very frustrating, especially if the medications prescribed by your doctor don't seem to have the desired effect. In these instances, it can be tempting to exhaust all possible solutions for bringing your pain under control. A popular option for many people with arthritis is complementary and alternative therapies, which are treatments that fall outside the scope of traditional medicine. Examples include naturopathic medicine, special herbs, acupuncture and meditation.
Before you try any of these treatments, always inform your health-care provider of any complementary and alternative therapies you are taking, receiving or would like to try. Your health-care provider can offer valuable advice about these treatments.
For further information, refer to The Arthritis Society's Complementary and Alternative Therapies Guide [PDF].
Surgery is something that you and your doctor may consider if one of your joints becomes badly damaged and is no longer functioning or where your pain cannot be managed in other ways. Benefits include less pain and better movement and function. There are a number of different kinds of surgery for RA, ranging from minor procedures to complete joint reconstruction. It's important to remember that surgery is not a treatment for RA.
WHAT QUESTIONS SHOULD I ASK MY DOCTOR?
Patients who learn about their treatment program and talk to their doctor about it tend to report fewer symptoms, including less pain and greater mobility. Be sure to talk with your doctor about your RA and ask questions about the disease and the different kinds of treatments. Before making a decision, you should understand what you can expect from a medication, what its possible side effects are and other important information. Also, ask what steps you can take to get your disease under control.
To help you get started, here are some common questions you may want to ask about RA treatment:
- What local resources are available so I can better educate myself about RA?
- Should I be referred to a physiotherapist or occupational therapist?
In regards to my medications:
- What are the possible side effects and how often do they occur?
- What should I do to minimize the chances of side effects?
- How will I know if the medication is working and how long will this take?
- Who do I contact if I have concerns about the medication?
- Are there medications I should stop taking now that I am beginning this new treatment?