Rheumatoid arthritis

 

Rheumatoid arthritis (RA) literally means: rheumatic joint inflammation. The course of the disease is erratic. RA is a chronic autoimmune disease that causes joint pain, stiffness, swelling and decreased movement of the joints. The chronic (recurrent) joint inflammations can lead to severe damage to your joints. The reason for the chronic (recurrent) joint inflammations is that your natural immune system is disrupted. Your immune cells turn against the ‘own’ body cells and not against harmful invaders from outside (for example viruses, bacteria). Sometimes the disease is very active in your body and you have many complaints of pain, swelling, stiffness of the joints and fatigue, sometimes there are quiet periods and you are (almost) complaint-free. You can have RA inflamed joints, especially in the hands, feet, knees, wrists and ankles. The connective tissue in the skin, lungs, nerves, blood vessels and the heart can also become inflamed.

It is important to detect the disease early (early diagnosis) and to treat it quickly. The condition cannot be cured, but the treatment focuses on stopping the inflammations and damage to the joints. With many people, the complaints get worse over time. After a few years, the cartilage in the joint may also have deteriorated due to the inflammation. Sometimes an artificial joint (prosthesis) has to be placed in, for example, knee or shoulder.

A major problem is the fatigue in patients with RA. People with rheumatoid arthritis can experience fatigue every day without having to work or exercise hard. This is an important difference with ‘normal’ fatigue after a strenuous activity. The severity of the fatigue is in no relation to the activity that has been carried out or the effort that has been made. The fatigue is suddenly there and you fall over.

Rheumatoid arthritis is the most common form of autoimmune arthritis. RA can occur at all ages and occurs more often in women than in men. The disease most often begins between the ages of 30 and 50. However, RA can start at any age. In children we speak of juvenile idiopathic arthritis.

Rheumatoid arthritis affects for example more than 1.3 million Americans. About 75% of RA patients are women. In fact, 1 – 3% of women may get RA in their lifetime.

Cause

The cause of rheumatoid arthritis (RA) is not yet known, but it is an autoimmune disease. The immune system, which is made up of special cells, proteins (antibodies), tissues and organs, defends people against germs and microorganisms every day. In most cases, the immune system is effective in keeping people healthy and preventing infections. But sometimes problems with the immune system can lead to illness and infection. The immune system gets disrupted.
In your body immune cells (immune system) and proteins (antibodies) have the task of detecting and fighting everything that is not ‘normally part of the body’. These are, for example, bacteria and viruses. So in rheumatoid arthritis your immune cells (immune system) not only clean up invaders from the outside, but also attack the body’s own healthy cells and proteins. The immune cells (immune system) therefore target their own healthy cells and proteins in the body (autoimmune disease) and there is an excess of inflammatory proteins in your body. These cause (chronic) inflammations in, for example, joints, tendons, muscles, organs, blood vessels or nerves. If the inflammation remains present for a long period of time, it can cause damage to the joint, which cannot be reversed once it occurs.
The immune system may be disrupted by hereditary factors and environmental factors, such as smoking. There is evidence that autoimmune conditions run in families. Hormones can also play a role in women.

Hereditary factors
Rheumatoid arthritis (RA) is not a hereditary disease. But a predisposition to a certain hereditary factor may increase the possibility of developing rheumatoid arthritis (multi-factorial inheritance). For instance, certain genes that you are born with, may make you more likely to get RA. In certain families we often see more people with rheumatoid arthritis. If you have RA, the chance that your first-degree relatives (parents, brothers, sisters or children) also get that disease is slightly higher than average. Rheumatoid arthritis is more common in patients with a specific genetic predisposition (HLA type of the shared epitope hypothesis) and is more severe then.

Environmental factors
Environmental factors are also important in the development of rheumatoid arthritis. Smoking is an important risk factor and rheumatoid arthritis is more common in smokers. In patients who are anti-CCP positive or have the rheumatic factor, smoking can stimulate the immune system and also cause other complaints, for example rheumatoid nodules. These are small, firm lumps that develop under the skin, usually near joints that are inflamed. Smoking also ensures that some medicines work less effectively.

Hormones
In women, hormones and use of the contraceptive pill may play a role in the symptoms caused by rheumatoid arthritis. Many women can develop severe symptoms during menstruation and during the menopause, probably because of the decrease in estrogen levels in the blood. Pregnant women often suffer less from their illness. In an active rheumatoid arthritis, menstruation can become disrupted. If the disease activity increases, you will be prescribed more or a different type of anti-inflammatory medicine. If the disease activity remains the same, you can fight the symptoms with heat and exercises.

Complaints

Rheumatoid arthritis (RA) progresses differently for everyone who gets the disease. Sometimes the course of your illness is mild with few complaints, but at other times the disease progresses more aggressively and you have inflammatory symptoms (increased body temperature, pain, swelling, hot inflamed joints), pain, stiffness and fatigue getting worse. The inflammatory symptoms can occur alternately in different joints and in the morning there may be more physical complaints than in the afternoon.

The joint stiffness in the active rheumatoid arthritis is often the worst in the morning. It may last one to two hours, but even the whole day is possible. The stiffness generally improves with movement of the joints. Stiffness for a long time in the morning is a clue that you may have RA, as this is not so common in other conditions. For instance, osteoarthritis most often does not cause prolonged morning stiffness.
Other signs and symptoms that can occur in rheumatoid arthritis include:
Loss of energy.
Loss of appetite.
Dry eyes and mouth caused by a related health problem Sjogren’s syndrome.
Low fevers.
• Firm lumps, called rheumatoid nodules, which grow beneath the skin in places such as the elbow and hands. Some people with RA, particularly those with more advanced or poorly controlled RA, form rheumatoid nodules. These are small, firm lumps that develop under the skin, usually near joints that are inflamed. The nodules can be small or as large as a walnut. Treatment isn’t required, but certain medications can help reduce the size of larger nodules if they’re bothersome or they can be surgically removed. Usually, the nodules are painless and pose no risk.

Illness activity
You will notice that rheumatoid arthritis becomes more active if you suffer from the following symptoms for at least two weeks or longer:
• your joints in the hands, feet, knees, wrists and ankles become inflamed, are stiff, hot, swollen and painful and limit your daily movement.
• your tendons, mucous membranes and muscles become inflamed, become stiff and weaken. You become less mobile and your condition deteriorates.
• your body temperature is increased and you feel flu-like with fever, weakness and little appetite.
• you suffer from severe fatigue, feel lethargic and have a lack of energy. People with rheumatoid arthritis can experience fatigue every day without having to work or exercise hard. This is an important difference with an ‘ordinary’ fatigue. The severity of the fatigue is in no relation to the activity that has been carried out or the effort that has been made.

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Complications

Often you do not notice anything of the start of a starting inflammation in rheumatoid arthritis. This happens when you experience complaints. If you have an active rheumatoid arthritis (RA), one or more complications may arise.

Complications can be:
the development of comorbidities, such as diabetes, cardiovascular diseases, high blood pressure and osteoporosis. Risk factors include, for example, high cholesterol levels in the blood, the development of diabetes, increased blood pressure, a change in liver or kidney function (due to medication), obesity, hormonal changes (menopause and penopause) and smoking.
getting stiff and weakening of tendons, mucus, muscle.
the tearing of a tendon (tendon rupture). The synovium around the tendon can become inflamed and the tendon weakened by the inflammation. If the tendon rubs along a sharp bone part, the tendon can tear off. A torn tendon suddenly develops, is painless and can occur mainly in the hand or wrist. You notice that there is something wrong, if your fingers seem ‘loose‘ or if you get stiffer fingers, hands or feet.
the development of a nerve inflammation due to a vascular inflammation (vasculitis). The small blood vessels to the nerve become inflamed and you experience deafness or tingling in an arm or leg.
the development of nerve and/or spinal cord compression. The joints in the spine are called facet joints. Two facet joints are located at the back of each vertebral body. Facet joints help stabilize the spine and assist in preventing excessive spinal movement. However, when rheumatoid arthritis affects the facet joints, spinal instability may develop, which could lead to nerve and/or spinal cord compression. You may experience headaches, neck pain, tingling, numbness, incontinence or even paralysis in the arms or legs. Complaints can be fingers that feel like sandpaper, tingling in the fingers, jumping legs due to increased reflexes, urinary problems, a feeling of a band around the legs and walking becomes worse.
the development of carpal tunnel syndrome (CTS). A nerve can get trapped by pressure from inside or outside. If the nerve is trapped for a long time, there may be signs of discomfort, for example in the wrist. Carpal tunnel syndrome is an inflammation in the tendon sheaths of the wrist, causing sensation and tingling in the 3 middle fingers due to the swelling and pinching of the nerve.
the development of tarsal tunnel syndrome (TTS). The tarsal tunnel syndrome in the foot is caused by a swelling of the ankle, which gives pressure on the nerve on the inside of the ankle, just above the heel. This causes tingling or burning pain in the toes, foot sole or heel.
the development of inflammation of organs and tissues through the connective tissue in, for example, skin, lungs, nerves, blood vessels and the heart.
the development of a blood vessel inflammation (vasculitis). This is an inflammation of mainly small or medium blood vessels in the skin or cuticles with reddish-blue or red-brown discoloration and/or wounds due to poor blood supply. Vasculitis in organs such as kidneys, heart, lungs and eyes causes symptoms such as skin discoloration, fatigue, feeling sick, losing weight, a constant slight increase in body temperature and increased blood sedation.
• In the case of pulmonary inflammation, the blood vessels that run to the pulmonary membrane are ignited. You have either no or hardly any complaints or you suffer from pain when breathing, shortness of breath or fever. There may also be fluid behind your lung, which leads to shortness of breath by pressing the lung.
an inflammation of the outer heart membrane, because the blood vessels are inflamed to the heart membrane with sometimes a small amount of fluid around the heart. In rheumatoid arthritis, there is a 30% -50% of people with inflammation of the heart, but only a small number of them develop symptoms (for example, pressure on the chest or pain).
the development of rheumatoid nodules. Some people with RA, particularly those with more advanced or poorly controlled RA, form rheumatoid nodules. These are small, firm lumps that develop under the skin, usually at the elbow or forearm and usually near joints that are inflamed. The nodules can be small, or as large as a walnut. Treatment isn’t required, but certain medications can help reduce the size of larger nodules if they’re bothersome. In some cases, they can be surgically removed. Usually, the nodules are painless and pose no risk.
the creation of pressure spots. Your joints can change their position because of swelling. Toes may then, for example, become trapped in shoes as a result of which wounds are caused by pressure spots.
the inflammation of the synovium. Swelling may occur, because either the lining of the joint, known as the synovium, swells (synovitis) or the synovial fluid increases in volume (an effusion). It is an active process: inflammatory cells (mainly white cells) and more blood enter the joint, while many inflammatory molecules, such as small proteins (peptides) are released into the soft tissues around the joint. The increased blood flow makes the joint swell and feel warm. The inflammatory materials cause joint fluid to collect in and around the joint, which adds to the swelling.
having the secondary form of Sjögren’s syndrome. Sjögren’s syndrome causes inflammation in tear glands (dry eyes), salivary glands (dry mouth and lips), glands of the nose, throat, lungs, vulva and vagina (dry mucous membrane) or dry skin. One out of three people who have Sjögren’s syndrome also have arthritis. A person may have signs of a rheumatic disease, but not have the dry eyes or mouth associated with some forms of Sjögren’s.
the development of eye complaints. In rheumatoid arthritis you can get dry eyes, a burning sensation, itching, pain, eye inflammation (for example conjunctivitis), reduced vision or even blindness of the eye.
the development of bone loss (osteoporosis) as a result of rheumatoid arthritis by reason of less or limited movement or by treatment with corticosteroids. Your bones become more fragile and can break faster and you are twice as likely to have a bone fracture.

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Diagnosis

Your doctor will base your diagnosis on a combination of the medical history, his findings and additional test results.

Anamneses
At the first visit, the doctor asks you a number of questions to get a good picture of your condition. You can think of the following questions:
– When did your complaints start?
– Can you describe your complaints?
– How are your working conditions?
– What medication do you use?
– Do rheumatic diseases occur in your family?
– What is your medical history?
– Are you under the treatment of other specialists and for what?

The early symptoms of rheumatoid arthritis (RA) can be very mild, which makes the diagnosis sometimes more difficult. Some viral infections can cause symptoms that can be mistaken for RA. Rheumatoid arthritis is diagnosed by examining the joints and organs, reviewing x-ray or ultrasound images and examining blood test results. There is no one test to diagnose RA.

Physical examination
Rheumatoid arthritis is diagnosed in a physical examination by examining the affected joints and organs and reviewing x-ray or ultrasound images.
The doctor examines the nature of your symptoms, the number of inflammations in affected joints and organs and asks how long you are already suffering from your symptoms.
X-rays can help in detecting RA, but may turn out to be normal in the stage of early arthritis. Even if normal, initial X-rays may be useful later to show if the disease is progressing. If the disease has become more active and the inflammatory activity is increased, a beginning joint damage can be seen on an X-ray.
MRI and ultrasound scanning can be done to help confirm or judge the severity of RA.
Generally the symptoms will need to be present for more than three months to consider this diagnosis by reviewing x-ray or ultrasound images.

Blood tests
The 2010 Rheumatoid Arthritis Classification Criteria from the American College of Rheumatology (ACR) include CCP antibody/ACPA testing, along with the rheumatoid factor, as part of its criteria for diagnosing rheumatoid arthritis.
• Rheumatoid factors are proteins produced by your immune system that can attack healthy tissue in your body. A rheumatoid factor is an antibody or blood protein, found in about 80% of patients with RA in time, but in as few as 30% at the start of arthritis. They do not directly damage the joints, but cause inflammation. These inflammations then damage the joint tissue. If the rheumatoid factor and/or anti-CCP antibodies are present in the blood, the disease progression is often more serious.
Anti-citrullinated protein antibodies (ACPA) and anti-cyclic citrullinated peptides (anti-CCP) antibodies are evidence of rheumatoid arthritis. Antibodies are small proteins in the bloodstream that help fight against foreign substances called antigens. However sometimes these antibodies are also found in people without RA. In rheumatoid arthritis (RA), ACPA/anti-CCP have emerged as clinically relevant diagnostic markers due to their high specificity for RA. Their diagnostic value is particularly evident in diagnosing early disease and they are usually already detectable at the onset of disease or even prior to the clinical phase. According to the ACR, CCP antibodies may be detected in about 50-60% of people with early RA, as early as 3-6 months after the beginning of symptoms. Anti-cyclic citrullinated peptides (anti-CCP) is an auto-antibody against your body’s own protein CCP. In the Netherlands it was discovered that anti-citrullinated protein antibodies (ACPA) were present in 50% of patients with early rheumatoid arthritis (RA). If the rheumatoid factor and/or ACPA/anti-CCP values are present in the blood, combined with joint inflammation, the disease progression is often more serious.

Sedimentation speed. Blood tests also measure the degree of inflammation through the sedimentation rate of the red blood cells. The erythrocyte sedimentation rate (ESR) is measured by a laboratory test. An erythrocyte sedimentation rate (ESR) test is also called a sedimentation rate test or sed rate test. The test measures the sedimentation rate of red blood cells (erythrocytes) through the speed at which the red blood cells settle, due to gravity, in an upright, narrow tube of blood. The upper part of the blood in the tube is the plasma, which becomes visible as a column of clear, yellowish liquid after the sedimentation of the red blood cells. The length of this column of plasma is measured after one hour and expressed in millimetres per hour (mm/hour). The erythrocyte sedimentation rate values in the blood can become higher with joint inflammation. The more severe the inflammation, the higher the sedimentation rate values. But the doctor cannot use these values to make the definite diagnosis, because sometimes the sedimentation rate values are not or hardly increased, while you can still have rheumatoid arthritis (RA).
• C-reactive protein (CRP) is a protein that is produced by your liver and can be found in your blood. CRP values in the blood can become higher with joint inflammation. The levels of CRP in your blood will also rise when you have an infection or major tissue injury. High CRP levels will fall when the underlying trigger is under control. The more severe the inflammation, the higher the CRP values. But the doctor cannot use these values to make the definite diagnosis, because sometimes the CRP values are not or hardly increased, while you can still have rheumatoid arthritis (RA).
Anemia means that the number of red blood cells in your blood has dropped sharply or that there is too low a content of hemoglobin (HB), an oxygen transporting and iron-containing protein, in the red blood cells. A shortage of red blood cells can be caused by a disturbance in the production (shortage of building materials or deviations in the bone marrow), by a sudden or slow loss of blood or by an increased breakdown of red blood cells in the body (haemolysis). According to some estimates, 30 to 70% of people with rheumatoid arthritis develop anemia. The different types of anemia, that can affect people with rheumatoid arthritis, include:
Anemia of chronic disease. This condition occurs in people with an inflammatory disorder. The body may not make enough red blood cells or the red blood cells may not live for as long as they should. It is possible for someone to have a combination of anemia of chronic disease and iron-deficiency anemia.
Iron-deficiency anemia. This type of anemia, iron deficiency anemia, occurs when the body does not have enough iron to make red blood cells. Sometimes this is due to a lack of iron in your diet, although it can also develop because your body cannot absorb iron effectively. Iron forms one of the building blocks of the red blood dye (hemoglobin). The ingestion of iron takes place in the first part of the intestine. For this, the diet must first contain sufficient iron and secondly, the stomach and duodenum must function properly. There can be an iron deficiency • with regular excessive blood loss (heavy menstruation, birth, illness or tumor in the gut) • with increased iron demand (growth period, pregnancy) • with reduced iron absorption (gastric or intestinal abnormality). It is possible for someone to have a combination of anemia of chronic disease and iron-deficiency anemia.
Hemolytic anemia. This condition occurs when the body destroys healthy red blood cells. This destruction can occur in immune disorders and infections or as a reaction to certain medications. The hereditary forms of haemolytic anemia can be due to cell membrane abnormalities (the cell’s outer shell), the inside chemistry of the cell or the production of abnormal forms or amounts of hemoglobin. The abnormal cells become damaged and are destroyed in the bloodstream. It is also possible that the immune system of the body recognizes its own red blood cells as foreign enemies, after which the cells are trapped by the spleen from the bloodstream. Hereditary haemolytic anemias must be treated for life.
A non-hereditary (acquired) haemolytic anemia can develop gradually, but also develop very quickly. The course of this form of anemia depends on the cause and severity of the anemia. A mild form of hemolytic anemia often requires no treatment. However, severe hemolytic anemia can be life-threatening, if not treated. A non-hereditary haemolytic anemia can occur because the red blood cells are broken down under the influence of • the development of red blood cells that show abnormalities of the cell wall due to a lack of certain proteins in the red blood cell. The body destroys these cells faster than normal. The destruction can occur continuously or occur suddenly • the body’s immune system, which destroys the red blood cells by the formation of antibodies against the red blood cells in an autoimmune haemolytic anemia. This can also occur with the use of certain medicines • mechanical causes. Damage to the cell walls (membranes) of red blood cells may be due to changes in the small blood vessels. An artificial heart valve can cause damage to the cell walls of red blood cells and also the heart-lung machine can damage the cell walls during open-heart surgery. Damage may also occur in women with elevated blood pressure during pregnancy or in the limbs of participants in marathons or other strenuous activities • other causes. Malaria, blackwater fever, tick-borne diseases, snake venom and certain chemicals can attack and destroy red blood cells causing hemolytic anemia.
Macrocytic anemia. This anemia causes red blood cells to grow too large. These oversized red blood cells may not be able to deliver oxygen as efficiently as healthy red blood cells. Macrocytic anemia is a form of anemia where the patient has abnormally large red blood cells. The red blood cells have a low hemoglobin level, as with all other forms of anemia. Hemoglobin is an iron-containing protein that transports oxygen through the body. Macrocyte anemia is almost always due to a shortage of folic acid or vitamin B12 deficiency. The body does not absorb enough vitamins due to an underlying disease or else patients do not take enough food with these vitamins. Drugs and other conditions also sometimes cause this type of anemia. Weakness, paleness and confusion are the best known symptoms.

Anemia with rheumatoid arthritis might also be caused by:
• One potential cause is the medication that is used to treat the rheumatoid arthritis, such as steroids or methotrexate. These medications can cause lesions in the membranes of the gut. This damage can make the body less able to digest iron, which can lead to anemia.
• Another potential cause may be a side-effect of the use of drugs to suppress the immune system, such as azathioprine or cyclophosphamide. A side-effect of this type of drugs is reduced bone marrow production and it is the bone marrow that produces red blood cells.
• A third potential cause might be the reduced lifespan of red blood cells. Rheumatoid arthritis may also result in the reduced lifespan of red blood cells, which could lead to anemia if the body is unable to produce new red blood cells at a sufficient rate.

Treatment

Rheumatoid arthritis (RA) cannot be cured. The goal of current treatments for rheumatoid arthritis is to improve joint pain and swelling and to improve the ability to perform day-to-day activities functioning at, or near, normal levels. Early diagnosis and starting with rapid treatment can limit or prevent further lasting (permanent) damage to the joints and organs. With the right medications, when the symptoms are completely controlled, the disease is in “remission”.
No single treatment works for all patients. It sometimes takes a while before the right treatment is found.

Drug treatment
Drugs without a prescription
• For the pain you can get a simple painkiller with the active ingredient paracetamol without a prescription. Paracetamol helps against pain and fever, does not cause stomach problems, usually does not cause side effects and can be easily combined with other medications.
• An NSAID, an anti-inflammatory analgesic in a lower dose. The abbreviation NSAID stands for Non-Steroidal Anti-Inflammatory Drugs, such as diclofenac, naproxen and ibuprofen. These painkillers inhibit inflammation.

Do you have physical complaints? Always go to your doctor or specialist for a proper diagnosis and proper treatment.

Drugs on prescription
This is provided by your doctor or rheumatologist or internist.
The aim of treating with drugs is to inhibit the immune system so that the joint inflammation stops without reducing the resistance to pathogens. Good treatment can prevent further damage to the joints and organs. The prescribed drugs ensure that you suffer less from pain and that the inflammation of the joints and tissue of the organs is slowed down. In the choice of drugs, your doctor looks at the severity of the disease, the side effects that the drug can give and the reaction of your body to the drug. Again and again, your doctor weighs up the damage that the disease can cause to the joints and the possible side effects of a drug. How this balance goes down is different for everyone.

Drugs are the most important means in treating rheumatoid arthritis for reducing pain and stopping or preventing inflammation.
The most important drugs that can be prescribed are:
• An NSAID, an anti-inflammatory drug, such as naproxen, ibuprofen, meloxicam or indomethacin. These are drugs that are effective against inflammation, swelling, pain, stiffness and fever, but do not prevent joint damage. They do not contain corticosteroids (steroids). There is no proof that any one NSAID is better than others. Your doctor will prescribe these prescription drugs with a higher dose of the active substance. The exact effective dose varies from patient to patient. High doses of short‐acting NSAIDs give the fastest relief of symptoms. Given in the correct dose and duration, these drugs give great relief for most patients. The NSAIDs may cause stomach upset, gastrointestinal (GI) bleeding, ulcers or diarrhea, but they are well tolerated by most people when used for the short term. Some people cannot take NSAIDs because of health conditions such as ulcer disease, impaired kidney function or the use of blood thinners.
• A corticosteroid (an artificial adrenal cortex hormone) is an anti-inflammatory drug that resembles the natural hormone that the body produces in the adrenal cortex. Corticosteroids mimic the effects of hormones your body produces naturally in your adrenal glands, which sit on top of your kidneys. When prescribed in doses that exceed your body’s usual levels, corticosteroids suppress the inflammation. This can reduce the signs and symptoms of inflammatory conditions, such as arthritis. Corticosteroids also suppress your immune system, which can help control conditions in which your immune system mistakenly attacks its own tissues. A corticosteroid drug can be quickly effective for a joint swelling that is localized (not widespread) by an injection or shot into the effected joint or tendon sheath (the membrane around a tendon). Very inflamed joints may benefit from corticosteroid injections (cortisone shots). Examples are prednisone or prednisolone.
• A conventional synthetic DMARD (Disease-Modifying Anti Rheumatic Drug), for example methotrexate (Rheumatrex, Trexall, Otrexup, Rasuvo), sulfasalazine (Azulfidine), gold, hydroxychloroquine (Plaquenil), azathioprine, leflunomide (Arava) and cyclosporine may be prescribed. Gold is an older DMARD that is often given as an injection into a muscle, but can also be given as a pill (Ridaura). The antibiotic minocycline (Minocin) also is a DMARD as well as azathioprine (Imuran) and cyclosporine (Neoral, Sandimmune, Gengraf). These three drugs and gold are rarely prescribed for RA these days, because other drugs work better or have fewer side-effects. A DMARD has different mechanisms of action and suppresses joint inflammations in a number of forms of arthritis. When using a DMARD at an early stage of your condition, your joints will be less damaged by the inflammations. These drugs not only relieve symptoms but also slow down progression of the joint damage. Often, DMARDs are prescribed along with non-steroidal anti-inflammatory drugs, such as NSAIDs and/or low-dose corticosteroids, to lower swelling and pain. DMARDs have greatly improved the pain, swelling, and quality of life for nearly all patients with RA.
• A biologic DMARD (TNF alpha inhibitors, Interleukin inhibitors, B cell inhibitors and T cell inhibitors). A biologic is a biologic DMARD, a drug that can affect your immune system. If you are healthy, the immune system itself makes enough antibodies to defend itself against pathogens (viruses and bacteria). This balance is disrupted in people with a chronic inflammatory disease. A biologic can restore that balance. The drugs can block the immune system chemical signals that lead to inflammation and joint/tissue damage.
FDA-approved drugs of this type include abatacept (Orencia), adalimumab (Humira), anakinra (Kineret), certolizumab (Cimzia), etanercept (Enbrel), golimumab (Simponi), infliximab (Remicade), rituximab (Rituxan, MabThera) and tocilizumab (Actemra). Most often, patients take these drugs with methotrexate, as the mix of medicines is more helpful.
• A biosimilar. A biosimilar drug is a drug that is developed to be highly similar and clinically equivalent to an existing biologic. A biosimilar drug contains a version of an active substance of an already approved biologic drug (the ‘reference drug’ or ‘originator drug’). Similarity to the reference biologic in terms of quality, structural characteristics, biological activity, safety and efficacy must be established, so that there are no clinically meaningful differences from the biologic in terms of quality, safety and efficacy. Research has shown that the biosimilar is just as effective as the original biologic inhibitor in the treatment of arthritis.
Biosimilar drugs are not the same as generic drugs, which contain simpler chemical structures and are identical, in terms of molecular structure, to their reference drugs.
• A targeted synthetic DMARD (Disease-Modifying Anti Rheumatic Drug), a JAK inhibitor. The targeted synthetic DMARDs, the so-called JAK (Janus Kinase) inhibitors, contain the active substances baricitinib or tofacitinib. These medicines together form a new group because they work very specifically on the enzyme Janus kinase in your body. People, who cannot be treated with methotrexate alone, may be prescribed a JAK inhibitor such as tofacitinib (Xeljanz). The JAK inhibitor is also an option if the conventional synthetic DMARDs do not work sufficiently against the chronic inflammations or if you do not respond well to the biologic DMARDs because of the side-effects or the toxicity.
Sarilumab (Kevzara) was approved to treat adults with moderate to severe active rheumatoid arthritis, who do not respond well to or have intolerance to DMARDs, such as methotrexate. It is an injectable prescription medicine called an interleukin-6 (IL-6) receptor blocker. Sarilumab is used to treat adult patients with moderately to severely active rheumatoid arthritis (RA) after at least one other DMARD has been used and did not work well or could not be tolerated.

Use of drugs and adherence

• It is important that you take the drugs as prescribed. In order to get your illness under control, it is very important that you take your drugs on a regular basis every day. If you do not, there is no good concentration of the drug in your blood and therefore the drug will work less well.
• Do you have trouble remembering when and how many of your drugs you should take on a daily basis and at what time of the day? Then buy a drug dispenser, in which you can sort your drugs per day.
• Do you have difficulty or objection to taking the drug prescribed to you, for example because of possible side-effects? Then that can lead to you no longer taking the drug regularly. Discuss this with your doctor!

Deterioration of your illness and/or complications
The doctor will look at:
• The dosage and amount of drugs you use.
• Switching to another drug in the same type or a completely new type of drug.
• Combining different drugs at the same time.

Your doctor can tell you
• whether the drug can work for you.
• how you can best use the drug.
• how much and how often you can use the drug.
• how you can best reduce the drug.

You should always tell your doctor or specialist
• if you use other drugs (bought or prescribed by another doctor).
• if you have another medical condition.
• whether you will be operated on soon.
• if you have previously been prescribed an anti-inflammatory analgesic that has caused side-effects.
• whether you want to become pregnant or are pregnant.
• if you are breast-feeding.
This is important because your doctor or specialist has to make a careful choice between different drugs.

Side-effects
• All drugs may have side-effects when used, so ask your doctor or pharmacist what side-effects you can expect or read the leaflet.

Reduce or stop
• If you stop using a drug yourself or reduce the number of drugs yourself, your symptoms may worsen. Always consult your doctor or specialist first if you want to use less drugs or want to stop.

Alternative treatments

There are many types of alternative treatments. This refers to all treatments that fall outside normal scientific medical care. No scientific evidence has been provided for the operation of these treatments. The alternative treatments are also called ‘complementary‘ because they can supplement the regular medical treatment by your doctor.
Many people choose an alternative treatment in addition to their regular medical treatment. They hope that this helps extra against their complaints or better helps to deal with the complaints.

Can an alternative treatment be a replacement for your regular medical treatment?
No, if you opt for an alternative treatment method, it is always a supplement to your regular medical treatment. You should not stop your regular treatment, because otherwise you run unnecessary health risks. Always consult your attending doctor before you start an alternative treatment.

What alternative treatments are there for example?
There are many different alternative treatment methods available, which can also be combined. Some examples are:
• Chinese medicine (acupuncture, pressure point massage, nutrition and tai chi).
• homeopathy (products made from plants and minerals).
• Bowen therapy.
• Ayurveda.
• Bach flower treatment.
• shiatsu, foot-sole and classic massage.
• Touch for Health.
• Reiki.
• dietary supplements.

What do you have to pay attention to?
• Many alternative treatments have not shown that they actually work. If you choose to try alternative treatment, make sure that your complaints do not increase. Stop an alternative treatment as soon as your symptoms increase.
• Always consider first why you want to follow an alternative treatment.
• Prepare yourself by looking up and reading information about the alternative treatment. Consult with your attending doctor, because certain complaints may be reduced by some alternative treatment methods.
• Determine yourself in which alternative method you trust for the relief of your complaints and whether you want to start.

What can you do best when choosing an alternative treatment?
• Always consult your doctor about the alternative treatment method you want to follow.
• Consult with your attending doctor and with the alternative therapist if they want to discuss your treatment with each other.
• Choose an alternative therapist who has followed a recognized vocational training and is affiliated to a professional organization.
• Ask your alternative therapist in advance about the purpose, duration, costs and risks of the treatment. How much money you spend depends on which treatment you choose and how long it takes.
• Do not stop your regular medical treatment, as this may worsen your symptoms.
• Weigh during treatment whether you want to continue or stop if your symptoms get worse, if you do not notice any effect of the alternative treatment or if you get side-effects.

Why is your food important?

• Healthy nutrition is important to get the vitamins and minerals and other nutrients that your body needs.
• Obesity creates risks for your health and disease progression. In the case of arthritis and obesity, for example, obesity plays an important role in overburdening and osteoarthritis in the knees, hips and ankles. The pressure on your joints is then simply too great. Healthy eating and exercise (exercising a sport and active in the home and outdoors) can help to reduce or prevent excess weight.
• A healthy diet is always important and the dietitian can support you with the right dietary advice.

What is a healthy diet?
With a healthy diet your body gets the right amount of good nutrients, which it needs. You eat the quantities that your body needs. The dietitian can support you with the right nutritional advice.
The 5 courses to choose from are:
• Vegetables and fruit
• Bread, cereal products and potatoes
• Fish, legumes, meat, egg, nuts and dairy
• Lubrication and preparation fats
• Drinks.

Where can you get advice for a healthy diet?
• You can request advice from your doctor or a dietitian. The doctor can refer you to a dietitian. Some diets may possibly help against your symptoms. Consult with your doctor or dietitian if you want to try a certain diet. And make sure that you do not omit important foods from your daily diet.

What can you do with a painful or dry mouth?
Sometimes you can suffer from a dry or painful mouth for various reasons, also due to your illness. Tips:
• by chewing (for example piece of cucumber, sugar-free candy or chewing gum) and sucking (ice cube) the salivary glands are stimulated to produce saliva.
• good oral care is important: good tooth brushing, flossing and the use of mouthwash.
• rinse your mouth regularly, drink small amounts of water and use a mouth sprayer if necessary.
• let hot drinks cool down first.
• use ice or cold dishes, because the cold numbs the pain.
• do not use sharp herbs and spices, fruit juice, carbonated soft drinks, alcoholic beverages, very salty foods and sour food.
• food with hard crusts, nuts, bones and bones can cause injuries.
• use soup, gravy or sauce with the hot meal to make the food smoother.
• spreadable cheese, spreadable paté or salad, jam or honey on bread, porridge, drinking breakfast and custard, for example, swallows easier than dry spreads.
• if you need to use ground or liquid food, you can use a mixer to grind your meal with some extra moisture.

In some forms of arthritis or use of certain drugs intestinal complaints can occur. The intestinal complaints can arise from the influence of certain drugs on food intake. Conversely, the food you eat can have an effect on the way your drugs work.

Dietary supplements, fish fatty acids, glucosamine and vitamin D?
• Dietary supplements are available as pills, powders, drops, capsules or drinks and are intended as a supplement to inadequate daily nutrition. They contain vitamins, minerals or bio-active substances. These synthetic or isolated vitamins, minerals or bio-active substances have the same effect as the vitamins and minerals that are already naturally in your food and drink.
Many people choose an additional supplement, in addition to their daily diet. The users of dietary supplements indicate that they experience positive effects of the use of certain herbs, vitamins and minerals. The body absorbs the nutrients in pills more easily than the nutrients in food. But if you eat healthy and varied, you do not need additional nutritional supplements, because you already get enough nutrients, minerals and vitamins. Always report to your doctor and pharmacist that you are using dietary supplements.
• Fish fatty acids appear to have a mild anti-inflammatory effect with a high intake. Research has been done especially in rheumatoid arthritis. The advice is to eat oily fish twice a week.
• Glucosamine can act as a mild painkiller for osteoarthritis in the knee, but does not stop arthritis.
• Our body naturally makes vitamin D under the influence of outdoor sunlight. Vitamin D may have a beneficial effect in inflammatory arthritis, but that has not yet been proven sufficiently. People with Lupus erythematosus get vitamin D prescribed as they are not often outside, because sun exposure can lead to lupus flares and skin problems. Vitamine D is given with calcium tablets to ensure a good intake in the body, when you have osteoporosis or osteoarthritis.

Living with the illness

Patient education is important in order to cope with rheumatoid arthritis (RA). Finding that RA is a chronic illness can cause worry about the future and feelings of isolation or depression. Thanks to greatly improved treatments, these feelings tend to decrease with time as energy improves and pain, inflammation and stiffness decrease.
It is important to emphasize to patients to be physically active and do low-impact aerobic exercises, such as walking, and exercises to boost muscle strength. This will improve your overall health and lower the pressure on your joints. But it is also important to, if necessary, scale back activities when the disease flares to gentle range-of-motion exercises, such as stretching. This will keep the joint flexible. In general, resting is helpful when a joint is inflamed or when you feel tired. A physical or occupational therapist can help with the activities.

Advice
Avoid overloading of vulnerable joints.
When opening a jar, it might be impossible or very difficult to do so with your hand joints. Use a tool to make the operation lighter. An occupational therapist or physical therapist can advise you on the right choice of aids or adjustments. Their advice is not only about the choice of the tool, but also on how you can use the tool and where you can purchase it.
Divide your body strength over multiple joints.
Use your large joints as much as possible instead of your small vulnerable joints.
Avoid a peak load in activities or a long-term overload of your joints.
Alternate heavy and light work with each other.
Take rest breaks.
Take a short break periodically between your activities or during a burdensome activity.
Ensure enough physical activity.
Make sure you get enough exercise by exercising at least 30 minutes per day.
Ask for help, when needed.
Do not be modest and ask for help if you really need it.

Abbott Immunology I Rheumatoid arthritis - hybrid medical animations

The Doctors I Arthritis: More than Achy Joints

Nature video I Immunology of the rheumatoid joint.

Manipal Hospitals I How Is Rheumatoid Arthritis Treated?

Mechanisms in Medicine I Treatments for Rheumatoid Arthritis

Mechanisms in Medicine I The Pathological Processes - Persistence and Destructiveness of Synovitis

Covenant Health I Rheumatoid Arthritis

Videos sources

Manipal Hospitals I How Is Rheumatoid Arthritis Treated? I https://youtu.be/YQUSloX_XgA
Abbott Immunology I Rheumatoid arthritis I https://youtu.be/imR4hCwrGmQ
The Doctors I Arthritis: More than Achy Joints I https://youtu.be/BHTeJeTsQLk
Nature video I Immunology of the rheumatoid joint I https://youtu.be/nYjzl3Xc_0E
Mechanisms in Medicine I Treatments for Rheumatoid Arthritis I https://youtu.be/L13pGJ7n58U
Covenant Health I Rheumatoid Arthritis I https://youtu.be/YTLARL39bFA
Mechanisms in Medicine I The Pathological Processes Leading to Persistence and Destructiveness of Synovitis I https://youtu.be/-9Bj8g22qCs
Patient Education Library I Rheumatoid arthritis I https://www.ypo.education/rheumatology/rheumatoid-arthritis-t60/video/

Accountability text rheumatoid arthritis
The information about rheumatoid arthritis is general.
Every situation is different, so if you have any questions or complaints, always consult your doctor, medical specialist or pharmacist.

Patient videos
The patient videos are provided for general education only. Individuals should consult a qualified health care provider for professional medical advice, diagnosis and treatment of a medical or health condition.

The Caribbean Arthritis Foundation does not provide medical advice, diagnosis or treatment!
The contents of the Caribbean Arthritis Foundation Site, such as text, graphics, images, and other material contained on the Caribbean Arthritis Foundation Site, (‘Content’) are for informational purposes only.