Rheumatoid arthritis

Rheumatoid arthritis: description

Rheumatoid arthritis (RA) is also referred to as (primary) chronic polyarthritis. It is an inflammatory joint disease. Affected are especially the small joints on hands and feet.

Rheumatoid arthritis is the most common inflammatory joint disease in the world. In Germany, around 800,000 people are affected, or about one percent of the population. About two thirds of the patients are female. Although rheumatoid arthritis can occur at any age, most patients are between 55 and 75 years old at the onset of the disease. Ten percent of patients have a first-degree relative (ie, a parent) who also has rheumatoid arthritis. The likelihood of having identical twins with both is about 15 to 20 percent.

rheumatism

Rheumatism is a term that is heard more often in everyday life. Colloquially, in addition to rheumatoid arthritis, other diseases of the so-called rheumatic type are meant as, for example:

• ankylosing spondylitis
• Reiter’s syndrome
• Psoriatic arthritis

Other related diseases are vasculitis (vascular inflammation) and collagenosis (autoimmune connective tissue diseases) such as lupus erythematosus or scleroderma. In the vernacular, joint inflammation of a cause other than rheumatism are referred to, such as osteoarthritis or gout. In the medical sense, this is not correct.

Rheumatoid arthritis: Special forms

There are some special forms of Rheumatoid Arthritis:

Caplan syndrome: Rheumatoid arthritis in combination with a quartz dust bug (silicosis). Doctors also talk about silicoarthritis. Caplan syndrome typically occurs in hard coal mining workers.

Felty’s syndrome: Felty syndrome is a severe form of rheumatoid arthritis that affects mostly men. In addition to arthritis, the spleen is swollen and the number of white blood cells (leukocytes) and platelets (platelets) is reduced.

Age Rheumatoid Arthritis (late onset rheumatoid arthritis, LORA): Age rheumatoid arthritis is a common disease. It breaks out only after the age of 60 and often affects only one or a few large joints. In addition, there are often general symptoms such as fever, performance kink, weight loss and muscle atrophy.

Juvenile Rheumatoid Arthritis: Juvenile rheumatoid arthritis is one of the most common chronic childhood diseases. Their causes are usually unclear. It is assumed that a – partially unrecognized – bacterial infection strongly activates the immune system in those affected. As a result, the body’s own tissue is destroyed (autoimmune reaction).

Systemic arthritis: Still’s disease is a subset of juvenile rheumatoid arthritis, affecting not only the joints but also other organ systems such as the liver or spleen. The prognosis of this disease is unfavorable.

Rheumatoid arthritis: symptoms

Rheumatoid arthritis begins with nonspecific symptoms such as

• fatigue
• slight fever
• Heaviness of the musculature
• fatigue
• anorexia
• depression

Many patients initially think of a flu infection or a sports injury. Only later in the course of typical rheumatoid arthritis symptoms. These include pain and swelling of the small joints on the fingers and feet, usually on both hands or feet simultaneously (symmetrical infestation). Above all, a strong handshake causes severe pain in the patients (Gaenslen sign).

In addition, patients complain that the joints feel stiff in the morning. This morning stiffness lasts more than half an hour and, for example, causes the patient difficulty holding the coffee cup.

Rheumatoid arthritis can also lead to circulatory disorders of individual fingers. Later, larger joints in the middle of the body may be affected, such as the elbow, shoulder and knee joints or the upper cervical spine. The distal joints (distal interphalangeal joints, DIPs) as well as the thoracic and lumbar spine are usually unaffected in rheumatoid arthritis.

Other Rheumatoid Arthritis Symptoms

Rheumatoid arthritis can attack other structures as well as joints. In this way can arise:

• Carpal Tunnel Syndrome: Constriction of the median nerve on the wrist due to thickened, inflamed tendon sheaths
• Sulcus ulnar nerve syndrome: Ulnar nerve irritation on the elbow
• Baker’s cyst: fluid accumulation in the popliteal fossa that may affect bowing
• Rheumatic nodules: nodular structures that form in the subcutaneous fatty tissue along the tendons or at pressure points
• Sicca syndrome (secondary Sjögren syndrome): dysfunction of the salivary and lacrimal glands

Rheumatoid arthritis: organ manifestations

Rheumatoid arthritis can also affect the internal organs. Possible consequences are:

• Cardiac valve disorders
• Pituitary inflammation (pleurisy)
• Connective tissue remodeling of the liver (liver fibrosis)
• Renal inflammation (glomerulonephritis)

Rheumatoid arthritis: causes and risk factors

The exact cause of rheumatoid arthritis is still unknown. But there are different theories about disease development. For one, the genetic material seems to have an influence. This is supported by the fact that rheumatoid arthritis frequently occurs in families. In addition, many patients have similarities in the so-called HLA genes. HLA stands for “Human Leukocyte Antigen”. The HLA proteins can mark cells as endogenous or foreign. Thus, the immune system knows which cells (foreigners) should be attacked and which are not (the body’s own). However, certain changes in the HLA genes can lead to this distinction no longer working and the immune system attacking the body’s own structures (autoimmune reaction). In this way, rheumatoid arthritis can arise, experts suggest. Studies have shown that about 70 percent of rheumatoid arthritis patients carry the HLA gene DR4 / DRB1. In the healthy population, only about 25 percent of people have this gene variant.

Another possible cause of rheumatoid arthritis are environmental influences in terms of infections or allergies. Pathogens such as herpesviruses or rubella viruses may be the cause of the disease. Smoking and obesity can also contribute to the onset of the disease if other risk factors exist.

Rheumatoid arthritis: Gradual joint destruction

Rheumatoid arthritis begins with inflammation of the synovial membrane (synovitis). In the further course it leads to arthritis, bursitis and tenosynovitis. The articular mucosa (also known as the synovial membrane or synovium) thickens, and immigrating immune cells and an increase in connective tissue cells results in a so-called pannus. It overgrows and destroys the articular cartilage and can also grow into the underlying bone. The consequences are malpositions and ankylosis (stiffening of the joints).

The attack of antibodies against the own mucous membrane (autoantibodies) sets in motion a vicious circle, since the destruction of the synovium releases further inflammatory substances. These mediators (for example TNF-α or interleukin-1) ensure that even more joint structures are destroyed, which leads to a renewed flare-up of the inflammatory reaction.

Rheumatoid arthritis: examinations and diagnosis

Most rheumatoid arthritis patients first seek out their family doctor. The nonspecific symptoms at the beginning of the disease are often misinterpreted as a harmless influenza infection. If rheumatoid arthritis is known to occur in your family, your GP will refer you to a rheumatologist. He can provide the correct diagnosis with a lot of experience and great expertise and initiate the necessary therapy.

To diagnose rheumatoid arthritis, the doctor first asks you in detail about your medical history (medical history). Possible questions are:

• Is someone suffering from rheumatism in your family?
• When are the complaints the worst?
• Which joints are affected?
• Have you noticed other symptoms in addition to joint pain?

Next, your doctor will examine you. For example, he looks closely at your finger and wrist joints and checks their flexibility.

Rheumatoid arthritis: blood test

Also important for the diagnosis is a blood test, because the rheumatoid arthritis can change unspecific blood values ​​in the sense of an inflammatory reaction:

• elevated CRP (C-reactive protein)
• strongly accelerated ESR (erythrocyte sedimentation rate)
• decreased Hb (hemoglobin = red blood pigment)
• elevated ceruloplasmin
• increased α2 and γ bands in electrophoresis
• Anemia (anemia)

Laboratory data that may indicate rheumatoid arthritis include rheumatoid factor, anti-CCP antibodies and other autoantibodies:

At the rheumatoid factor they are antibodies against so-called Fc fragments of antibodies of the class IgG. They can be detected in 65 to 80 percent of all patients. Then there is a so-called seropositive rheumatoid arthritis. However, the rheumatoid factor may also be positive in healthy individuals or be absent in some patients (then it is a seronegative rheumatoid arthritis).

Anti-CCP antibodies are directed against cyclic citrullinated peptide: Citrulline is an amino acid (protein building block), which is found in larger quantities in the coagulant fibrin, but is rare in the rest of the body. Fibrin is released not only in the blood clotting, but also in inflammation in joints. Where citrulline antibodies dock, so must the inflammation, so the theory. Anti-CCP antibodies are often early on and detectable in many patients with rheumatoid arthritis in the blood.

Other autoantibodies such as ANA (antinuclear antibodies) are detectable in a few patients.

Rheumatoid arthritis: Imaging procedures

Imaging techniques help diagnose and determine the stage of the disease. X-rays of the hands and feet, especially at an advanced stage, make it easy to recognize changes in the joints resulting from rheumatoid arthritis, for example:

• Narrowing of the joint space
• chondrolysis
• ossification
• Gelenkauskugelungen (dislocations)

Other imaging techniques that can help diagnose rheumatoid arthritis include:

• Ultrasound (sonography): visualization of articular effusions and thickening of the tendons
• Scintigraphy (Nuclear Medicine Examination): Illustration of an increased metabolism in the inflamed area
• Magnetic Resonance Imaging (MRI): presentation of early changes at onset of disease

Rheumatoid arthritis: similar diseases

As already mentioned, there are many diseases associated with joint discomfort. Therefore, it is important to distinguish a rheumatoid arthritis against these diseases in the diagnosis. These include:

• ankylosing spondylitis
• psoriatic arthritis
• Polymyalgia rheumatica
• Sjogren’s syndrome
• Systemic lupus erythematosus (SLE)
• Rheumatic fever (postinfectious)
• gout

Rheumatoid arthritis: treatment

For rheumatoid arthritis therapy, the motto is “hit hard and early”, in German so “hard and early strike”. In this way, in many cases, the threat of joint destruction can be prevented or at least delayed for a long time. Treatment should begin as early as the first three months after onset of the first symptoms. Then it is the most effective. There are several medications that treat rheumatoid arthritis. In addition, supportive measures such as physiotherapy, thermal therapy, relaxation therapies or alternative healing methods are available. Undisputed is the need for a drug therapy.

Rheumatoid arthritis: drug therapy

There are several medicines for rheumatoid arthritis. A distinction is made between so-called basic therapeutics (also disease-modifying antirheumatic drugs, DMARD) and non-steroidal anti-inflammatory drugs (NSAIDs). DMARDs can partially halt joint destruction, NSAIDs are also used to relieve pain in acute onset.

The most important representative of the DMARD is methotrexate (MTX) with its good tolerability and best efficacy. It is used at the beginning of the disease and can be taken as the sole medication (monotherapy). Since it takes several weeks for MTX to fully develop its effect, additional glucocorticoids (cortisone) are given at the beginning of therapy. They are particularly effective and can repair rheumatoid arthritis-related damage to the joint. Due to their strong side effects they are not suitable as a basic therapy.

If six weeks after the start of treatment no improvement in symptoms has occurred, the dose of MTX will be increased. If no effect is detectable even after 12 weeks, additional DMARDs will be used with MTX – either the triple combination with sulfsalazine and hydroxychloroquine or the combination of two with leflunomide or ciclosporin.

If, after half a year, no treatment success can be reported, patients receive so-called biologicals (biologics). These can also be combined with MTX. Biologics are biotechnologically produced proteins that interfere with the immunological processes of the body. These include:

• TNF-α inhibitors such as adalimumab, etanercept, infliximab
• Abatacept (T cell activation inhibitor)
• Tocilizumab (interleukin-6 antibody)
• Rituximab (B cell antibodies)
• Anakinra (interleukin-1 competitor)

Which drugs work best varies from patient to patient. If you have found the right medication, your dose will be lowered gradually after the onset of a disease thrust. The aim is to determine the so-called maintenance dose, which is strong enough to keep rheumatoid arthritis at bay, but weak enough that the side effects are justifiable.

Rheumatoid arthritis: Side effects of therapy

All mentioned active substances can have side effects. These vary according to the dose and also vary from patient to patient – some people are more affected by them than others. Possible adverse drug reactions of MTX include:

• Blood disorders
• Kidney and liver damage
• Gastrointestinal complaints
• a headache
• skin rash

If MTX is not tolerated or can not be used for medical reasons (contraindications), other medicines will be used, for example, leflunomide, sulfsalazine or gold supplements. If rheumatoid arthritis is very mild, the antimalarial preparations chloroquine or hydroxychloroquine can be given alone.

During pregnancy, rheumatoid arthritis should only be treated with cyclosporine, azathioprine and sulfsalazine so as not to endanger the unborn child. In addition, MTX and leflunomide should be discontinued months before a planned pregnancy.

Rheumatoid Arthritis: Invasive Therapy

Rheumatoid arthritis can also be treated with an invasive therapy, that is, with measures that involve an intervention in the body. This includes:

• Joint Puncture: If there is an effusion in the affected joint, it can be punctured to drain the fluid and so relieve the discomfort.
• Radiosynoviorthesis (RSO): Radioactive substances are introduced into strongly inflamed joints. In this way, freedom from pain can be achieved after a few months in individual joints.
• Synovectomy: This surgery removes the synovial membrane, which contributes significantly to the symptoms of rheumatoid arthritis.
• Joint replacement: If a joint has been destroyed by rheumatoid arthritis, it may be replaced by a prosthesis.

In all invasive methods, care must be taken to strictly comply with hygienic regulations, as joints can easily become infected.

Rheumatoid arthritis: physiotherapy

Rheumatoid arthritis should not only be treated with medication but also with physiotherapy. This can:

• improve the mobility of the joints
• strengthen or relax the muscles
• Prevent misalignments
• reduce pain

Special manual therapy handles can loosen joint blockages and restore mobility. Massages help against muscle tension.

Rheumatoid arthritis can also be treated by thermotherapy. In phases of acute inflammation, cold applications help relieve pain and inhibit inflammation. Heat, on the other hand, stimulates the metabolism and promotes blood circulation. In phases of remission (temporary lessening of symptoms) tension can be resolved. If you have cardiovascular disease (such as high blood pressure, heart failure), you should, however, renounce the thermotherapy.

If rheumatoid arthritis is severe, you must adapt your lifestyle to the condition. As part of occupational therapy and rehabilitation you can practice activities of everyday life (at home, work and leisure) to maintain your self-employment (occupational therapy) or restore (rehabilitation).

Direct currents and alternating currents are also suitable for the supportive treatment of rheumatoid arthritis. They have different effects in different frequencies: Low-frequency therapy has analgesic and circulation-promoting properties, middle-frequency therapy strengthens muscles, and high-frequency therapy is a deep-action heat treatment. Caution: If you have a pacemaker and / or metal implants (such as a joint replacement), you should not use current treatments or only with restrictions.

Rheumatoid arthritis: alternative medicine

Also alternative medicine such as homeopathy or Traditional Chinese Medicine (TCM) are often used by patients in addition to the drug treatment. Also popular is naturopathy: There are several plants that can relieve symptoms of rheumatoid arthritis. These include:

• Nettle (anti-inflammatory, analgesic)
• Willow bark (analgesic, antipyretic)
• Devil’s claw (anti-inflammatory, analgesic)
• Frankincense (anti-inflammatory)

Rheumatoid arthritis: pain therapy, relaxation procedure

To better manage the pain, many patients with rheumatoid arthritis benefit from psychological pain therapy. The progressive muscle relaxation after Jacobson and autogenic training can relieve the symptoms.

Rheumatoid arthritis: sports and no smoking

Also do regular exercise, even if the joints hurt. Endurance sports help you feel better and keep your body fit. So you can prevent muscle tension.

Also, you should not smoke (anymore). The absence of nicotine can positively influence the course of rheumatoid arthritis.

Rheumatoid arthritis: diet

A meat-poor diet should have a beneficial effect on rheumatoid arthritis. Meat contains larger amounts of arachidonic acid – a building block for painkillers and inflammatory substances (prostaglandins). It is also increasingly included in dairy products. If the body lacks this acid, it produces less prostaglandins, and the inflammation weakens, according to the theory. From the diet you should not take more than 350 milligrams of arachidonic acid per week. Already with two meat meals weekly this limit is reached. Therefore, the recommendation is: Put meat on your diet only once a week and cover your other protein needs with fish and vegetable protein (such as legumes).

Other polyunsaturated fatty acids inhibit the production of arachidonic acid in the body. Therefore, preferably eat foods that contain many unsaturated fatty acids such as linseed oilseed rape, wheat germ, soybean and walnut oil.

The so-called eicosapentaenoic acid (EPA) also inhibits the formation of arachidonic acid in the body. EPA belongs to the omega-3 fatty acids and is contained in fish oil. It looks chemically confusingly similar to arachidonic acid and binds to the same receptors in the cell. However, no inflammatory substances are formed from EPA. EPA thus displaces the arachidonic acid from the metabolism, because both compete for the same enzymes. As a result, the number of painful and swollen joints decreases. If you can not make friends with fish dishes (at least twice a week), EPA is also available in the form of capsules containing pure fish oil. Studies have shown that fish oil can reduce the number of swollen joints. However, rheumatoid arthritis did not affect its disease activity or progression.

A healthy, balanced diet can support but not replace drug therapy. It also helps to prevent other diseases, such as cardiovascular disease and osteoporosis. Anyone who is overweight with a healthy diet will also spare his joints!

Rheumatoid arthritis: remedy

In order to cope better with the disease in everyday life, there are various aids, the cost of rheumatoid arthritis are often taken over by the health insurance:

Orthopedic shoes and insoles: Metatarsal, ball or toe rollers provide support and ensure that the pressure is better distributed; Heel wedges support the shortened foot behind; Shoe customisations adapt to the changed foot shape; Soft insoles or insoles cushion pleasantly.

Rails with and without joint:Supporting splints or bandages maintain joint flexibility and remove excessive pressure. There are also movable rails that use hinges to secure the direction and amount of movement of the joints; Also available are immobilizing splints that immobilize a joint overnight or in acute pain.

Walking aids: Depending on the degree of disability, a simple walking stick with or without a special grip, a crutch or a crutch can help. When walking, they give the necessary security. In the case of a particularly pronounced disability, a so-called rollator can also be helpful. This is a walker with brakes, seat board and small storage space that allows longer distances or an independent purchase.

Special tools: The raised toilet seat, handrails, shower wheelchair and bath lift make it easier to carry out thorough personal hygiene without external assistance, even in the case of severe restrictions on mobility – an important prerequisite for a good quality of life.

Rheumatoid arthritis: disease course and prognosis

Rheumatoid arthritis is bumpy. This means that highly inflammatory, painful conditions alternate with asymptomatic phases. At the beginning of the disease, there are often more relapses. Overall, the disease, classified according to the prevailing symptoms, often occurs in the following stages:

• Stage 1: Shallow onset of joint swelling and pain, morning stiffness and general signs of illness.
• Stage 2: Progressive decrease in joint mobility, muscle and bone atrophy, involvement of connective tissue (capsules, tendon sheaths, bursa).
• Stage 3: Beginning destruction of articular cartilage and bone. Gradual damage to the connective tissue (loosening of the ligaments and joint capsule), resulting in instability and malposition of the joints. Increasingly limited mobility. Spread of the disease to other regions (cervical spine, large joints, temporomandibular joints).
• Stage 4: Beginning joint stiffening, rough deformations; extensive disability and immobility. Patients are dependent on outside help in everyday life.

During pregnancy, the symptoms improve frequently.

Rheumatoid arthritis: complications

Without appropriate therapy, rheumatoid arthritis increasingly destroys cartilage, bone and connective tissue. This results in typical deformities of the fingers and feet:

• Ulnardeviation of the fingers (the fingers point in the direction of the little finger)
• Buttonhole deformity (flexion deformity in the middle finger joint, hyperextension in the finger-and-base joint)
• Gooseneck deformity (flexion deformity in the finger and metacarpophalangeal joint, hyperextension in the middle of the finger)
• 90/90 deformity of the thumb (flexion deformity in the metacarpophalangeal joint, hyperextension in the end joint)
• Hallux valgus, hammer toes, or phalanges pointing to the sides

In addition, many patients additionally develop osteoporosis. Then you should take a lot of calcium, for example about dairy products, broccoli or leeks. In addition, vitamin D helps with bone loss. It is found in large quantities in fish. In addition, the body can also produce vitamin D using sunlight.

Rheumatoid arthritis: prognosis

Rheumatoid arthritis is not curable. With the right treatment, however, a rest of the disease (remission) can be achieved. However, it is important that patients take their medicines throughout their lives and have their rheumatologist continuously assisted – even during periods when the disease is at a standstill. Thus, a resurgence of rheumatoid arthritis can be detected early and treated.

Overall, rheumatoid arthritis varies individually for each patient. It is therefore difficult to make a prediction about the course. However, a rough prognosis can be estimated on the basis of various factors: If the rheumatoid factor is present in the blood, the CCP antibodies are particularly high and the patient is a smoker, then one can assume a severe course. Most are the young patients, in which more than 20 joints are affected. Because with them the Rheumatoid arthritis often manifested outside the joints (extra-articular), their life expectancy is reduced in comparison to the healthy population.