Early treatment best for rheumatoid arthritis
"My doctor has recently told me that I have rheumatoid arthritis. Could you give me a little more information about this condition, and what treatments might be used?" Esme, 54 years old.
Arthritis is the general term for swelling or inflammation in one or more joints. It affects over 1 million New Zealanders at some point in their lives, and can be painful, unpredictable and disabling.
The most common types of arthritis are osteoarthritis (known as "wear and tear" arthritis), gout and rheumatoid arthritis. Rheumatoid arthritis (RA) is particularly important to detect early on, as it tends to progress and can result in gradual destruction of joints if left untreated. RA will affect around 1 in 100 people.
RA occurs three times more often in women than men, and the typical age range for first developing symptoms is 20-55 years, so Esme you do "fit" the profile for this condition. It is an autoimmune condition, which means that it can affect other systems in the body as well as joints, most commonly the skin or eyes. The following symptoms can be caused by RA, but unfortunately they may also occur in other conditions, making it a little hard to diagnose in some people:
* Joint swelling, pain and stiffness – this is usually worse in the morning, compared with osteoarthritis that tends to worsen as the day goes on. The joints are often affected in a symmetrical manner, so if the small joints of the right hand are affected, it is likely the same joints on the left hand will be. The most common sites for RA are hands, feet, wrists and ankles. Less commonly, it will affect knees, hips, shoulders, elbows and neck.
* Nodules form on the elbows and forearms – these small painless lumps are harmless, but can make diagnosing RA a little easier.
* Tenosynovitis – inflammation around the tendons can occur, causing pain similar to overuse syndrome.
* Anaemia and tiredness.
* Malaise, weight loss, muscle aches can occur.
* Occasionally, inflammation can affect other parts of the body, including the lungs, heart and blood vessels.
Typically RA will flare up over a few weeks, with symptoms getting gradually worse. It tends to be a chronic relapsing condition, which means that it is usually present for life, and will come and go with varying degrees of severity. In the more severe cases, it can progress quite rapidly, so the sooner you start treatment the better. If it is left untreated, the damage and erosion within the joints can be irreversible, leaving permanent disability and pain.
Your doctor will send you for blood tests and probably X-rays of the affected joints, to try and work out if you do have RA - if it appears that you do, as is the case for you Esme, it is likely you will be referred to a specialist known as a rheumatologist to discuss treatment options.
The treatment options include:
* Disease modifying drugs – known as DMARDs, this group of medicines not only ease the symptoms of RA, but also reduce the damage that occurs in the joints. Commonly prescribed DMARDs include methotrexate, sulfasalazine, penicillamine, leflunomide, azathioprine, cyclosporin and mycophenolate. Often patients need more than 1 DMARD to adequately control their RA, and it may take several months of treatment before any substantial benefit is noted.
* Biological medicines, or "mabs" – this newish group of drugs can be highly effective, but are reserved for use when a good trial of a DMARD has failed. Unfortunately they are expensive and need to be administered by injection, but they can be a lifeline for patients with severe RA that is not responding to other treatments.
* Steroids – oral or injected steroids, such as prednisone, can be really helpful at rapidly settling down a flare-up of RA. They can also be injected directly into particularly painful or inflamed joints. Unfortunately, they cannot be safely used long-term, except in low doses, but are a really good temporary solution.
* Anti-inflammatories – common anti-inflammatories such as ibuprofen, naproxen or voltaren can be really helpful at reducing the pain, swelling and stiffness associated with RA.
* Pain relief – paracetamol or codeine can be useful for controlling your pain, especially if you can't take anti-inflammatories. They are most effective when taken regularly, so talk to your doctor about what dose to take and how often.
* Physiotherapy and exercise – it is important to keep as fit and active as you can, with any type of arthritis. Not only is this good for protecting your joints, and the muscles that surround them, but it is also crucial for optimising your functioning and mental well-being. Many patients find low-impact exercise such as yoga, tai chi or pilates very helpful, and many get symptom relief from hydrotherapy. Esme, I would suggest you talk to your doctor or specialist about a referral. if you are not already seeing a physiotherapist or rehabilitation specialist.
Coming to terms with the diagnosis of a chronic illness is often a difficult process, especially if you are experiencing significant loss of function or ongoing pain. There is help available, both for your physical symptoms and to offer emotional support. If you would like more information, contact arthritis.org.nz .
Cathy Stephenson is a GP and medical forensic examiner.