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Rheumatoid arthritis: disease of the joint lining can be debilitating
My mother has rheumatoid arthritis. What is the long-range prognosis for this disease?
Rheumatoid arthritis is an autoimmune disease where the immune system attacks the cells lining the joints. This lining, called synovium, becomes inflamed, leading to damage to bone, cartilage, tendons, and ligaments. Unfortunately, there is no cure for rheumatoid arthritis, but there is treatment to lessen the pain and inflammation inherent in the disease and to prevent joint destruction.
Unlike osteoarthritis, which affects such large, weight-bearing joints as the hips and knees, rheumatoid arthritis typically involves the smaller joints in the hands, wrists, and feet. The joints tend to be involved in a symmetrical pattern, so that, for example, if the knuckles on the right hand are inflamed, those on the left will be inflamed as well. In some cases, the larger, weight-bearing joints also become inflamed.
The onset of rheumatoid arthritis is usually slow. Most people initially experience fatigue, loss of appetite, low-grade fever, and vague muscular symptoms. Eventually, joint pain appears, with the joints feeling warm, swollen, and tender. Only a couple of joints are affected at first, but as the disease progresses, other joints become involved.
Rheumatoid arthritis can strike at any age, says Joseph H. Korn, M.D., director of the Arthritis Center at the Boston University School of Medicine and chief of the Rheumatology Section at Boston Medical Center, with a slightly increasing incidence as one gets older. Women are three times more likely than men to have rheumatoid arthritis, most likely because of hormonal influences on the immune system.
Most treatments for rheumatoid arthritis are geared toward relieving pain, reducing inflammation, and slowing down or preventing the destruction of the affected joints. The three primary medical treatments include anti-inflammatory drugs, disease-modifying antirheumatic drugs, and corticosteroids.
Anti-inflammatory drugs, such as aspirin and ibuprofen, work immediately to suppress pain and inflammation in the joints. "These drugs are fairly effective," says Korn, "but there is no convincing evidence that they do anything to deter joint destruction." They only work, he adds, if they are taken regularly; that is, once the patient stops taking the medication, the pain and inflammation return.
Disease modifying antirheumatic drugs, or DMARDs, work on the underlying mechanism of the disease. While they can decrease inflammation, they also have been shown to prevent bone and cartilage destruction. The most common of these drugs are methotrex- ate, which works well in most patients, Korn says. Newer DMARDs include leflunomide, etanercept, and inflixamab, all of which are quite effective. Use of DMARDs can occasionally cause serious side effects, including damage to the kidneys and bone marrow and infection.
"Many patients treated with corticosteroids improve dramatically in the short term, but steroids can also cause long-term side effects that are not reversible," says Korn. These include atherosclerosis, osteoporosis, cataracts, and aggravation of diabetes.
Surgery, which shows no evidence of affecting the course of inflammatory disease, is used only to correct joint deformity and dysfunction caused by rheumatoid arthritis.
Because rheumatoid arthritis is a systemic disease, there are many extra-articular (outside of the joint) features of the disease as well, Korn says. These include rheumatoid nodules, which are masses usually located over joints; pericarditis, or inflammation of the lining of the heart; and a destruction of the blood vessels called vasculitis, as well as potential damage to the renal, pulmonary, and cardiovascular systems.
While rheumatoid arthritis is a chronic disease, its course varies. Some people have a mild form, while others have a severe case. Regardless, says Korn, "life expectancy for rheumatoid arthritis patients is substantially reduced" because the disease often compromises other organ systems. Rarely does the disease go away, he says, although there may be temporary relief from the symptoms.
"Health Matters" is written in cooperation with staff members of Boston Medical Center. For more information on rheumatoid arthritis or other health matters, call 638-6767.