Articles from prior issues of The Advocate

January/February, 1998

Rheumatoid Arthritis Treatment Focuses On Rest, Exercise and Medication
from the Mayo Clinic Health Letter, June 1997

WHEN PEOPLE THINK OF ARTHRITIS, they usually think of osteoarthritis, the most common form of arthritis. Osteoarthritis is the pain and stiffness that results from normal wear and tear on the joints over time. Rheumatoid arthritis (RA), however, is caused by an immune disorder. Its symptoms are more generalized and usually more severe. The disease typically strikes the hands, feet, and other joints. It causes painful swelling, inflammation and sometimes deformity. Years ago this disease attacked, devastated the joints and left people in wheelchairs. Today doctors are finding that rest, exercise, more aggressive use of medications, and sometimes surgery, can help many people with rheumatoid arthritis to live normal lives.

Joint Invasion

Lining each of the joints is a membrane called the synovium. With the onset of RA, the white blood cells - whose normal job is to attack unwanted invaders such as viruses - move from the blood stream into the synovium. There, the blood cells appear to cause the synovium to become inflamed. The inflammation results in the release of chemicals that over months or years cause thickening of the synovium. The chemicals also digest bone, cartilage, tendons, and ligaments in the joint. Gradually, the joint loses its shape and alignment. Eventually, it may be destroyed. Joints most often affected by rheumatoid arthritis are wrists, hands, feet and ankles. The disease can also invade elbows, shoulders, hips, knees, neck and jaw. Occasionally, it can cause inflammation in membranes surrounding internal organs, such as the heart and lungs.

More than ‘aches and pains’

The most common signs and symptoms of rheumatoid arthritis are joint swelling, stiffness and pain. The pain may be similar to that of a headache or toothache. Affected joints may also feel warm to the touch, and the skin covering them may appear reddish. On days when the disease is more active, the patient actually feel “sick.” Symptoms may include fatigue, loss of appetite, fever, sweats and difficulty sleeping. About one-fifth of people with rheumatoid arthritis also develop rheumatoid nodules -- lumps of tissue under the skin, often over bony areas such as the elbows. The disease varies from person to person. Some people experience symptoms that come and go. These episodes are called flares and remissions. Others may have continuous symptoms that generally worsen with time. The cause of rheumatoid arthritis is unknown, Many researchers believe an infection triggers the disease among people who carry a genetic susceptibility. Researchers believe that you can’t actually inherit the disease, but you can inherit a tendency to develop it. But this hasn’t been proven. Some people with rheumatoid arthritis have a protein in their blood called the rheumatoid factor. High levels of rheumatoid factor tend to be associated with more severe forms of the disease. But, not everyone who has the protein develops the disease. And not all people who have rheumatoid arthritis carry the protein.

Three types of medications

There is no treatment that can cure or reverse rheumatoid arthritis. However, there are medications that can relieve its symptoms and slow or halt its progression.

The three types of drugs used are:

Nonsteriodal anti-inflammatory drugs (NSAIDs) - This group of medications, which includes aspirin, helps relieve pain and inflammation. Side effects may include stomach upset and slow joint damage. Therefore, NSAIDs should be taken with food.

Corticosteriods - These medications (cortisone, prednisone and others) reduce inflammation and slow joint damage. In the short term, corticosteriods can make you feel dramatically better. However, when used for many months or years, they become less effective and also cause serious side effects. Side effects may include easy bruising, thinning of the bones, cataracts, weight gain, a round face, diabetes and high blood pressure.

Doctors will often prescribe a corticosteriod to relieve acute symptoms, with the goal of gradually tapering off the medication.

Disease-modifying anti-rheumatic drugs (DMARDs) - These medications have been shown to slow or halt the progression of rheumatoid arthritis. In the past, they were used only if the patient had more severe rheumatoid arthritis and noticeable joint destruction. Today, DMARDs are prescribed early to try to prevent destruction. When taken in proper doses, the drugs aren’t toxic as once believed. Depending on the drug used, side effects can range from blurry vision to increased susceptibility to infection.

Three of the most commonly prescribed DMARDs are methotrexate (Rheumatrex), hydroxychloroquine (Plaquenil) and gold (Myochrysine, Solganal). Sometimes , a combination of DMARDs may be used if one alone isn’t effective. Because they don’t relieve symptoms, DMARDs are taken in addition to an NSAID, a corticosteriod, or both. The drugs are slow acting, so it may take months before you notice benefits.

A balancing act

Rest and exercise are also key parts of treatment. During times when the joints are more warm, swollen and painful, rest helps. It is important to continue to do range of motion exercises to keep the joints mobile, but one should not get overly tired or aggravate the joints with unnecessary walking, housework, or other activities. It is important for the patient to schedule a midday rest, even if he/she does not sleep. Exercise can be increased when the joints feel better or when there is less fatigue and morning stiffness. Although weight-bearing exercises were once forbidden, studies now show that they can strengthen weakened muscles without additional joint damage. If the exercise produces more pain or joint swelling, next time do less.

Joints in need of repair

For about one-third of people with rheumatoid arthritis, treatment can’t prevent joint destruction. When this occurs, surgery can often help restore joint function, reduce joint pain or correct a deformity. The entire joint may need to be replaced with a metal or plastic prosthesis. Surgery may also involve tightening tendons that are too loose, fusing bones to reduce pain, or removing part of a diseased bone to improve mobility.