Rheumatoid Arthritis: Causes, Diagnosis and Treatment

by Johnny Jacks

The prominent characteristic of Rheumatoid Arthritis is chronic symmetric polyarthritis, affecting both hands and feet. The severity of the disease varies over time, with the most common chronic manifestation of Rheumatoid Arthritis being joint destruction, deformity, and functional impairment.

What is Rheumatoid Arthritis?

Rheumatoid Arthritis is a systemic autoimmune disease characterized by painful and swollen joints that can severely impact physical and quality of life. In Rheumatoid Arthritis, patients may have some joints permanently inflamed, gradually becoming deformed and stiff, with weakening of the muscles.

What is Rheumatoid Arthritis?

What is Rheumatoid Arthritis?

Causes of Rheumatoid Arthritis

Joint inflammation is an autoimmune disease with unclear causes, often influenced by genetic, environmental, endocrine, immune, and infectious factors.

It has been observed that the heritability of Rheumatoid Arthritis accounts for approximately 50%, and is often associated with HLA alleles.

Infectious agents are also considered underlying causes of Rheumatoid Arthritis, such as Mycoplasma, Epstein-Barr virus, and Rubella virus.

Sex hormones also play a role in Rheumatoid Arthritis, where elevated blood prolactin is a risk factor.

Additionally, smoking has been found to increase the risk of Rheumatoid Arthritis. Social-economic, psychological, and lifestyle factors also impact the progression of Rheumatoid Arthritis.

Clinical manifestations and diagnosis of Rheumatoid Arthritis

The hallmark of Rheumatoid Arthritis (RA) is the persistent, symmetric, and polyarticular joint inflammation that affects both hands and feet. The severity of the disease varies over time, with the most common chronic form of RA leading to joint destruction, deformity, and functional impairment.

Moreover, RA also causes extra-articular damage to organs such as the skin, heart, lungs, and eyes. Patients with RA often experience pericarditis, arrhythmias, myocarditis, pulmonary fibrosis, pleural effusion, dry eyes, polyneuropathy, and vasculitis.

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Systemic manifestations of RA include fatigue, malaise, morning stiffness, weight loss, and mild fever. In most patients, RA develops insidiously, with systemic symptoms preceding joint inflammation and swelling.

Rheumatoid Arthritis (RA) can be diagnosed based on the criteria of the American College of Rheumatology (ACR) in 1987, if the patient has 3 out of 7 following factors:

  1. Morning stiffness in joints lasting longer than 1 hour.
  2. Swelling of soft tissue or fluid accumulation in at least 3 of 14 symmetric joints, including proximal interphalangeal, metacarpophalangeal, wrist, ankle, metatarsophalangeal, elbow, or knee joints.
  3. Swelling of at least 1 joint in the upper limbs such as the wrist, proximal interphalangeal or metacarpophalangeal joint.
  4. Symmetric joint inflammation.
  5. Subcutaneous nodules.
  6. Positive serum rheumatoid factor.
  7. Typical radiographic changes, such as erosions, juxta-articular osteoporosis, joint space narrowing, or bony proliferation with or without subluxation.

In addition, the patient should also be evaluated for extra-articular symptoms such as muscle atrophy, eye inflammation, subcutaneous nodules, pericardial effusion, or pleural effusion.

RA can also be diagnosed in the early stage before joint damage appears on X-ray based on the ACR/EULAR 2010 criteria, which include:

  1. The number of large joints affected (2-10 = 1 point, 1-3 small joints with or without large joint involvement = 2 points, 4-10 small joints with or without large joint involvement = 3 points, >10 joints with at least one small joint involvement = 5 points).
  2. Serology (either low-positive rheumatoid factor or low-positive anti-CCP = 2 points, high-positive rheumatoid factor or high-positive anti-CCP = 3 points).
  3. Acute-phase reactants (CRP or ESR) = 1 point.
  4. Symptom duration (≥6 weeks) = 1 point.

A score of 6 or higher indicates RA. It is important to differentiate RA from other conditions such as systemic lupus erythematosus, osteoarthritis, gout, or other forms of inflammatory arthritis.

How is low rheumatoid arthritis treated?

In the treatment of low rheumatoid arthritis, patients require comprehensive and long-term monitoring and treatment. Among them, classic DMARDs play an important role in stabilizing the disease and providing long-term treatment. Biological drugs such as TNF-α inhibitors, Interleukin-6 inhibitors, and B lymphocyte inhibitors are used if the patient has severe low rheumatoid arthritis or if treatment is ineffective.

Treating symptoms of Rheumatoid Arthritis

Treating symptoms of Rheumatoid Arthritis.

Treating symptoms of Rheumatoid Arthritis

The purpose of this treatment is to improve inflammation, reduce pain, and help patients maintain mobility.

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Selective COX-2 inhibitor non-steroidal anti-inflammatory drugs (NSAIDs) are used for long-term treatment of Rheumatoid Arthritis, including Celecoxib, Meloxicam, and Etoricoxib.

Or patients with Rheumatoid Arthritis who use non-selective NSAIDs include Diclofenac, Piroxicam, and Cyclodextrin, as directed.

Short-term corticosteroid therapy is administered to Rheumatoid Arthritis patients during flare-ups, as follows:

  • Rheumatoid Arthritis patients are given Methylprednisolone at a dose of 16 to 32 mg per day, taken after breakfast.
  • In severe cases of Rheumatoid Arthritis, intravenous Methylprednisolone is given at a dose of 40mg per day.
  • For patients with acute, severe, life-threatening Rheumatoid Arthritis, treatment is initiated with Methylprednisolone at a dose of 500-1000mg intravenous infusion per day for 30 to 45 minutes, for 3 days. Then, reduce to a standard dose, which can be repeated once a month if necessary.

For patients who are dependent on corticosteroids or who have adrenal insufficiency due to corticosteroids, long-term treatment is initiated with a dose of 20mg per day taken after breakfast. Then, gradually taper off and maintain the lowest dose possible below 5mg per day, or alternate days or discontinue when basic treatment is effective.

Basic therapy in rheumatoid arthritis

The basic treatment approach for Rheumatoid Arthritis involves the use of long-term therapy and monitoring of clinical and paraclinical symptoms to slow down or stop disease progression.

For patients with newly diagnosed Rheumatoid Arthritis, the following treatment protocol is typically used:

Methotrexate is initiated at a single dose of 10 mg/week, which can be adjusted based on response but should not exceed 20 mg/week. Alternatively, Sulfasalazine is used at a daily dose of 500 mg, increasing by 500 mg/week up to a maintenance dose of 1000 mg twice daily. Methotrexate can also be combined with Hydroxychloroquine or Sulfasalazine, or all three medications can be used in combination.

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For patients with severe Rheumatoid Arthritis who do not respond to classic basic treatment after six months, the following medications can be added:

Combination therapy of Methotrexate and anti-tumor necrosis factor alpha (anti-TNF-α) agents, such as Etanercept administered subcutaneously at a dose of 50 mg once weekly or Infliximab administered intravenously at a dose of 2 to 3 mg/kg every 4 to 8 weeks. Combination therapy of Methotrexate and Tocilizumab, an interleukin-6 antagonist, administered intravenously at a dose of 4 to 8 mg/kg per month. Combination therapy of Methotrexate and Rituximab, administered intravenously at a dose of 500 to 1000 mg every 2 weeks, with 1 to 2 treatment courses per year.

Combined treatment methods for rheumatoid arthritis

Patients with rheumatoid arthritis need to exercise and move to avoid joint stiffness. If a patient experiences acute inflammation, they should rest the joint in a functional position without straining or pressing it. Once inflammation symptoms subside, patients should gradually increase exercise intensity according to joint function.

Patients with rheumatoid arthritis can be treated with physical therapy and surgery when necessary. During treatment, complications such as gastrointestinal ulcers and enteropathy caused by proton pump inhibitors should be avoided, and precautions should be taken against osteoporosis.

Patients with rheumatoid arthritis should be monitored regularly during treatment, detect damage in a timely manner, and evaluate the effectiveness of the treatment.

These are some basic information about the causes, diagnosis, and treatment of rheumatoid arthritis, and it is hoped that they will be useful to readers.

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