Pain Management and Rheumatoid Arthritis

Arthritis is a general term that describes inflammation in joints. That inflammation is characterized by redness, warmth, swelling, and pain.

Rheumatoid arthritis is a type of chronic arthritis that occurs in joints on both sides of the body (such as hands, wrists, or knees). This symmetry helps distinguish rheumatoid arthritis from other types of arthritis.

In addition to affecting the joints, rheumatoid arthritis may occasionally affect the skin, eyes, lungs, heart, blood, nerves, or kidneys.

Symptoms of rheumatoid arthritis include:

• Joint pain and swelling
• Stiffness, especially in the morning or after sitting for long periods
• Fatigue

Rheumatoid arthritis affects everyone differently. In most people, joint symptoms develop gradually over several years. But in some, rheumatoid arthritis may progress rapidly and yet other people may have rheumatoid arthritis for a limited period of time and then enter a period of remission.

Rheumatoid arthritis affects about 1% of the U.S. population. It is three times more common in women than in men. It usually occurs in people 20 to 50 years old, however, young children and the elderly also can develop rheumatoid arthritis.

The exact cause of rheumatoid arthritis is unknown, but it is thought to be due to a combination of genetic, environmental and hormonal factors. With rheumatoid arthritis, something seems to trigger the immune system to attack the joints and sometimes other organs. Some theories suggest that a virus or bacteria may alter the immune system, causing it to attack the joints.

Research hasn't been able to determine exactly what role genetics plays in rheumatoid arthritis. However, some people do seem to have a genetic or inherited factor that increases their chance of developing rheumatoid arthritis.

Once the immune system -- the disease fighting center of the body -- is triggered, immune cells migrate from the blood into the joints and produce substances that cause inflammation. The increased number of cells and inflammatory substances within the joint irritate the area and cause cartilage (cushioning material at the end of bones) to wear down and the joint lining (synovium) to swell and produce fluid.

As the cartilage wears down, the space between the bones narrows. If the condition worsens, the bones could rub against each other, causing significant pain.

As the swelling and inflammation worsens, the joint lining may invade or erode into the bone, resulting in irreversible damage to the bone. All of these factors cause the joint to become very painful, swollen, and warm to the touch.

The diagnosis of rheumatoid arthritis is based on a combination of factors, including:

• The specific location and symmetry of painful joints.
• The presence of joint stiffness in the morning.
• Presence of bumps and nodules under the skin (rheumatoid nodules).
• Results of X-ray tests that suggest rheumatoid arthritis.
• Positive results of blood tests called the rheumatoid factor and the anti-CCP antibody

Most, but not all, people with rheumatoid arthritis have one or both antibodies in their blood. The rheumatoid factor may be present in people who do not have rheumatoid arthritis. Other diseases also can cause the rheumatoid factor to be produced in the blood. Therefore, the diagnosis of rheumatoid arthritis is based on a combination of several factors and not just the presence of the rheumatoid factor in the blood.

People with RA may have a mild anemia. Blood tests may also reveal an elevated erythrocyte sedimentation rate (ESR), a marker of inflammation.

There are many different ways to treat rheumatoid arthritis. Treatments include medications, rest and exercise, and surgery to correct damage to the joint.

The type of treatment will depend on several factors including the person's age, overall health, medical history and severity of the arthritis.

There are many drugs available to decrease joint pain, swelling and inflammation, and possibly prevent or minimize the progression of the disease.

Medications that offer relief of arthritis symptoms (joint pain, stiffness and swelling) include:

• Anti-inflammatory painkiller drugs, such as aspirin, ibuprofen or naproxen
• Topical (applied directly to the skin) pain relievers
• Corticosteroids, such as prednisone. They can be injected directly into joints.
• Narcotic pain relievers

There are also many strong medications called disease-modifying antirheumatic drugs (DMARDs) that are used to treat RA. These drugs usually work by interfering with or suppressing the immune system attack on the joints. They include:

• Anti-malaria medications, such as hydroxychloroquine
• Chemotherapy drugs, such as methotrexate, Imuran, and Cytoxan
• Organ rejection drugs, such as cyclosporine
• Biologic treatments, such as Arava, Enbrel, Humira, Kineret, Remicade, Orencia, and Rituxan
• Miscellaneous drugs, such as Azulfidine, penicillamine, gold and minocycline
• Arava

Some of these medications are traditionally used to treat other conditions such as cancer or inflammatory bowel disease, or to reduce the risk of rejection of a transplanted organ. However, when chemotherapy drugs (such as methotrexate or Cytoxan) are used to treat rheumatoid arthritis, the doses are significantly lower and the risks of side effects tend to be considerably less than when prescribed in higher doses for cancer treatment.

The biologic treatments in particular have greatly improved the long-term outcomes for many patients with RA. However, they are very expensive and are given either by self injection or by intravenous infusion. By altering the immune system, they also can increase the risk of serious infection and so are often chosen for those with more severe disease.

When joint damage from the arthritis has become severe or pain is not controlled with medications, surgery is an option to restore function to a damaged joint.

A balance of rest and exercise is important in treating rheumatoid arthritis. During flare-ups (worsening of joint inflammation), it is best to rest the joints that are inflamed. This may be accomplished by the temporary use of a cane or joint splints.

When joint inflammation is decreased, guided exercise programs are necessary to maintain flexibility of the joints and to strengthen the muscles that surround the joints. Range-of-motion exercises should be done regularly to maintain joint mobility.

Although there is not yet a cure for rheumatoid arthritis, early aggressive treatment has been shown to help prevent disability. There are many different methods available for decreasing the pain and inflammation. Research is in progress to determine the cause of rheumatoid arthritis and the best treatment for it.

WebMD Medical Reference

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