Rheumatoid arthritis

Rheumatoid arthritis is one of a group of conditions called inflammatory arthritis, which also includes psoriatic arthritis and ankylosing spondylitis and related conditions, such as lupus. They cause pain, stiffness and swelling in your joints.

Inflammation is a normal part of your body’s immune response to fight disease and prevent infection. However, in rheumatoid arthritis your immune system is overactive and mistakenly attacks healthy tissues in your joints — this is called an autoimmune disease. 

The severity of rheumatoid arthritis varies from mild to severe. Over time, if left untreated, chronic inflammation can damage healthy bones and cartilage in your affected joints.

Although all joints can be affected, the most commonly affected joints are:

• Hands
• Feet
• Knees
• Wrists

Elbows, hips and shoulders are less commonly affected. 

With the right treatment, you should be able to continue to enjoy life with your symptoms mostly under control.

Rheumatoid arthritis doesn’t usually run in families and can affect anyone. It is the second most common type of arthritis in the UK, after osteoarthritis, affecting around 400,000 people in the UK. It occurs more often in women than in men.

The main differences between rheumatoid arthritis and osteoarthritis are the:

• Onset — rheumatoid arthritis can occur at any age, though usually in your 40s, and progresses quickly; osteoarthritis starts later, usually after age 60, and develops gradually
• Underlying cause — rheumatoid arthritis is an autoimmune disease while osteoarthritis is caused by wear and tear with age

The most common rheumatoid arthritis symptoms are:

• Joint stiffness eg if you can’t bend your fingers
• Loss of function with certain tasks or movement
• Aching and throbbing joints, especially in the morning
• Swollen joints that are also painful — this can affect any joint but usually starts in small joints before progressing to bigger joints
• Tendonitis
• Trigger finger

You may also experience general symptoms outside your joints, including: 

• Anaemia
• Depression
• Fatigue
• Fever and flu-like symptoms
• Inflammation of tissues outside your joints
• Unexplained weight loss

Symptom patterns

In most cases, symptoms first develop in the hands, feet and wrists, most notably in the morning, easing off by midday. Symptoms may come and go until they become regular.

Cold, damp weather can make your symptoms worse and at times your symptoms can be significantly worse — these are called flare-ups.

There is no definitive test for rheumatoid arthritis and other conditions can cause similar symptoms. Your GP will ask about your symptoms, check the movement of your joints and perform a physical examination. 

If they think you have rheumatoid arthritis, they'll recommend a blood test and refer you to a rheumatologist (a doctor who specialises in diagnosing and treating arthritis). 

A blood test will check for several different proteins that can indicate rheumatoid arthritis. Your blood test may measure: 

• Anti-cyclic citrullinated peptide (anti-CCP) — antibodies that attack healthy tissue in your body
• C-reactive protein (CRP) levels — a measure of inflammation
• Erythrocyte sedimentation rate (ESR) — a measure of inflammation
• Rheumatoid factors — proteins produced by your immune system when it mistakenly attacks healthy tissue
• Your full blood count — this can:
• Check if you have anaemia, which is common in people with rheumatoid arthritis
• Help rule out other conditions 
• Indicate your general health 

To identify the type of arthritis you have and monitor how the disease progresses over time, your rheumatologist may also take images of your joints, such as:

• An X-ray
• MRI scan
• Ultrasound scan

If you receive a diagnosis of rheumatoid arthritis, your rheumatologist may assess how you cope with everyday tasks.

Rheumatoid arthritis occurs when your immune system makes antibodies that mistakenly attack the healthy linings of your joints. Your joint linings, therefore, become inflamed. This inflammation causes chemicals to be released that damage nearby bones, cartilage, ligaments and tendons. Over time, this causes the joints to become deformed and misaligned, and eventually, the joints are destroyed. 

Some people have a greater tendency to develop autoimmune diseases. However, what triggers the autoimmune response in rheumatoid arthritis is unknown. It may be linked to:

• Drinking a lot of coffee or eating a lot of red meat
• Genetics — rheumatoid arthritis doesn't usually run in families but there is evidence of genes playing a small role; the risk of inheriting rheumatoid arthritis is low 
• Infection
• Injury
• Smoking — this increases your risk of rheumatoid arthritis
• Stressful or emotional events such as a bereavement or childbirth

Women are more likely to develop rheumatoid arthritis, which may be due to the female sex hormone oestrogen, although this hasn’t been proven.

There is no cure for rheumatoid arthritis. However, early treatment can lengthen the gaps between flare-ups to months or even years, and reduce any long-term joint damage. Medications include:

Disease-modifying anti-rheumatic drugs (DMARDs) 

Eg hydroxychloroquine, leflunomide, methotrexate and sulfasalazine. DMARDs block the effects of chemicals that are released when your immune system attacks your joints. 

DMARDs take several months to start having an effect and although most people tolerate them well they do have side effects, including: 

• A sore mouth
• Diarrhoea
• Headaches, nausea and loss of appetite
• Hair loss
• Negative effects on your blood cells and liver — you will have regular blood tests to check for this
• Negative effects on your lungs — this is less common but you may need to have a breathing test and chest X-ray

Biologics 

Eg etanercept and infliximab. Biologics are usually only prescribed when other treatments are no longer working. They are injected and usually taken alongside a DMARD. They work by stopping certain chemicals in your blood from attacking your joints. 

Side effects include: 

• Feeling nauseous
• Fever
• Headaches
• Infections
• Skin reactions at the injection site 

In some people, dormant infections eg tuberculosis (TB) and shingles can recur. 

JAK inhibitors

Eg baricitinib and tofacitinib. This is a new treatment for severe rheumatoid arthritis. It is usually only prescribed if you can't take DMARDs or biologics, or if these treatments were not effective. They are taken as tablets one to two times a day, usually alongside a DMARD.

Non-steroidal anti-inflammatory drugs (NSAIDs)

These can be taken with painkillers or instead of painkillers. Your doctor may recommend a traditional NSAID eg ibuprofen, diclofenac or naproxen, or a type of NSAID called a COX-2 inhibitor eg celecoxib or etoricoxib.

NSAIDs can reduce joint inflammation and pain. However, they will not stop the disease from getting worse over time and can increase your risk of serious stomach problems eg internal bleeding.

Painkillers

Eg over-the-counter painkillers, ibuprofen or paracetamol.

Steroids

These are powerful medicines that can reduce inflammation, pain and stiffness. They can be given as a tablet, an injection into a painful joint or an injection into a muscle to relieve pain in many joints.

Steroids only provide short-term pain relief eg when waiting for your DMARD medication to start working or during a flare-up. If steroids are taken for long periods of time, they can cause major side effects, including: 

• Bruising easily
• Muscle weakness
• Osteoporosis 
• Thinning skin
• Weight gain

Whichever medication you take, your GP or rheumatologist will monitor your condition over time and make any necessary changes to your prescription.

A physiotherapist will advise you about any exercises you can do, which may ease your symptoms by improving your fitness, joint flexibility and muscle strength.

It is important to try to stay active as inactivity will weaken the muscles around your joints.

An occupational therapist can provide you with advice and training to help you protect your joints at home and work.

Surgery

If your joints are badly damaged, you may need surgery to restore their mobility. Surgeries include: 

• Arthroscopy to remove inflamed tissue — a thin, telescope-like tube with a camera and light at the end is inserted into your joint through a small cut in your skin; other surgical instruments are inserted into the joint through other small cuts in your skin and are used to remove the inflamed tissue
• Finger, hand and wrist surgery — this includes: 
• Carpal tunnel release
• Release of tendons in the fingers to resolve abnormal bending
• Removal of inflamed tissue lining your finger joints
• Joint replacement eg hip replacement — in severe cases, all or part of a joint (eg hip, knee or shoulder) will be replaced with a prosthetic joint, which usually lasts 10–20 years

Rheumatoid arthritis can be life-threatening as it increases your risk of developing other serious conditions and symptoms, including:

• Cardiovascular disease — a group of conditions affecting your heart and blood vessels, which can lead to a heart attack or stroke; you can reduce your risk by eating a healthy diet, exercising and, if you smoke, quitting
• Carpal tunnel syndrome — this is common and is caused by compression of a nerve in your forearm
• Cervical myelopathy — dislocation of joints in your spine that cause the spinal cord in your neck to be compressed; this can occur if you have rheumatoid arthritis for a long time and can cause permanent damage; it needs urgent treatment
• Inflammation elsewhere in your body — this includes in inflammation in your: 
• Blood vessels (vasculitis) — this causes narrowing, scarring, thickening and weakening of your blood vessel walls
• Eyes — this can cause scleritis or Sjogren's syndrome
• Heart — this can cause pericarditis, which in turn causes chest pain
• Lungs — this can cause pleurisy or pulmonary fibrosis, which can cause a persistent cough, chest pain and shortness of breath
• Joint damage — erosion of joint bones, damage to cartilage and breaking of tendons (eg in the backs of your fingers), which can cause permanent joint deformities; joint damage varies from mild to severe
• Osteoporosis — weak bones that are more likely to break; rheumatoid arthritis increases your risk due to poor mobility resulting from the condition and  potential treatment with steroids

Rheumatoid arthritis increases your risk of developing these conditions because it can reduce the amount you exercise due to joint pain and stiffness. Rheumatoid arthritis may also be treated with medications that increase your blood pressure or suppress your immune system, which puts you at greater risk of certain conditions.

Two in 10 people with rheumatoid arthritis have a mild form and can lead a normal life for many years. One in 10 with the disease become severely disabled. Seven in 10 have an intermediate form of the disease and can lead full lives but will need to adapt their lifestyle. 

Medications for rheumatoid arthritis have improved over the years. Taking medications alongside making lifestyle changes can significantly improve your outlook for rheumatoid arthritis.

Rheumatoid arthritis can have a huge impact on your life and make daily tasks difficult. It often needs long-term treatment alongside changes to your lifestyle. 

Try to prioritise self-care, eating healthily and getting regular exercise. Your doctor may recommend that you get the annual flu vaccination and pneumococcal vaccination. Also, make sure you take your medication and attend regular reviews with your GP and/or specialist doctor.

You may want to look into the self-management course provided by the National Rheumatoid Arthritis Society, where you can learn about techniques to manage your pain and goal-setting exercises for everyday life. 

Coping with rheumatoid arthritis can affect your mood and mental health. Talk to your healthcare team if you are struggling. You can also try joining support groups where you can talk to others who have rheumatoid arthritis. 

If you are trying for a baby, speak to your GP. Certain medications for rheumatoid arthritis should not be taken when you are trying for a baby. If you are managing a young family, you may be able to get extra support from your health visitor or an occupational therapist. 

Treatments for rheumatoid arthritis often suppress your immune system, which can increase your risk of getting coronavirus. Treatments that suppress your immune system include: 

• Biologics — this includes abatacept, adalimumab, anakinra, belimumab, certolizumab pegol, etanercept, golimumab, infliximab, ixekizumab, rituximab (if taken in the last 12 months), sarilumab, secukinumab, tocilizumab and ustekinumab
• DMARDs — this includes azathioprine, ciclosporin, leflunomide, methotrexate, mycophenolate mofetil, mycophenolic acid, sirolimus and tacrolimus
• JAK inhibitors — this includes baricitinib, tofacitinib and upadacitinib

However, it is important that you do not stop taking your medication for rheumatoid arthritis during the coronavirus pandemic. If you do, your risk of complications and flare-ups will significantly increase. 

If your doctor has identified you as "clinically extremely vulnerable", strictly follow all coronavirus guidelines, including: 

• Not seeing anyone outside your social bubble
• Staying at home whenever possible and avoiding crowded spaces
• Staying two metres away from people
• Washing your hands regularly and using hand sanitiser
• Wearing face coverings when you are outside
• Working from home

You should be extra careful if you:

• Are on immune-suppressing drugs and daily steroids
• Are on two or more immune-suppressing drugs and are aged 70 or older
• Are on two or more immune-suppressing drugs and have another long-term condition
• Have a lung disease caused by an inflammatory condition
• Have been treated with cyclophosphamide in the last six months
• Take steroid tablets daily