Unit 5 Case Study: Rheumatoid Arthritis

RA is an autoimmune disease. It is also a systemic disease, which means it can affect the whole body. It occurs when a person’s immune system mistakes the body’s healthy tissues for foreign invaders.

As the immune system responds,  occurs in the target tissue or organ. In the case of RA, this can be the joints, lungs, eyes, and heart.

Signs and symptoms of RA usually occur in the wrists, hands, or feet and include:

• pain or achiness in more than one joint
• stiffness in more than one joint that lasts longer than 30 minutes
• swelling in more than one joint
• symmetrical joint involvement
• a general feeling of being unwell
• low-grade 
• appetite loss
• weight loss
• weakness
• joint deformity
• loss of function and mobility
• unsteadiness when walking

According to the , people do not typically receive a diagnosis of RA until they are in their 60s. Symptoms may start slowly and often get worse gradually over time.

People with RA usually experience periods when symptoms get worse, known as flares. RA symptoms may flare up due to stress, overactivity, or stopping medications.

Flares are followed by remissions when symptoms go away or are mild. Most people continue to experience flares and remissions throughout their lives.

RA usually affects the same joints on both sides of the body. Pain and stiffness tend to get worse after sleep or periods of inactivity.

Severe RA can lead to other complications throughout the body and cause joint damage that may lead to disability. Treatment can help manage the severity of symptoms and may reduce the likelihood of experiencing complications.

The images below show how RA can appear in different parts of the body.

VIEW GALLERY5

If a person has a diagnosis of RA, the doctor may refer them to a specialist known as a , who will advise on treatment options.

Treatment will aim to:

• prevent flares and reduce their severity if they occur
• reduce inflammation to the joints
• relieve pain
• minimize any loss of function caused by pain, joint damage, or deformity
• slow down or prevent damage to the joints and organs

Options include medications, , occupational therapy, counseling, and surgery.

Medications to manage symptoms

Some drugs can help to relieve symptoms and slow disease progression.

 are available over the counter (OTC) from pharmacies. Examples include Motril, . Long-term use and high doses can lead to side effects. These include:

• bruising
• gastric ulcers
• high blood pressure
• kidney and liver problems

 reduce pain and inflammation and may help slow joint damage, but they cannot cure RA. If NSAIDs do not work, a doctor may inject a steroid into the joint. Relief is usually rapid, but the effect is variable. It can last a few weeks or months, depending on the severity of symptoms.

Corticosteroids can help with acute symptoms or short-term flareups. However, a doctor will limit these injections to no more than three times per year because of their impact on the soft tissue structures in the joints. More frequent injections can potentially damage these structures or cause them to tear off where they attach to the bone.

Disease-modifying antirheumatic drugs (DMARDs)

The  recommends treatment with disease‐modifying antirheumatic drugs (DMARDs), either alone or with other treatments, in people with moderate to severe RA.  (Rheumatrex, Trexall) is an example of a DMARD.

DMARDs affect how the immune system works. They can slow the progression of the RA and prevent permanent damage to the joints and other tissues by interfering with an overactive immune system. A person usually takes a DMARD for life.

These types of medications are most effective if a person uses them in the early stages of RA, but it can take several weeks to a couple of months to fully experience the benefits. Some people may have to try different types of DMARDs before finding the most suitable one.

Side effects can include:

• liver damage
• immune-related disorders
• increased risk of infections
• , stomach upset, and 
• abnormal blood counts

Biologic treatments

Biologic treatments, such as tumor necrosis factor-alpha (TNF-alpha) inhibitors, also change how the immune system works. When the human body faces an infection or other threat, it produces , an inflammatory substance. TNF-alpha inhibitors suppress this substance and help prevent inflammation.

TNF-alpha inhibitors can reduce pain, morning stiffness, and swollen or tender joints. People usually notice an improvement 2 weeks after starting treatment.

Examples :

• certolizumab pegol (Cimzia)
• golimumab (Simponi

Possible side effects :

• a higher risk of infection
• demyelinating diseases, which damage the myelin sheath that normally protects nerve fibers
• skin reactions

Occupational or physical therapy

An occupational therapist can help a person learn new and effective ways of carrying out daily tasks. This can minimize stress to painful joints. For example, a person with painful fingers might learn to use a specially devised gripping and grabbing tool.

A physical therapist can advise people about using assistive devices, such as a cane, and help individuals develop a suitable exercise plan.

Surgery

In some cases, a doctor may recommend surgery to:

• repair damaged joints
• correct deformities
• reduce pain

The following procedures are possible:

• arthroscopic surgery, a procedure to remove inflamed joint tissue
• surgery to release tendons responsible for unusual bending in the fingers
• carpal tunnel release to relieve nerve compression in the hand and wrist
• arthroplasty, or total joint replacement

Causes

Nobody knows what causes the immune system to malfunction, leading to RA.

Some people appear to have  that make developing RA more likely. One theory is that bacteria or a virus triggers RA in people who have this genetic feature.

In RA, the immune system’s antibodies attack the synovium, the smooth lining of a joint. When this happens, pain and inflammation result.

Inflammation causes the synovium to thicken. Eventually, if left untreated, it can invade and destroy cartilage — the connective tissue that cushions the ends of the bones.

The tendons and ligaments that hold the joint together can also weaken and stretch. The joint eventually loses its shape and configuration. The damage can be severe.