Rheumatoid Arthritis (RA)

Rheumatoid Arthritis (RA) is an auto-immune disease, in which the immune system attacks the joint lining (synovium).  Inflammation causes pain and swelling, worst in the morning, easing up if just a little with gradual movement as the day goes on.  The bad thing is, that over the years joints get destroyed.  Hands and feet are most commonly affected, but any joint can become involved.  However, the course of RA is very variable.  Many patients never wind up with major disabilities.

RA can affect more than just the joints.  The inflammation can occur in the lungs, heart, eye, and elsewhere.  In addition, the constant inflammation can weaken other parts of the immune system, making it easier to get infections, even heart attacks.

The disease can attack any joint, but most commonly the small ones, especially at first.  We think about the possibility of RA when a patient complains of pains in hands &/or feet, that are worse in the morning, lasting at least an hour.  We begin the diagnosis by ordering some or all of the following blood tests:

• Complete Blood Count (CBC):  If there’s Anemia of Chronic Disease, the kind of anemia that has nothing to do with iron, we suspect some sort of inflammation going on
• Erythrocyte Sedimentation Rate (ESR, “Sed Rate”):  Also a hint that there’s some sort of inflammation happening
• C-Reactive Protein (CRP):  Just like the ESR above
• Rheumatoid Factor:  An antibody that’s elevated in RA.  But a fair number of people without RA are positive, and some who have the disease are negative.
• Cyclic Citrullinated Peptide (CCP):  A protein that’s very specific for RA.  If it’s present, the diagnosis is virtually certain.  But a negative test doesn’t mean anything.

However, we don’t necessarily rush to do these tests.  The first three can be positive for many other reasons, including lots of viral infections that cause joint pain but go away on their own (forever).  Since many people have Rheumatoid Factor in their blood, but will never develop RA, if we find it during a viral infection that involves the joints, we’ll make a wrong diagnosis that the patient will carry the rest of their lives.  They might even wind up on toxic medications.  Rheumatologists may insist on waiting for 2 full months of joint pains until they’ll be willing to make the diagnosis, or at least 4-6 weeks.

Some people have “sero-negative” RA, which means that Rheumatoid Factor is negative, but the disease is the same.  If x-rays of hands, wrists, feet, or ankles show early joint destruction, the diagnosis is sure.  However, ideally we’d make the diagnosis before anything occurs.  We do this by way of the first three tests above, along with typical symptoms.  But I prefer that a rheumatologist make the formal diagnosis, since medications are tricky, and are taken for life.

Aspirin and NSAID medications relieve the inflammation of RA, but they do not prevent joint destruction, or other complications.  A variety of other drugs do, but all of them have their own risks and toxicities.  Many, called “biologics,” are expensive (and are heavily advertised on TV, showing happy patients bouncing playfully in springtime, while a sing-song voice in the background quickly summarizes a long list of main dangers, some fatal).  I let rheumatologists prescribe them.