Welcome to this Dipex module.

What is arthritis?

Arthritis simply means inflammation in a joint. The end bit 'itis' means inflammation and can be used for inflammation in any organ. For example pharingitis is a sore throat, appendicitis an inflamed appendix. A common cause of inflammation is infection caused by viruses or bacteria and inflammation is the bodily process for fighting infection. It is highly evolved in humans but happens in all living creatures. It's the inflammatory process that we target when treating rheumatoid arthritis. There are of course lots of other forms of arthritis and perhaps I should start off by describing the most common one, osteoarthritis. This comes with advancing age to most of us. Here the inflammatory reaction is mild but it's enough to break down the cartilage and leave little bits of debris which the body then attempts to remove with enzymes. So inflammation doesn't always mean infection. Researchers have spent a lot of time looking for an infective cause for rheumatoid arthritis and none have been found.

Let's now move to rheumatoid arthritis which affects about 1% of the population. A common story would be say for instance a woman in her early 30s goes to bed perfectly well and in the morning has an unpleasant aching and stiffness in her hands. This could then jump to the feet and then to the knees and then to the elbows and so on. Often it jumps to the same joints on the opposite side. The knuckles are the most common place for it to start, especially the second and third knuckles. Of course it's painful. It's stiff and this is a big worry. Most people know someone who has had the disease and consequently they have a big fear of being crippled. Fear of the unknown sends people quickly to their doctor seeking reassurance and advice. 

It can be very difficult to reassure people early in the stage of rheumatoid arthritis. For instance the doctor may not be certain that is the disease you've got because certain viruses can cause diseases that look very much like rheumatoid arthritis and they can last for at least a year before settling. But your doctor will know that it's important to get you on to treatment as quickly as possible. 

At the first visit to your doctor he or she will order some blood tests to measure the amount of inflammation in your blood and to look for rheumatoid factor. I'll come back to rheumatoid factor later. He may also screen you for viruses that can mimic rheumatoid arthritis. Whilst awaiting the results of these tests he will almost certainly give you painkillers and anti-inflammatory drugs. A common one of these is brufen which of course you can buy without prescription. It works well but is not a cure and its effects are likely to be partial. Almost everyone at this stage says “We don't like taking tablets”. Of course no one likes to be ill and some will seek complimentary cures. Many are advertised but none with any proof of working. Others may seek to change their diet but in fact no diets are known to work specifically in rheumatoid arthritis. If any complimentary medicine or diet were known to work doctors would certainly recommend them. They are no more keen to give drugs than patients are to take them.

A few weeks later the doctor now has the results of the tests and he's got the advantage of course of knowing what has happened since you were last seen. Three things of course could have happened. You could be exactly the same or you could be a lot better or even completely normal or you could be worse, possibly much worse. Taking the last first, the disease may now be jumping from one joint to another. One day it's in the knee or the knees, a few days later in a shoulder or both shoulders. By the end of the week an elbow or both elbows and they don't quite straighten as well as they should. No sooner has one joint appeared and appeared to be getting better then another pops up in its place. Medical shorthand for this is you have an intermittent, flitting, peripheral polyarthritis. That's a fairly bland way of describing something that everyone would find frightening. The word 'poly' just means many. Sometimes the disease just starts in one joint. That we call a monoarthritis or a few joints an oligoarthritis. Each of these patterns of arthritis suggest diagnostic possibilities and also has an influence on the prognosis.

Let's now take the best position, that is the disease has gone away. Rheumatoid arthritis can do this early on. Coming for a week or two, going for a few weeks or months and then popping back again. This pattern we call palindromic arthritis. These attacks can be very painful but aren't always. If the arthritis has gone it may also suggest that this was in fact a viral arthritis, as so-called post-viral or reactive arthritis. The doctor also has the blood results and will have measured the amount of inflammation. He does this measuring your ESR, a simple blood test, a plasma viscosity or a test known as the CRP. If the values have gone above the normal range of values found in healthy people it all suggests inflammation and tells us roughly how much you've got. The lower the test, the better, the higher the more worrying. However these are not specific tests and many things can trigger off inflammation. For instance just rotting teeth or periodontitis can also do it. The most useful and specific test is the rheumatoid factor which measures a part of the immune inflammatory reaction though sometimes even this does not go up with rheumatoid arthritis and it is necessary to understand this test to understand some of our treatments.

The inflammatory reaction is divided into the fast system generated by cells such as white blood cells or neutrophils and a much slower system generated by more immune-based T-cells or B-cells. It doesn't matter at the moment what these stand for. In rheumatoid arthritis the immune cell system responds much more strongly than expected i.e. the immune response is exaggerated. Some doctors refer to this as an autoimmune reaction, almost as if the body was attacking itself. This slow immune response is also how the body deals with tricky infective insults such as viruses which can hide in cells and are not easily attacked by the fast acting neutrophils. Rheumatoid arthritis is an example of a disease that seems triggered by our slow immune system but doesn't seem to have been precipitated by an infective episode.

Now the rheumatoid factor test measures an antibody, an immunoglobulin produced by B-cells and it seems to be attacking another sister immunoglobulin. We don't know why and we're trying to find out. It seems to have no useful purpose and that is very odd. 

So your doctor has found inflammation and a positive test for rheumatoid factor and he now is most likely to refer you to a specialist. You might expect him to X-ray the joints at this stage but he may delay a little while whilst getting specialist advice because an X-ray at this stage doesn't necessarily add to the diagnosis. Your specialist is likely to take X-rays and he's looking to see if you have or have not developed erosions of the bone. These are small punched out holes in the bone that can be very classically linked to rheumatoid arthritis. 

How do they come about? The lining of the joint, the synovium or the synovial membrane which is normally very thin becomes thickened with the inflammation and it gets red and swollen inside though you can't see it but it would look very much like conjunctivitis, inflammation of your eyes. The cells keep pouring into the synovium. It becomes swollen. It starts to organise itself and then it nibbles away at the bone edges and the cartilage, that is erosions. 

So the doctor's referred you to a specialist, usually a consultant rheumatologist, a physician who deals especially with diseases affecting the muscle and joints. Waiting lists to see a specialist can be quite long but serious diseases such as rheumatoid arthritis are of course given priority over those that are not. Of course every patient whose in pain thinks their disease is serious and very frustrating it can be if you have to wait many more, much more than a week or two before getting a specialist opinion. Now bear in mind that a consultant usually has only 30-40 minutes for a patient and in that time he's got to make a diagnosis and work out whether it is rheumatoid arthritis or other, or another disease like it. He's got to arrange a variety of tests and he may also be anxious to start you on treatment to settle itself down. This is very hard to do in a 30 minute slot and it's for this reason that DIPEx has produced this website to assist you with getting extra information. The more information you have the more in control you are.

When you visit your doctor (specialist) you can expect a full examination because unfortunately rheumatoid arthritis can occasionally spread outside of your joints and involve other areas. These could be your lung, your heart, your bloodstream, many areas can be affected by so-called systemic rheumatoid arthritis and at this point your doctor will assess whether you have these complications or not. All of these factors influence your treatment. So he has the results of your blood tests. He's got a full examination to assist him in making a decision and at this stage he now needs to reconsider your drug therapy.

Now everyone at this point wants to voice their own individual fears and anxieties because they feel that things are getting out of control. The specialist knows he needs to discuss the drugs with you in detail but all your problems can't be dealt with simultaneously. He may well seek advice also from nurses, from physiotherapists and occupational therapists who will also give you advice and help you come to a nice decision. If you are uncomfortable about the drugs that are being recommended by all means ask for further information and time to think about it and perhaps discuss it again with your own family doctor or the nurse in the local surgery. Remember however, your doctor, your specialists will be very anxious to start to you on something as soon as he or she can because the longer you delay giving treatment the more likely there is to have damage and erosive damage of affecting the bones. His best chance of treating you is to treat you early. He may at this stage be considering a variety of different drugs but one way and another they all work by dampening down the inflammatory reaction which we've described and the immune and the slow immune response that stems from it. 

One, a very effective way of doing this though we rarely use it are steroids. These were discovered in the 1950s and they don't cure rheumatoid arthritis but they dramatically suppress the inflammatory reaction at all its points and so the disease almost miraculously settles. However these drugs come at a cost so we only use them for very short lengths of time. People talk about the side-effects of drugs but these aren't really side-effects. Steroids if given in high enough dose for long enough will cause problems to everyone. 

Now, steroids are often given early in the disease but just for a short time to get on top of it whilst your doctor is now trying to give you a slower acting drug that immune normalises the system. Now what do I mean by immune normalisation? As we have discussed patients with rheumatoid arthritis have an exaggerated slow moving immune response. What all the drugs of the next class that I'm going to describe for you do is damp that down to near normal. The first drugs that were discovered that are helpful in doing this were gold and penicillamine. These are drugs that we don't use so much now, don't use so much now but nevertheless are effective at dampening it down. More useful drugs, more commonly used are sulfasalazine, methotrexate and now leflunomide. Careful long-term trials have been undertaken in lots of people with arthritis and all these drugs have been proven without doubt to work.

Let's discuss methotrexate because it's the most commonly used drug to treat arthritis. This drug is only taken once a week. It's a very good drug. It's given in low doses to people with rheumatoid arthritis and it will steadily immune normalise you. At much higher doses methotrexate can also be used to treat cancer and people are concerned about the side-effects of this drug because of the side-effects of high doses. However, at the doses that we use and with careful monitoring side-effects are rarely a significant problem for most people. So he starts you on weekly methotrexate and steadily increases the dose over the next few months hoping to get on top of the disease and then to steadily lower the dose down again checking all the time on the amount of inflammation in your blood using tests that we've described like the ESR or CRP. Your doctor will check the blood tests for you but you may also take an interest yourself. You'll be given a monitoring card and it doesn't take long to soon learn how to use these cards so that you can get a feel for what is happening yourself.

Let's now look at a fairly unusual scenario that the drug is not working and the attacks of tiredness and the flares in arthritis continue. Perhaps let's discuss tiredness. This is a very important symptom and often it's not discussed in clinics but it has a major impact on your life, your behaviour and your relationships. It's hard to see the tiredness of RA in another person. It's just not obvious. Partners often become extremely intolerant. The patient wants to go to bed early. The partner wants to go out. The partner would like to have sex but the patient doesn't. You're at work and a small matter that would not normally trouble you leads to a response that is just one step too far. The husband comes home. He wants his tea, doesn't say it nicely and normally and you fly off the handle. All these things happen to patients with rheumatoid arthritis when they're tired. I don't know of a patient with rheumatoid arthritis who doesn't suffer from fatigue and doesn't get episodes when they need just to sit down and feel they're going to burst into tears. It's very important to understand that this is a common reaction and most important to make sure that your relatives know that despite the fact there is not much to see that you can be a little bit brittle. When they understand they'll be tolerant. Often a good idea to bring your partner to the clinic to discuss this matter with your doctor or with a nurse.

What causes this strange fatigue? The synovial membrane which we've discussed produces little short proteins known as peptides which can affect your brain and create this flu-like or fatigue-like symptom. Now let us imagine again a worst-case scenario where the fatigue is getting worse all the time. The joints aren't settling. You've been given methotrexate or sulfasalazine but they haven't worked perfectly. Your doctor at this point, and I might add this is rare, may consider giving you a new type of therapy altogether known as anti-TNF. TNF is a peptide which is one of the major molecules that causes this fatigue-like syndrome. Anti-TNF is an antibody directed against this peptide and it helps limit the fatigue and has in many patients an amazing effect on the inflammation in their joints. To block TNF, investigators have produced either an antibody or a different kind of receptor that couples with it. The drugs have been proven to work extremely well in animals with arthritis and in most people. Anti-TNF has to be given by injection under the skin or into a vein. It is very expensive and therefore doctors are restricted in those people they can use it on mainly due to the cost but with time more people will be able to access this drug.

Now a drug that can so dramatically reduce the inflammatory reaction is unlikely to do this without possible side-effects. You will remember that inflammation is designed to fight infection. And that's the slight downside of anti-TNF treatments is that it increases your chance of getting certain but not all infections. For instance if you've had tuberculosis in the past we wouldn't be able to give you TNF easily and without anti-tuberculosis therapy because it could reactive your disease but your specialist will check all these things if the need comes for anti-TNF therapy. 

So we've discussed rheumatoid arthritis. You understand it to be an inflammatory reaction. You understand that we don't know the cause of rheumatoid arthritis but most research efforts point to an exaggerated, excessive, immune response. You now understand that we're trying to get your immune response back down to normal, not too much, not too little. And that we're doing in order to stop the erosive crippling bone damage. Modern treatments are very effective at doing that in the majority of people. However, try to remember that a positive attitude also has a rather miraculous effect on your immune system. People who have a confidence about them and work hard and keep busy do a lot better than people who are overwhelmed by what can appear to be an overwhelming disease. 

We hope you enjoy this module. We're very grateful to all the patients who've contributed their time and effort to putting it together. It is worth your while concentrating on it and coming back to it. You will certainly get a lot more information and a well-informed patient gets better treatment.

Thank you very much.