What is rheumatoid arthritis?
Arthritis literally means joint inflammation. Rheumatoid arthritis is a chronic (more than 6 weeks) course in which small joints (hand joints, wrist and foot joints) and elbows are primarily involved, and causes damage to the joint; It is an autoimmune inflammatory joint disease that can affect many organs and systems. It causes injury by causing damage to the joint. Rheumatoid arthritis is a common disease, affecting one out of every hundred people at some point in their life. It can develop at any age, but most often begins between the ages of 40-60. It is 3 times more common in women than men.
What is a joint?
The joint is the name given to the points where two bone ends meet in our body. Joints provide movement and flexibility of various parts of our body. However, there are also a small number of immobile joints. The movement of the bone is provided by the muscle attached to the bone by tendons. The bone end points forming the joint are covered with cartilage (cartilage). The joint surface is surrounded by a membrane called the synovium and externally by the joint capsule. Inside the joint is a type of lubricating joint fluid called synovial fluid, which prevents friction. There are muscles and ligaments around the joint. The joint capsule, ligaments and muscles support and stabilize the joint.
What are the causes of joint pain?
Joint pain can occur for many reasons, including inflammation of the tendons that make up the structure of the joint, inflammation of the joint membrane, narrowing of the joint space and abrasions, destabilization of the joint, erythema nodosum (painful, red, swollen nodules) located close to the joint.
What are the causes of rheumatoid arthritis?
Immune (immune) system; It is a system that protects us against bacteria, viruses or all kinds of foreign substances (antigens) that can enter our body and fights them. In autoimmune diseases, the immune system also fights against some body tissues of the person by producing immune serum (antibodies). While this may be directed to a certain organ such as the thyroid and liver, it may sometimes be systemic rather than organ specific. Here rheumatoid arthritis is one of the systemic autoimmune connective tissue diseases. It is not known exactly what causes this perversion in the immune system. However, the genetic structure of the person and environmental factors (smoking and some infections) can cause this. Inflammation that develops in and around the joint causes damage to the joint (cartilage, bone and ligaments) over time.
Which joints does rheumatoid arthritis involve?
The small joints of the fingers and toes (excluding the extreme joints), the wrist and ankle are the most affected, the knees and elbows are the second, and the hip, shoulder and neck are less frequently affected. rheumatoid arthritis; The sacro-iliac joint does not involve the lumbar and dorsal spines, the extreme joints of the hand and foot.
What are the symptoms of rheumatoid arthritis?
Joint symptoms: Pain and swelling in the involved joints, increased temperature over the joint, and limitation of movement. In the morning or at rest, there is stiffness (stiffness) in those joints that lasts for at least an hour.
Extra-articular symptoms: There may be malaise, mild fever and weight loss. Anemia and fatigue are common. In one in four patients, on the elbow, on the hand or in different parts of the body; There may be painless lumps (nodules). It could be tendinitis (tendon inflammation). Because, like the joint surface, tendons (ligaments) are covered with a membrane called synovium. With the compression of the nerves traveling between the tendons due to the inflammatory tissue; entrapment neuropathies may develop. When the wrist joint is involved, numbness and tingling (carpal tunnel syndrome with median nerve compression) occurs in the first three fingers of the hand and the inner surface of the 4th finger. Generally, in arthritis in the elbow joint, numbness and tingling (ulnar nerve compression and cubital tunnel syndrome) occur on the outer surface of the 5th and 4th fingers. When the ankle joint is involved (tarsal tunnel syndrome with posterior tibial nerve compression), numbness and tingling may develop from the inner part of the ankle to the toes. In far fewer patients with rheumatoid arthritis, the inflammation can involve other organs such as the lungs, heart, blood vessels, or eyes. Then it can cause much more various complaints and serious problems.
How does rheumatoid arthritis develop and progress?
It usually starts with complaints of pain, swelling, and stiffness lasting more than one hour in the morning, especially in the small joints of the hands, sometimes feet, wrists, within weeks, sometimes months. At first, this was a period of time, and then it started to become continuous. Similar complaints may occur in large joints such as knees, elbows, shoulders, and ankles. Although it is less common, with a rapid and noisy onset, complaints may begin in many joints or in a single large joint within a week. Sometimes it can start with arthritis called palindromic rheumatism, which occurs within hours or within a few days.
Apart from pain, there are muscle aches, weakness, fatigue, anemia, weight loss and sometimes mild fever.
The severity of rheumatoid arthritis varies from person to person. It is a chronic disease. It takes many years; sometimes it lasts a lifetime. The disease progresses with exacerbations and remissions (calmly). An exacerbation often has no cause or trigger; however, sometimes it can be triggered by reasons such as turning of seasons, stress, infection.
Left untreated, joint damage develops with each exacerbation. Due to inflammation, damage develops first on the cartilage and then on the underlying bone. The duration and severity of this damage differ from person to person. As a result, it causes disability leading to limitation of range of motion in the joint. In particular, movements such as holding and grasping in the hand joints cannot be performed (such as swan neck, buttonhole views, muscle atrophy). Since these disabilities usually develop in the first two years of illness; Early recognition and control of the disease is very important.
How is rheumatoid arthritis diagnosed?
While the presence of swelling and pain for 6 weeks or more, especially in small joints such as the hand joints, facilitates the diagnosis of rheumatoid arthritis, it is difficult to diagnose for a shorter duration or single joint involvement or large joint involvement. For this reason, the course of arthritis may need to be observed by the doctor under pain and inflammation relieving drugs for a while. As blood tests; complete blood count, liver and kidney function tests, CRP (C-reactive protein-inflammation marker), ESR (erythrocyte sedimentation rate-inflammation marker), RF (rheumatoid factor-an autoantibody that can support the diagnosis of rheumatoid arthritis in the presence of clinical findings) and ACPA (anti-inflammatory) -citrulline peptide antibody-test that more strongly suggests the diagnosis of rheumatoid arthritis) is performed. Chest X-ray and direct films of the involved joints can be taken. However, there are no descriptive findings on direct joint radiographs in the early period. It occurs after years (narrowing in joint spaces, small dents in the bone). Therefore, if your doctor deems it necessary, joint ultrasonography or magnetic magnetic imaging with drugs may be requested. Thin-slice lung tomography may be ordered if lung involvement is suspected. If there are eye and heart involvements, further evaluations are made and treatment is planned.
Rheumatoid factor; While it is positive in only half of the patients at the time of diagnosis of the disease, it becomes positive in eighty percent after 5-10 years. Rheumatoid factor can also be found in healthy people (5-15%). It may also be positive after some chronic infections (such as tuberculosis, subacute bacterial endocarditis, hepatitis C infection), other organ-specific or systemic autoimmune diseases.
ACPA (formerly anti-CCP); It is more specific than RF in the diagnosis of rheumatoid arthritis, but it is not sufficient for the diagnosis, joint findings must also be present.
Some other associated diseases and possible complications:
People with rheumatoid arthritis have a higher-than-normal risk of developing certain diseases. These; cardiovascular diseases due to accelerated atherosclerosis (coronary heart disease, myocardial infarction, stroke), anemia (anemia of chronic disease), infections (joint infection or extra-articular infections), osteoporosis, dry eye, eye inflammation (episcleritis). However, control of the disease and preventive treatment and susceptibility to these are no different from healthy people.
Other complications:
– Trap neuropathies; carpal, cubital, and tarsal tunnel syndromes (described above),
– Tendon ruptures (especially behind the fingers),
– Cervical myopathy; It is a rare but serious complication in patients with long-standing rheumatoid arthritis. It is the compression of the spinal cord due to the slippage of the vertebral joint at the top. It needs to be fixed surgically immediately.
What is the importance of early diagnosis and treatment?
Rheumatoid arthritis causes permanent damage to the joints involved. Early diagnosis and initiation of drugs that modify the disease are very important in order to prevent disability due to the disease.
What are the treatments for rheumatoid arthritis?
There is no treatment to completely eliminate rheumatoid arthritis. But treatments make a big difference in reducing symptoms and preventing disability. Goals of treatment:
-Reduce disease activity as much as possible to prevent joint damage.
-Reducing pain and stiffness in the joints.
-To treat other symptoms of the disease, if any.
-To prevent the development of disease-related risks such as cardiovascular disease and osteoporosis.
Nonsteroidal anti-inflammatory drugs (such as naproxen, diclofenac, indomethacin) and low-dose corticosteroid (5-10mg/day) are used in the early period to reduce pain and inflammation in patients. Usually, a stomach-protecting drug is added to the treatment in terms of their side effects. These treatments are discontinued when the effect of disease-modifying drugs occurs; Sometimes it can be used for a short time in disease exacerbations.
To reduce disease activity and prevent joint damage; As soon as rheumatoid arthritis is diagnosed, disease-modifying rheumatism drugs should be started. These drugs are; methotrexate, sulfasalazine, leflunamide and hydroxychloroquine. Although gold salts have been used successfully in the treatment of rheumatoid arthritis in the past, today their use is quite limited due to their expensiveness and side effects. It is still used in some European countries. Among these treatments, methotrexate is a gold-standard treatment agent and is included in the treatment as long as the patient tolerates it. Other drugs are usually added to it and used in double and triple treatments. If methotrexate is not tolerated at all, leflunamide can be substituted. Since methotrexate causes folic acid deficiency, an equivalent dose of folic acid must be supplemented during treatment. Complete blood count, CRP, liver and kidney function tests should be followed before and during treatment (first trimester-monthly, then every three months). Despite the combined use of these treatments (3-6 months), the disease activity continues or if the patient cannot use them due to reasons (development of side effects, the person has some other co-morbid disease); Biological treatments can be started.
Biological treatments used in rheumatoid arthritis are also often combined with methotrexate. Biological therapies: Those against tumor necrosis factor (TNF) alpha—infliximab (Remicade), etanercept (Enbrel), adalimumab (Humira), certolizumab pegol (Cimzia), golimumab (Simponi); -tocilizumab against interleukin-6; anti-CTLA4-co-stimulatory blockade-abatacept; B-lymphocyte-reducing therapy—rituximab and interleukin-1 versus anakinra (Kineret) and canacunimab (Ilaris). During the use of biological treatments; Patients should be evaluated for tuberculosis reactivation, especially before and after anti-TNF therapy. It should be investigated before treatment whether there are conditions such as demyelinating disease, advanced heart failure, pregnancy, drug reaction, hepatitis BC infection, presence of cancer.
Other treatments; drugs such as cyclosporine, azathioprine, cyclophosphamide, penicillamine, mycophenolate mofetil; Their use is limited, but they are other treatment agents that can be used in the presence of serious systemic findings.
Under all these treatments, rheumatoid arthritis patients have an increased susceptibility to infections. Therefore, vaccination should be done for preventable diseases. If there is no immunity, it is recommended to receive hepatitis B and A vaccine, annual flu vaccine and pneumococcal vaccines (every 5 years or long-acting-lifelong).
It is necessary to keep the patient as active as possible. With regular exercises, both the preservation of joint range and muscle strength should be preserved. Swimming is good exercise. In the company of a physiotherapist, exercises that can be done by himself should be learned and the patient should be able to do it independently.
Corrective surgeries in some cases with very advanced deformities; orthopedics (such as hip and knee prostheses) and hand surgery.
Patients should be told that they have a long-term disease (which will continue for years, perhaps for a lifetime). Therefore, patient education is very important. The better the person knows about his/her illness, the less his/her anxiety will decrease and he/she will learn to cope with it and to live together.
Rheumatoid arthritis patients! You have a lot to do. Don’t be detached from life. Do not fall into disinformation or unnecessary fears while researching your disease on the internet. By reaching support groups for your illness, meet people with the same illness and learn about their stories, feelings and ways of coping, and share yours. Be at peace with your illness and learn to live with it. Remember that there are millions of people with the same disease as you.
