Rheumatoid arthritis

Rheumatoid arthritis is a form of polyarthritis, which affects several joints. Essentially it represents a self-perpetuating inflammation, which runs havoc in the joints for years. Without treatment, it ultimately ruins the ligaments, the cartilage layer of articular surfaces and the bones. Over time, this process progressively limits the patient's movements. This way the disease eventually decreases work capacities and proper functioning both in the society and in the family.

Only in the middle of the last century was the disease exactly described and categorised to the group of rheumatological disorders. The progressive internal destruction of the joints can be revealed by X-rays. The internal mucosal lining of the joints proliferates and shows signs of severe inflammation, which resembles a chronic infection. However, neither any sort of pathogenic microorganisms have been isolated, nor any proposed mechanisms of infection have been verified from these foci. The disease afflicts almost, with equal frequency, every human race in the population of each continent. In the European population, about 0.5 % is affected, 75% of whom are women. In the family of the inflicted, the disease is more frequent, which reflects a certain genetic propensity.

Since the inflammatory process cannot be attributed to pathogens, only the development of immunology and the discovery of the groups of autoimmune disorders identified the process as the commonest form of autoimmune disorders. Autoimmunity, an abnormal activity of the immune system, provides comprehensive explanation for all aspects of rheumatoid arthritis This dysfunction is partly related to inherited factors, but the trigger of the self-maintaining inflammation can also be a "foreign" signal, indeed a pathogen or a modified component of your own body. Such candidates are an "innocent" bacterium of the gingival flora or those altered proteins of the bronchi, which underwent chemical modification by cigarette smoke. The culprits which are responsible for pathologic recognition and the maintenance of the inflammatory process belong to the immune system. They consist of immune genetical features and regulatory and "executive" molecules which control the immune cells or destroy the inflamed tissue.

How does rheumatoid arthritis start?

The disease typically starts gradually. It may be introduced by fatigue and weakness. First, the small joints of the hands become painful, which is recognized by the patient upon clenching and hand-shaking. The simplest medical test also relies on it: if the examiner or the patient himself exerts pressure on the row of the metacarpo-phalangeal joints; it provokes sharp pain, which refers to the presence of an inflammation. It is very characteristic if the patient, while getting up early in the morning, experiences stiffness in the above mentioned joints and in the interphalangeal ones. However, the disorder may first afflict a bigger joint, most frequently the wrists or knees. If the onset is abrupt, infectious or gouty arthritis should also be considered. Frequently, rheumatoid arthritis starts in the form of recurring gonarthritis. If you develop these symptoms, you should turn to your doctor immediately and ask for a consultation with a rheumatologist. The laboratory tests may reveal changes reflecting to a general inflammatory response, but soon specific antibodies may appear supporting the diagnosis of rheumatoid arthritis. Early recognition is of vital importance because the immediate, modern and consistently applied therapy started at the beginning of the disease does not only decrease the symptoms, but it may also delay the progress or even inhibit the development of the disease.

What means does the therapeutic arsenal of rheumatoid arthritis consist of?

Anti-inflammatory drugs provide symptomatic relief, but they do not influence the eventual progress. Our new "biological weapons", the antagonists, which have been designed according to the features of the target, represent the so far most effective molecular tools of the therapy. They harness the pathologic proliferation and activity of the immune cells and neutralize or block the immune cell-derived mediators. The treatment should be initiated with the administration of drugs containing Methotrexate. The efficacy of the consistent treatment has been demonstrated over decades. The compound is available both in the form of an injection and tablets. The next step is biological therapy, which yields the best, presently available results together with the continuation of Methotrexate treatment. Combined with the medical treatment, physical activity in the form of exercises is indispensable in preserving your functional capabilities, retaining your muscle strength.

How can a rheumatoid arthritis patient take part in the successful treatment?

The least serious outcome and the best therapeutic results require the trust and active cooperation of the patient. This can be achieved only if the patients are familiar with the state-of-the-art methods, the principles of the diagnosis, and the treatment of their disease. They should also be informed about and comply with the therapeutic protocols of their disorder. Therefore, health-care providers have to provide comprehensive information about the disease so that optimal decision could be made together with the patients about treatment and lifestyle.

What sort of lifestyle should you follow to prevent the development of the disease, and what measures can mitigate the progress and severity of it?

Although external triggers predominate in the development of the disease, they are not sufficiently characterized to establish the definite preventive measures. To identify these factors, a large survey was carried out with the involvement of more than 100 000 American nurses. The subjects were followed-up in two periods of twenty years, which, therefore, covered approximately 5 million cumulative years of observation. Rheumatoid arthritis developed in 1200 nurses during this time. It was obvious that the group of overweight or obese women showed the highest incidence.

In the sufferers of rheumatoid arthritis of a Swedish patient register, lifestyle characteristics were screened. It became obvious that those who regularly do some sport or at least intensely so some exercise, rheumatoid arthritis starts later and presents in a milder form with less pain.

compiled by
Dr. László Hodinka
National Institute of Rheumatology and Physiotherapy