Rheumatoid arthritis (RA) is a chronic systemic autoimmune disease of unknown cause. According to the American College of Rheumatology (ACR), it affects 1.3 million Americans. The most common early manifestations are fatigue, symmetrical and distal extremity swelling, erythema, and pain (which may be both generalized and focal). Deformity and weakness also may occur. (See Comparing a normal joint to one with RA by clicking on the PDF icon above.)
The variable onset of RA, subjectivity of symptoms, elusive manifestations, and occurrence in relatively healthy young females can frustrate both patients and healthcare providers trying to make a definitive diagnosis. It also can give rise to myths and misconceptions about the disease. Read on to clear up misunderstandings you may have.
MYTH: RA is like any other arthritis form and can be improved through lifestyle and other changes.
Many people think RA is a form of osteoarthritis that responds to increased exercise, weight loss, and physical therapy. These interventions may help manage symptoms as secondary treatments. But they don’t affect the cause of RA, which (unlike osteoarthritis) is an autoimmune disorder. What’s more, it’s not enough just to prescribe pain medications: In RA, pain stems from joint damage, and pain medication alone won’t decrease joint destruction. Joints are affected by an autoimmune response in the synovial fluid, which leads to their destruction.
MYTH: RA is triggered by stress, excess weight, and unhealthy eating.
Experts know little about the causes and triggers of RA, but many believe both genetic and environmental factors play a part in activating the immunologic cascade that attacks the joint’s synovial lining. Some researchers suggest that because the disease seems to have a random onset, the trigger probably is a random immunologic process. We lack clear evidence that infections, stress, diet, or physical or emotional responses are triggers. However, once the immunologic cascade is activated, cigarette smoking is a significant environmental factor affecting disease severity.
MYTH: RA affects only the joints.
For most RA patients, the disease impairs activities of daily living. By 5 years after diagnosis, 33% of patients aren’t working due to RA-induced disability. After 10 years, approximately 50% have substantial functional disabilities. In addition, RA shortens life expectancy by 5 to 10 years. A poor prognosis is linked to persistent erosive disease, extra-articular involvement, seropositive results for rheumatoid factor, and comorbidities. Both RA and its treatments create a complex web of increased risk factors as the disease progresses. Also, comorbid conditions can affect the patient’s prognosis, outcome, quality of life, risk of disability, mortality, and need for hospitalization.
MYTH: RA is easily diagnosed through simple blood tests and X-rays.
Although laboratory tests can aid diagnosis and ongoing management, RA diagnosis remains primarily clinical, based on the patient’s history and presentation. The ACR recommends the following baseline tests:
- complete blood count with differential
- rheumatoid factor (RF)
- erythrocyte sedimentation rate (ESR)
- C-reactive protein (CRP)
- anticyclic citrullinated peptide antibody assay (anti-CCP).
Unfortunately, none of these tests conclusively confirms or rules out RA. Any inflammatory process can cause positive ESR and CRP results. Hypochromic anemia may occur in chronic inflammation. Although the likelihood of RA decreases if these tests are normal, normal results don’t exclude RA.
On the other hand, positive results for RF and anti-CCP combined raise the probability of RA to at least 90%. Negative results for both tests make RA unlikely but don’t rule it out. RF is false-negative approximately 31% of the time; on the other hand, a positive result may indicate any of several disorders, including Sjögren’s syndrome, mixed connective tissue disease, systemic lupus erythematosus, systemic sclerosis, mixed cryoglobulinemia, systemic vasculitis, chronic sarcoidosis, and neoplastic disorders. The anti-CCP test specifically identifies RA 95% of the time but has a false-negative rate approaching 33%.
X-rays may show joint erosion and decalcification of adjacent bones. With the availability of new medications and treatments, the goal in early disease stages is to start treatment before these changes occur. Recently, magnetic resonance imaging (MRI) has proven valuable in detecting early synovitis that may elude clinical examination. Research and analysis of the cost-effectiveness of MRI for early diagnosis are underway.
MYTH: RA patients should take NSAIDs as long as possible before starting other drugs.
Until recently, the conventional wisdom was to avoid aggressive therapies early by starting patients on nonsteroidal anti-inflammatory drugs (NSAIDs) and to prescribe one drug at a time. But numerous studies during the 1990s showed that early aggressive therapy with disease-modifying antirheumatic drugs (DMARDs) decreased inflammation and slowed progression of joint destruction more effectively than when these drugs were started later. Since then, several new RA medications and drug classes have been developed.
The focus of drug therapy has evolved from monotherapy to aggressive combination therapies using multiple drugs and doses. Combination therapies that are adjusted quickly when the patient responds poorly are more likely to lead to remission or control of the destructive process in RA. Many of the early drug combinations include methotrexate, now considered the cornerstone of early treatment. Multiple drug classes are used to treat RA, and many more drugs and drug classes are currently being researched.
MYTH: Little hope exists for accurate diagnosis and effective treatment.
Although RA remains elusive and sometimes baffling, much progress has been made in understanding, detecting, and treating it. It has become clearer that treatment must be tailored to the individual patient with the goal of achieving remission. Strides over the last 15 years, such as aggressive combination therapies, DMARDs, and biological drugs, are enabling patients to live and work with the disease. (See Where to get more information by clicking on the PDF icon above.)
Positive outcomes for RA patients include maintaining functional status, decreasing the need for hospitalization, reducing disability and mortality, improving prognosis, and enhancing quality of life. Research into new medications and the causes of joint inflammation and destruction may soon allow earlier diagnosis and treatment with fewer complications.
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Gayle Walker-Cillo is a clinical specialist in the emergency department (ED) at Morristown Memorial Hospital in Morristown, New Jersey. Marylou Killian is a nurse practitioner in the ED at Margaretville Memorial Hospital in Margaretville, New York.