The definition of Rheumatoid arthritis (RA) is a systemic auto-immune disease characterized by inflammatory polyarthritis which affects peripheral joints, especially the small joints of the hands and feet. This is a chronic and progressive disease in which if the process of inflammation is untreated may lead to cartilage and bone erosions and joint destruction (Ferri, 2018, p. 1125).
Incidence and prevalence
As according to Ferri (2017), RA is a chronic inflammatory disease that affects joints and other organ systems. RA affects 0.5% to 1% of the population worldwide (p. 1111), and “annual incidence in northern Europe and the United States 0.15 to 0.60 per 1000. Nearly three times as many women have this disease then men (Arthritis Foundation, 2018, p. 1). The age of women who get this is between 30 – 60 years of age. In men it often occurs later in life. The chances of patient getting Rheumatoid arthritis is increased if a family member has this disease.
Pathophysiology
Cause of RA unknown, but evidence shows combined effect of environmental, epidemiologic, infectious, and genetic factors. (Grossman, & Porth, 2014, p.1500).
Researcher are not fully sure what causes this disease but have connected this disease to having a gene maker called HLA, these patients have a five fold greater chance of developing RA (Arthritis Foundation, 2018, p. 1). The other gene’s that are connected are: STAT4, TRAF1, C5, and PTPN22. The biggest trigger in RA is female hormones, 70% of people are women, the other triggers are obesity, stressful events and emotional trauma.
RA is a systemic autoimmune disease. Immunologic processes result in inflammation of synovium producing antigens and inflammatory by-products that lead to destruction of articular cartilage, edema, and production of a granular tissue called pannus. And granulation tissue forms adhesions that lead to decreased joint mobility (Grossman, & Porth, 2014).
Physical assessment and examination
- Arthritis
- Pain, swelling, warmth in one or more peripheral joints, frequently with symmetric small joint involvement, often associated with >1 hour of morning stiffness and constitutional symptoms (such as fever, fatigue, weight loss, and episcleritis)
- Most common joints involved include metacarpophalangeal joints, proximal interphalangeal joints, and metatarsophalangeal joints as well as wrists
- Other affects joints involved include elbows, shoulders, hips, knees, and ankles.
- Skin manifestations
- Rheumatoid nodules: nontender, firm nodules on extensor surfaces and pressure points, usually in rheumatoid factor positive (RF+) disease.
- Cardiac manifestation
- Pericarditis (most common)
- Myocarditis
- Valvular nodules
- There is an increased risk of cardiovascular disease compared to the general population, probably due to accelerated atherosclerosis from systemic inflammation
- Pulmonary manifestations
- Pleural disease: exudative effusions, pleuritic
- Interstitial lung disease up to 10% clinically significant
- Bronchiolitis obliterans
- Cryptogenic organizing pneumonia
- Pulmonary nodules
- Neurologic manifestations
- Entrapment neuropathy: carpal tunnel, tarsal tunnel, cubital tunnel most commonly involved
- Peripheral neuropathy, cervical myelopathy, and cord compression in atlantoaxial subluxation
(Ferri, 2017, p. 1111).
To diagnosis RA, if the primary care provider suspects this disease they should refer this patient to a specialist called Rheumatologist. This specialist will do a full history and physical asking about personal and family medical history, recent and current symptoms (pain, tenderness, stiffness, difficulty moving) (Arthritis Foundation, 2018, p. 1). The specialist will do blood test that will measure inflammatory levels (ESR and CRP), he will also test for antibodies (anti-cyclic citrullinated peptide, CCP). Now both of these tests are not an absolute, these can be found in other diseases that have inflammatory processes. He can then do imaging test such as x-rays, ultra sound and MRI, the specialist is looking for joint damage, erosion and loss of bone within the joint or narrowing in the joint space. Again, he may not see all or any of these things due to being at an early stage of the disease.
Diagnostic Evaluation
- As according to Ferri (2017) there are found variables constitute new criteria in definite RA: for score greater or equal to 6 are considered to have definite RA
- The number and size of involved joints (0-5 points, with higher scores for a large number of small joints affected)
- Levels of rheumatoid factor (RF) and anticyclic citrulinated peptide (CCP) antibody (0-3 points, with a higher score for a high-titer positive RF or anti-CCP
- Elevated erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) (1 point)
- Symptom duration > or = 6 weeks (1 point)
- Lab tests:
- RF
- Anti-CCP
- ESR and CRP
- CBC with differential
- Synovial fluid analysis, synovial biopsy
- X-rays, MRI, Bone scan, and /or Ultrasound
(Ferri, 2017, p. 1112).
The whole point of treatment in RA is to stop inflammation, relieve symptoms, prevent joint and organ damage, improve physical function and overall well-being and reduce long-term complications. Medication that slow the process of RA are corticosteroids, DMARD’s, biologics and JAK inhibitors.
Treatment Management
- NSAIDs to relieve pain and inflammation: can be used initially to relieve pain and mild inflammation
- DMARDs to reduce disease activity
- Corticosteroids to reduce inflammatory process: can be used initially to reduce inflammation rapidly until DMARDs treatment take effect.
- Nonpharmacologic modalities:
- Local comfort measures: heat and cold applications
- Relaxation techniques
(Ferri, 2017, p. 1113).
Patient education
Patient and family should always educated regarding chronic nature of RA with characteristic exacerbations and remission with time, and encourage patient the importance of exercise regularly during remission period. Patient should educated regarding medication regime, and consistence regarding medication administration, in which including regular periodic laboratory testing as needed with RA treatment plan of care. Patient should always be provided information regarding the use of any complementary or alternative therapies, and should emphasized and updated with current treatment plan of care, and educate patients to avoid “miracle cures”. Rather, early referral to rheumatologist may be necessary, and Orthopedic may consulted regarding corrective surgery if needed.
Self-management of RA would consist of foods rich in antioxidants such as fish, vegetables, fruits and olive oil. Balanced physical and rest, hot and cold therapies, topical treatments, natural and alternative therapies, supplements, and positive attitude and support system.
References:
Arthritis Foundation. (2018). Rheumatoid arthritis causes. Retrieved from https://www.arthritis.org/about-arthritis/types/rheumatoid-arthritis/causes.php
Arthritis Foundation. (2018). Rheumatoid Arthritis Diagnosis. Retrieved from https://www.arthritis.org/about-arthritis/types/rheumatoid-arthritis/diagnosing.php
Arthritis Foundation. (2018). Rheumatoid arthritis symptoms. Retrieved from https://www.arthritis.org/about-arthritis/types/rheumatoid-arthritis/symptoms.php
Arthritis Foundation. (2018). What is Rheumatoid arthritis? Retrieved from https://www.arthritis.org/about-arthritis/types/rheumatoid-arthritis/what-is-rheumatoid-arthritis.php
Ferri, F. F. (2017) Ferri’s clinical advisor, 2017, 5 books in 1
Ferri, F. F. (2018). Ferri’s clinical advisor 2018 E-book: 5 books in 1
Grossman, S. C. & Porth, C. M. (2014) Porth’s pathophysiology: Concepts of altered health states. (9th. Ed)
