rheumatoid arthritis

Inflammation of the joints; a chronic progressive disease, it begins with pain and stiffness in the small joints of the hands and feet and spreads to involve other joints, often with severe disability and disfigurement. There may also be damage to the eyes, nervous system, and other organs. The disease is treated with a range of drugs and with surgery, possibly including replacement of major joints.

Rheumatoid arthritis most often develops between the ages of 30 and 40, and is three times more common in women than men. It is an autoimmune disease and thus some of the recently developed treatments involve drugs which deactivate those parts of the immune system responsible for tissue damage.

In the West it affects 2–3% of women and nearly 1% of men; an estimated 165 million people worldwide suffered from rheumatoid arthritis in 1995. In children rheumatoid arthritis is known as Still's disease.

Symptoms Rheumatoid arthritis affects the whole body. Degeneration of the ‘collagen’ component of the fibrous connective tissues occurs. This degeneration is common to all connective tissue diseases. Rheumatoid arthritis usually starts slowly with general ill health, tiredness, anaemia, loss of weight, and painful stiffness. Occasionally onset may be sudden, with a raised temperature and joint pains resembling an acute infective arthritis or rheumatic fever. Next the small joints of the hands and feet become swollen and painful, then the larger joints become involved, sometimes even the spine. The pain and stiffness are worse in the mornings and after rest, easing after movement. Muscle wasting and general loss of weight follow. The flexor muscles retain greater power than the extensors, and their pull, unless corrected, causes flexion deformity of the joints. This, together with the swelling of the joints and the marked muscular wasting, gives the typical deformity of severe rheumatoid arthritis. The inflammatory process in rheumatoid arthritis starts in the synovial membrane of the affected joints and later spreads to the joint capsule, the adjoining tendons, and the joint cartilage. Fibrous tissue replaces normal tissue, resulting eventually in disorganization of the joint and sometimes complete ankylosis (fixation). The pain, particularly on attempted movement, is considerable. It is difficult to forecast the course of the disease. Remissions alternating with exacerbations occur. Pregnancy and jaundice inhibit its progress. About 50% of cases remain stationary for many years, while other cases become progressively worse. The mode of onset gives no indication of the subsequent progress of a case.

Treatment Treatment consists of rest and in preventing, by splinting and other means, the development of deformities. Physiotherapy encourages active and passive movements and generally maintains muscle tone. It is essential to build up the general and psychological condition of the patient. Many treatments have been tried and failed. Removal of teeth and tonsils and surgical treatment of other possible foci of infection used to be widely practised in the belief that focal infection was a cause of the disease. This belief is no longer held. Gold injections have proved helpful in some cases. Simple aspirin or codeine tablets are most valuable in relieving pain, and in many cases aspirin also seems to have some specific curative effect. Hench and his colleagues in the USA first demonstrated in 1949 the effects of cortisone and ACTH (adrenocorticotrophic hormone) on rheumatoid arthritis. Patients given the hormone were at first relieved of their symptoms, and after a few days were able to move freely and without pain. It was thought that a cure had been found and that a diminished secretion of adrenal hormones was the causative factor in rheumatoid arthritis. It was soon realized, however, that this was not the case. When cortisone is withdrawn, and even when it is continued, symptoms tend to return, and it is now known that it only suppresses temporarily the inflammatory condition of the joints, and does not cure the disease. A committee of the Medical Research Council reported in 1954 and 1955 on a comparative trial of aspirin and cortisone in two selected groups of cases. After two years' treatment neither group showed any marked improvement over the other. Nevertheless cortisone and other steroids, such as prednisone, have proved of benefit in relieving acute cases, and it is a great help to the patient's morale to be free for a time from distress. Steroid therapy may also be valuable in tiding a patient over an exacerbation of the disease. The use of these drugs is, however, contra-indicated in certain conditions such as heart failure, diabetes, high blood pressure, renal disease, and tuberculosis, and they must always be given with caution. More recently other drugs have been developed. While aspirin remains the most widely used analgesic (pain-killing drug), anti-inflammatory drugs such as phenylbutazone (Butazolidin), indomethacin (Indocid), and ibuprofen (Brufen) also have their place, and may bring considerable relief from pain. Other compounds that are used with some success include penicillamine and cytotoxic drugs. Most of these must be taken under strict medical control. At a late stage in rheumatoid arthritis the joint changes often progress to those of osteoarthritis causing further disability. In more recent years the use of total joint replacements (see arthroplasty) in the hand, hip, and knee in particular, has meant that many people with rheumatoid arthritis have been able to maintain some degree of pain-free mobility.