Arthritis in its many forms is the leading cause of chronic disability in the United States, encompassing a wide variety of complaints focusing on joint pain. If you notice pain, redness, and swelling in your joints, it's important to see a physician, as the arthritis could be a consequence of another disorder.
When people say arthritis they are generally referring to either rheumatoid arthritis or osteoarthritis. Osteoarthritis affects around 30 million people in the United States and is connected to a mechanical problem in the joint itself.
Rheumatoid arthritis affects three million people in the United States and is caused by auto-immune inflammation, resulting in large, painful joint swelling. While joints in the hands are most commonly affected, rheumatoid arthritis can cause a potentially very serious inflammation of the lungs or the heart in some rare cases.
Diagnosis
Medical students are taught that if a patient's pain is at its worst upon waking up in the morning but improves over the course of the day, rheumatoid arthritis is more likely. Conversely, osteoarthritis becomes more painful over the course of the day. Formal diagnosis is slightly more complex, with some grey area in between.
Osteoarthritis is far more common than rheumatoid arthritis, with 30 percent of women in their 60s exhibiting some signs of osteoarthritis. Both forms of arthritis are more common in women than in men, likely due to the unknown overall increased incidence of auto-immune disorders in women.
While blood tests for antibodies seen in rheumatoid arthritis can solidify a diagnosis, they are mainly used to rule out more serious problems. Radiographic images (X-rays) may be taken to see how far the joint damage has progressed. Fluid may be taken from the affected joint for analysis, in a process called needle aspiration. A thorough medical history, a list of current medications, and tests for strength, general mobility and pinpointing the most painful motions are all typically part of an in-office evaluation.
Rheumatoid arthritis
Rheumatoid arthritis affects joints in the fingers, wrists, knees and elbows. Unlike osteoarthritis, rheumatoid arthritis is usually symmetrical. The inflammation can lead to severe deforming changes in the knuckles of the hands. Rheumatoid arthritis occurs mostly in people aged 20 and above, but juvenile forms exist. In children, the disorder can present with a skin rash, fever and pain. While the causes of rheumatoid arthritis are genetic, it is not usually passed on from one generation to the next.
Osteoarthritis
Osteoarthritis is primarily a mechanical rather than an autoimmune problem, but the causes are also found in gene expression. More importantly, increasing weight profiles of Americans heavily contribute to the injuries that can trigger osteoarthritis and other joint problems, especially in the weight-bearing spine and knees. Certain genetic disorders such as Marfan syndrome can also directly cause osteoarthritis. Heavy exercise is not linked to later development of osteoarthritis. In fact, moderate levels of exercise can actually help the painful symptoms improve.
Lupus
Lupus is a collagen vascular disorder that can be present with severe arthritis. Other features of lupus include a skin rash, extreme photosensitivity, hair loss, kidney problems, lung fibrosis and constant joint pain. Lupus can be difficult to diagnose, with a long list of possible symptoms but little consistency. Blood work looking for auto-immune molecules such as anti-Smith or anti-ssRNA may be the only clue that the patient’s joint pain isn't rheumatoid arthritis.
Gout
Gout is an underlying metabolic disorder that causes very painful arthritis symptoms late in life. The symptoms are due to crystals of uric acid accumulating in a joint. Most importantly, unlike other forms of arthritis, gout occurs in extraordinarily painful episodes in a singular joint, with long periods of time separating the attacks. Gout is covered more thoroughly in another article here on dailyrx.com.
Psoriatic arthritis
Psoriasis is a skin rash due to auto-immune dysfunction. The rash on the skin can involve underlying joints, especially on the hands, and the inflammatory process and treatment is very similar to rheumatoid arthritis.
Medical Treatment
Therapy for arthritis mostly focuses on suppressing symptoms, but the joint destruction is difficult to stop. Painkillers, anti-inflammatory drugs such as Advil (ibuprofen), Tylenol, (acetaminophen), corticosteroids, disease-modifying anti-rheumatic drugs (DMARDs) and the newer category of biological response modifiers can be tried in various combinations until an effective treatment is found that minimizes side effects.
Over the counter treatment for osteoarthritis includes acetaminophen and non-steroidal anti-inflammatory drugs, the most common being ibuprofen. Current medical literature does not support supplements such as omega-3 fatty acids, chondroitin sulfate and glucosamine, as results were identical to placebo in extended trials.
Acupuncture has been shown to provide relief for many patients, but does not seem to show permanent benefits, either. Corticosteroids can be very helpful in immediately treating a crisis, but should be used sparingly, as effects do not last and chronic use of corticosteroids comes with a long list of very problematic side effects.
Patients given methotrexate must be closely monitored for problems with their intestines, blood disorders, heart and lung problems. Liver toxicity is an issue and liver panels need to be ordered regularly. Patients who may become pregnant will have difficulty getting a prescription for methotrexate because of its very high potential for causing birth defects.
For example, another drug used to treat rheumatoid arthritis, sulphasalazine, is a lot more powerful than methotrexate, but side effects can be substantial. Some patients may only experience nausea and a skin rash that go away, but in some patients a life-threatening skin rash can occur, and bone marrow failure has been documented.
Monoclonal antibody treatments such as Enbrel (etanercept), Remicade (infliximab), Humira (adalimumab), Simponi (golimumab), and Rituxan (rituximabn) are very effective in some patients, but can be quite expensive, with treatment as high as $10,000 per year.
Conclusion
Ultimately, due to the high level of expertise needed to balance the side effects of the various medications against adequately treating the level of impairment from the arthritis, patients with rheumatoid arthritis will need to consult a rheumatologist, a doctor who specializes in inflammatory diseases of the joints. There are many different ways to combine the drugs listed above, and each patient may have a unique treatment to best fit their situation.
It is also important to involve a pharmacist in managing your medication for rheumatoid arthritis, as some of the prescription drugs used to treat rheumatoid arthritis may change liver function, altering blood levels of any other pharmaceutical drugs you may be taking.
