Rheumatoid Arthritis Treatment & Management

  • Author: Katherine Temprano, MD; Chief Editor: Herbert S Diamond, MD   more...
 
Updated: Apr 23, 2012
 

Approach Considerations

The optimal care of patients with rheumatoid arthritis consists of an integrated approach of pharmacologic and nonpharmacologic therapies. Many nonmedication therapies are available for this disease, including exercise, diet, massage, counseling, stress reduction, physical therapy, and surgery. The active participation of the patient and family in the design and implementation of the therapeutic program helps to boost morale and to ensure compliance, as does explaining the rationale for the therapies used.

Medication-based therapies comprise several classes of drugs, including NSAIDs, DMARDs, immunosuppressants, biologic response modifiers, and corticosteroids. Early therapy with DMARDs has become the standard of care, as it cannot only retard disease progression more efficiently than later treatment, but it may also induce more remissions.

In pregnant patients with rheumatoid arthritis, no special obstetric monitoring is indicated beyond what is performed for usual obstetric care. However, some of the medications used in treating this condition can have adverse effects on the fetus and may need to be discontinued several months before conception is planned.

Surgical treatments for RA include synovectomy, tenosynovectomy, tendon realignment, reconstructive surgery or arthroplasty, and arthrodesis.

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Possible Patient Presentations

Patients generally present with known rheumatoid arthritis and with an exacerbation of known disease or manifestations in other organ systems or other disease sequelae; less commonly, patients may present to the emergency department for a new diagnosis of RA.

Patients presenting with an initial onset of previously undiagnosed possible rheumatoid RA require symptomatic treatment with NSAID therapy and rapid referral for definitive diagnosis and institution of DMARD therapy. Delay of as little as 2-3 months in initiating joint-sparing therapy results in significant irreversible joint damage measured radiographically at 5 years.

In patients with known disease, increased pain, edema, and dysfunction are characteristics of rheumatoid flare (exacerbation). Flares may be local or systemic in nature. Laboratory evaluation may reveal elevation in acute phase reactants. Treatment consists of rest, NSAIDs, DMARDs, short courses of steroids (2-4 wk), and possibly intra-articular steroid injections. Pain relief is important and may necessitate short-term use of narcotic analgesics.

Felty syndrome

Felty syndrome is a triad of rheumatoid arthritis, neutropenia, and splenomegaly. Patients with Felty syndrome are prone to serious bacterial infections that result in higher rates of morbidity and mortality than for other patients with RA. This requires prompt diagnosis and initiation of antibiotic therapy.

Baker cysts

Ruptured Baker cysts are often confused with deep vein thrombosis (DVT). Baker cysts often occur fairly early in the course of the disease, with pain, edema, and inflammation in the posterior knee and calf. The diagnosis is best made with ultrasonography. Treatment includes rest, elevation, needle puncture of the calf, knee joint aspiration, and referral.

Carpal tunnel syndrome

Carpal tunnel syndrome (median nerve compression neuropathy) is evinced by pain and/or paresthesias in the median nerve distribution of the hand, a positive Phalen and/or positive Tinel test, or positive electromyography. Therapy includes rest, temporary immobilization, NSAIDs, and surgery.

Cervical spine instability

Cervical spine instability may be observed in patients with established rheumatoid arthritis who have degeneration of the ligaments and bone in the C-spine area. Degeneration of the transverse ligament can lead to instability at the C1-C2 level. Minor trauma can lead to neurologic sequelae due to inherent instability. Exercise caution when evaluating patients with RA after minor falls, motor vehicle accidents (MVAs), or other injuries. Cervical spine injury may occur spontaneously.

Go to Rheumatoid Arthritis of the Cervical Spine for complete information on this topic.

Keratoconjunctivitis sicca

Keratoconjunctivitis sicca occurs in approximately 25% of patients with rheumatoid arthritis. Symptoms include ocular discharge, foreign-body sensation, and dry eye. Episcleritis may progress to scleromalacia if left untreated. Treatment includes referral to ophthalmology, artificial tears, systemic NSAIDs, topical NSAIDs, systemic steroids, and cyclophosphamide.

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Complications of Treatment

Patients with an established diagnosis of rheumatoid arthritis who are being treated with DMARDS, particularly those treated with combination therapy, including the biologic response modifying agents such as anti-TNF antibody therapy, may present with serious infections and/or malignancies.[31, 32, 33]

Additionally, adverse events from RA medications may include liver toxicity, renal toxicity, bone marrow depression, lung inflammation, and skin manifestations.

Patients taking anti-TNF agents must avoid live-virus vaccines.

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Rheumatoid Arthritis and Pregnancy

Pregnancy alters the immune state, possibly contributing to a change in the course of rheumatoid arthritis.[34] For decades, the ameliorating effects of pregnancy on disease activity in women with RA have been observed. No specific guidelines address obstetric monitoring in patients with RA. Because little available data suggest a significant risk for preterm birth, preeclampsia, or fetal growth restriction in pregnant patients with this disease, no special obstetric monitoring is indicated beyond what is performed for usual obstetric care.

It is important to counsel patients about the teratogenicity and adverse effects of the medications used to treat rheumatoid arthritis before starting therapy. Patients may need a reminder about the importance of using contraception during DMARD therapy and that some of these medications may need to be discontinued several months before conception is planned. In addition to discontinuation, some patients who take DMARDs may require treatment with other medications to enhance their clearance.

Patients with rheumatoid arthritis must be monitored closely following delivery, because they have the potential to have arthritis flare-ups during the postpartum period.

Go to Rheumatoid Arthritis and Pregnancy for complete information on this topic.

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Pharmacologic Therapy

The American College of Rheumatology developed recommendations and algorithms for the use of nonbiologic and biologic DMARDs for patients with rheumatoid arthritis (RA).[35]

DMARDs

DMARDs represent the most important measure in the successful treatment of rheumatoid arthritis. These agents can retard or prevent disease progression and, thus, joint destruction and subsequent loss of function. Successful DMARD therapy may eliminate the need for other anti-inflammatory or analgesic medications; however, until the full action of DMARDs takes effect, anti-inflammatory or analgesic medications may be required as bridging therapy to reduce pain and swelling.

Many studies have revealed that early treatment of RA (ie, within months of onset) with DMARDs can not only retard disease progression more efficiently than later treatment, but it may also induce more remissions. Thus, early therapy with DMARDs has become the standard of care. It is important to note that patients with early forms of arthritis should be evaluated by and, if necessary, referred to physicians who are experienced in the diagnosis and treatment of RA.

DMARDs can be classified into xenobiotic and biologic agents. The xenobiotic DMARDs, which include gold salts (eg, aurothiomalate, auranofin), D-penicillamine, chloroquine and hydroxychloroquine (HCQ), sulfasalazine (SSZ), MTX, azathioprine (AZP), and cyclosporin A, have been widely used to treat rheumatoid arthritis (RA); some of these agents have been used for decades. The results of a retrospective cohort study found that the use of hydroxychloroquine may decrease the risk of diabetes in patients with RA. Further studies are needed to determine hydroxychloroquine’s preventive role in other patients at high risk for diabetes.[36] The results of a retrospective cohort study involving 121,280 patients found a lower adjusted risk of diabetes mellitus among individuals with RA or psoriasis who started a TNF inhibitor or hydroxychloroquine compared with other nonbiologic DMARDs.[37]

Injectable gold salts and penicillamine rarely induce sustained remission and have thus largely been supplanted by more effective agents. MTX and SSZ are the most active compounds in terms of frequency of remissions and time to onset of action and provide the best risk-benefit ratios. MTX alone or in combination with other agents has become the standard of care for moderate to severe RA.

Minocycline may act as a DMARD through its action as a matrix metalloproteinase inhibitor (MMPI). Leflunomide is the most recent addition to the xenobiotics and has activity similar to that of SSZ and MTX. Most of these drugs have been shown to improve signs and symptoms (as well as quality of life) and to significantly retard radiographic progression of RA.

Combination therapy

Combination therapy appears to be helpful in patients whose disease insufficiently or completely fails to respond to monotherapy with a DMARD. Several combinations have proved successful and without unexpected added risks; these combinations usually include MTX (ie, MTX plus SSZ plus an antimalarial, MTX plus leflunomide, or MTX plus biologic agents).

In combination with infliximab, MTX provides a superior response to monotherapy.[38] In combination with rituximab, MTX provides a superior response to monotherapy.[39] In combination with etanercept, MTX provides a higher rate of meaningful clinical response. Although the combination is not commonly used, cyclosporine with MTX results in greater clinical improvement than MTX alone. Triple therapy with MTX, SSZ, and HCQ may provide substantially greater clinical improvement than MTX alone or SSZ plus HCQ.[23] Toxicities of these drug combinations are rarely more significant than those occurring with any of the individual agents used alone, although liver and bone marrow toxicity may be increased if compounds affecting these organs are combined.

The most important and most common adverse events relate to liver and bone marrow toxicity (MTX, SSZ, leflunomide, azathioprine, gold compounds, D-penicillamine), renal toxicity (cyclosporin A, parenteral gold salts, D-penicillamine), pneumonitis (MTX), allergic skin reactions (gold compounds, SSZ), autoimmunity (D-penicillamine, SSZ, minocycline), and infections (azathioprine, cyclosporin A). Antimalarials may cause ocular toxicity. Nevertheless, these drugs, when used with appropriate clinical and laboratory control monitoring, are usually well tolerated. Adverse events typically become rarer after the first 2-3 months of therapy. Most adverse events are reversible with cessation of the drugs or with reduction of the doses.

In clinical trials, 30-70% of patients using DMARDs, either alone or in combination therapy, achieve partial responses, according to the American College of Rheumatology's disease activity score. Currently, predicting which patients' condition will not respond is not possible.

In clinical practice, there are 3 strategies to reduce disease activity as much as possible in patients whose disease do not respond or in those with clinical responses that are regarded as insufficient:

  • Increasing the dose of medication
  • Switching to other DMARDs
  • Initiating combination therapy

Because patients may require 2-3 months to achieve a full response to DMARDs, decisions regarding changes in medication are often delayed until that time.

The results of one study found that in patients with early, active RA, combination DMARD therapy with downward titration or intensive, triple-DMARD combination therapy is more cost-effective compared with DMARD monotherapy.[40]

Biologic agents

The recognition of TNF-alpha and IL-1 as central proinflammatory cytokines has led to the development of agents that block these cytokines or their effects. In addition to improving signs and symptoms and quality of life, all biologic agents significantly retard radiographic progression of joint erosions. The TNF blockers, which bind TNF and thus prevent its interaction with its receptors, include etanercept, infliximab, and adalimumab: infliximab binds to cells that express membrane TNF, whereas etanercept binds lymphotoxin (formerly termed TNF-beta) in addition to soluble TNF-alpha.

Biologic agents are expensive. Consensus statements do not recommend their use until at least one xenobiotic DMARD, usually MTX, has been administered without sufficient success. In clinical trials, up to 70% of patients achieve significant responses, but remissions are not usually observed.[41] Additionally, the results from one study noted that the presence of anti-Ro/SSA antibodies (anti-Ro) may be associated with a reduced response to infliximab versus other TNF inhibitors (eg, etanercept, adalimumab), thus possibly influencing the initial selection of TNF inhibitor.[42]

Adverse effects associated with the biologic agents include the generation of antibodies against these compounds, emergence of antinuclear antibodies, occasional drug-induced lupuslike syndromes, and infections (including tuberculosis). Rarely, demyelinating disorders and bone marrow suppression occur. Acute and chronic infections, demyelinating disorders, class 3 and 4 heart failure, and recent malignancies are contraindications for TNF blockers. Thoroughly searching for latent tuberculosis using chest radiography and/or purified protein derivative (PPD) testing is recommended before these agents are started.

Patients taking anti-TNF agents must avoid live-virus vaccines.

The results of one study noted that the use of anti-TNF therapy may double the risk of septic arthritis in patients with RA, with the risk being highest in the early months of therapy. While not significantly influenced by anti-TNF therapy, prior joint replacement surgery was also noted as a risk factor.[43]

Another study noted that hepatitis B virus reactivation can occur in both HBsAg-positive and HBsAg-negative/HBcAb-positive patients with detectable occult hepatitis B virus infection during anti-TNF-alpha therapy; antiviral prophylaxis may effectively reduce this reactivation.[44]

A 2007 clinician’s guide from the Agency for Healthcare Research and Quality (AHRQ) advised the following, with a medium level of confidence[45] :

  • For patients with early rheumatoid arthritis (ie, < 3 years’ duration) who have not previously taken MTX, monotherapy with MTX controls symptoms as well as monotherapy with adalimumab or etanercept.
  • Combining a biologic agent with MTX brings better symptom relief than using either agent alone.
  • For patients with early RA, the combination of MTX and SSZ does not work better than monotherapy with either drug.
  • Evidence is insufficient to determine if combining 2 biologic agents works better than using any 1 biologic agent alone.
  • MTX and most biologic agents increase the likelihood of serious infection.

The results of one study found that bone erosions in RA patients treated with TNF blockers showed a higher success rate of repair than erosions treated with methotrexate. After a 1-year follow-up, the TNF blocker group showed a mean width of 2 mm and a mean depth of 2.3 mm; the methotrexate group showed a mean width 2.4 mm and a mean depth 2.4 mm. Deeper lesions in the TNF blocker group were also particularly prone to repair when compared with more shallow lesions.[46]

In 2009, van Vollenhoven et al reported that in patients with early rheumatoid arthritis in whom MTX treatment fails, the addition of a TNF antagonist is superior to addition of conventional DMARDs.[47] In their study, 258 patients with early RA who did not achieve low disease activity after 3-4 months of MTX (up to 20 mg/wk) were randomized to receive additional treatment (in addition to MTX) with SSZ and HCQ or with infliximab. In the SSZ and HCQ group, 32 of 130 (25%) achieved the primary outcome defined as a good response, according to the European League Against Rheumatism (EULAR). In the infliximab group, 50 of 128 (39%) attained the primary outcome.[47]

A systematic review by Visser et al suggested that an initial PO MTX dose of 15 mg/wk with escalation of 5 mg/mo to achieve target doses of 25-30 mg/wk or maximum tolerable doses was the optimal, evidence-based dosing strategy.[48] Starting at higher initial doses or a too rapid escalation is limited by toxicity. Conversion from PO to SC administration of MTX is suggested for patients who have an inadequate response to oral therapy.

Fleischmann et al found that treatment with certolizumab monotherapy every 4 weeks effectively reduced the signs and symptoms of active RA in patients in whom DMARD therapy had failed.[49] Two hundred patients were randomized 1:1 to receive certolizumab 400 mg or placebo every 4 weeks for 24 weeks. At 24 weeks, 45.5% of the certolizumab group achieved a 20% improvement, according to the American College of Rheumatology criteria (ACR20), compared with 9.3% of the placebo group. Statistically significant differences between certolizumab and placebo were observed as early as week 1 through week 24.[49]

Smolen et al demonstrated certolizumab plus MTX was more efficacious than placebo plus MTX, rapidly and significantly improving signs and symptoms of RA and physical function and inhibiting radiographic progression.[50] Patients (n = 619) were randomized to receive certolizumab 400 mg at weeks 0, 2, and 4, followed by 200 mg or 400 mg plus MTX every 2 weeks, or placebo plus MTX every 2 weeks. Significantly more patients who received certolizumab 200 mg (57.3%) or 400 mg (57.6%) achieved ACR20, as compared with those who received placebo (8.7%).[50] Radiographic progression was significantly inhibited with certolizumab 200 mg or 400 mg, as compared with placebo. When compared with placebo plus MTX, certolizumab plus MTX significantly relieved signs and symptoms, improved physical function, and inhibited radiographic progression in patients with RA.[50]

Golimumab, a new human anti-TNF-alpha monoclonal antibody, inhibits TNF-alpha bioactivity, thereby modulating immune activity in patients with RA. Using a modified intention-to-treat analysis, Emery et al demonstrated that the efficacy of golimumab plus MTX is better than the efficacy of MTX alone (and the efficacy of golimumab alone is similar to that of MTX alone) in reducing disease signs and symptoms in MTX-naive patients.[51] Their 52-week, randomized, double-blind, placebo-control study was followed by an open-label extension through 5 years. Patients (n = 637) were randomized to receive placebo plus MTX (group 1), golimumab 100 mg plus placebo (group 2), golimumab 50 mg plus MTX (group 3), or golimumab 100 mg plus MTX (group 4). Intent-to-treat analysis showed no significant differences in the primary endpoint (ACR50) between group 1 and groups 3 and 4 combined, indicating efficacy of golimumab in RA.[50] The incidence of serious adverse events was similar among all treatment groups.

Although rituximab may be used as a sole agent, it is often used in combination with MTX. Rituximab has been shown to be effective in reducing the signs and symptoms in adult patients with moderately to severely active RA who have had an inadequate response to therapy with one or more TNF antagonists.[52, 53, 54]

Treatment with rituximab may deplete CD20+ B cells; a study by Bingham et al suggested that polysaccharide and primary immunizations should be administered before rituximab infusions to maximize treatment responses.[55] Their study showed responses to pneumococcal polysaccharide vaccine were less in patients with RA receiving rituximab and MTX (57% showed a 2-fold rise in titer in response to ≥1 serotype) than in those receiving MTX alone (82%). Decreased response to keyhole limpet hemocyanin (KLH) (neoantigen) was also seen in the rituximab-treated patients (47% vs 93%).[55] However, the ability to maintain a positive delayed-type hypersensitivity to a Candida albicans skin test was comparable in both groups, as was response to tetanus toxoid.

Data accumulated from 3 Swedish registries analyzed the cancer risk in 6,366 patients with rheumatoid arthritis (RA) taking TNF blockers; no increased risk for cancer with TNF blockers was observed. Data were compared with 61,160 patients with rheumatoid arthritis (RA) who were biologics-naive, 5,989 patients starting MTX, 1,838 patients starting DMARD combination therapy, and the general Swedish population. Results showed that, among patients taking TNF blockers (25,693 person-years of follow-up in 6,366 patients over 6 y), 240 developed first-time cancer, yielding a relative risk (RR) of 1.00 compared with the biologics-naive cohort. Similar RRs were shown with the other cohorts.[56]

Immunomodulators

Another biologic agent is anakinra (IL-1 receptor antagonist [IL-1ra]). IL-1ra occupies the IL-1 receptor without triggering it and prevents receptor binding of IL-1. In clinical trials, a significant response was observed in approximately 40% of patients with RA.

Abatacept is a selective costimulation modulator that inhibits T-cell activation by binding to CD80 and CD86, thereby blocking their interaction with CD28. CD28 interaction provides a signal needed for full T-cell activation that is implicated in rheumatoid RA pathogenesis. Maintenance doses may be administered as a monthly IV infusion or by the patient as a weekly SC injection.[57]

Tocilizumab (Actemra) is an interleukin 6 (IL-6) receptor inhibitor. It is indicated for moderate-to-severe active RA in adults who have had an inadequate response to one or more TNF-antagonist therapies. It may be used alone or in combination with methotrexate or other disease-modifying antirheumatic drugs.

Glucocorticoids

Glucocorticoids are potent anti-inflammatory drugs and are commonly used in patients with RA to bridge the time until DMARDs are effective. Timely dose reductions and cessation are important because of the adverse effects associated with long-term steroid use.

The results of one study found that the use of corticosteroids was associated with heart failure in patients with RA, independent of CV risk factors and CHD. Those patients who currently use methotrexate showed a lower risk of heart failure.[58]

Nonsteroidal anti-inflammatory drugs

NSAIDs interfere with prostaglandin synthesis through inhibition of the enzyme cyclooxygenase (COX), thus reducing swelling and pain. However, they do not retard joint destruction and, therefore, when used alone, are not sufficient to treat RA. Similar to glucocorticoids, these agents can be reduced in dose or discontinued with successful DMARD therapy.

Several dozen NSAIDs are available and can be classified into different groups of compounds. Commonly used NSAIDs include ibuprofen, naproxen, ketoprofen, piroxicam, and diclofenac.

Data from a Cochrane Database of Systematic Reviews study suggest that while the use of NSAIDs concurrent with methotrexate may be safe in the management of rheumatoid arthritis, anti-inflammatory doses of aspirin should be avoided.[59]

In the early 1990s, 2 isoforms of COX were discovered (ie, COX-1 and COX-2). Traditional NSAIDs inhibit both COX-1 and COX-2. The development of coxibs (COX-2 inhibitors), a new group of compounds, followed. These compounds have a significant preference for COX-2 over COX-1. COX-1 has a protective role, particularly in the stomach, whereas COX-2 is strongly up-regulated during inflammation.

Coxibs, with their selectivity for COX-2, have been shown to be clinically efficacious and are accompanied by significantly reduced GI toxicity, the major adverse event related to the use of nonselective COX inhibitors (ie, NSAIDs). Other adverse effects, such as water retention, hypertension, and abnormal transaminase levels, are observed with both nonselective and COX-2-selective drugs. Whether and to what degree nonaspirin NSAIDs, coxibs, or both have cardiovascular toxicity has not been definitively settled.

Analgesics

Acetaminophen/paracetamol, tramadol, codeine, opiates, and various other analgesic medications can also be used to reduce pain. These agents do not affect swelling or joint destruction.

Experimental therapies

Despite significant advances over the past decades, rheumatoid arthritis continues to be an incurable disease. The disease remains active in many patients whose conditions partially or completely fail to respond to DMARDs. Therefore, a vigorous search is under way for new therapeutic agents.

Several new CD20 B-cell-targeted biologic agents are under investigation, including atacicept, AMG 623, B3-FCc, Br3-Fc, belimumab, epratuzumab, ofatumumab, ocrelizumab, and TRU-015.

Xenobiotics directed at molecules involved in transduction of TNF, those involved with the receptor for the lymphotoxin-b receptor, or IL-1–mediated signals (eg, AMG 108, an IL-1ra) could prove helpful.

Inhibition of MMPs, although initially unsuccessful, could prove to be efficacious, as could agents that inhibit activation of osteoclasts.

Apheresis procedures are being investigated.

High-dose immunosuppression combined with autologous stem cell transplantation has been used in study protocols for patients whose conditions are resistant to other therapies.

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Nonpharmacologic Therapy

Rehabilitation program

The goals of rehabilitation for patients with rheumatoid arthritis include pain relief, increased range of motion (ROM), increased strength and endurance, prevention and correction of deformities, and provision of various counseling and educational services. Numerous nonpharmacologic methods are available to the physiatrist to assist patients in achieving these goals. These methods include therapeutic modalities, splints and orthotics, assistive device equipment, joint protection and energy-conservation techniques, and education and therapeutic exercise programs.[60, 61, 62]

Heat and cold therapies

Heat, either superficial or deep, is an effective modality for the relief of joint pain and stiffness caused by RA. In addition, it is also used to treat joints in preparation for ROM, stretching, and muscle-strengthening exercises. Heat may be administered via moist hot packs, electric mittens, a hot shower, spas, ultrasound, diathermy, or paraffin. Superficial and deep heating methods have been shown to raise the intra-articular temperature in patients with RA.

Cold is preferable for treatment of an acutely inflamed joint. Application of cold results in decreased pain and decreased muscle spasm. Cold may be delivered via ice packs, ice sticks, topical sprays, or ice water.

Orthotics and splints

Orthotic devices play an important role in the rehabilitation management of patients with rheumatoid arthritis. These devices are used to decrease pain and inflammation, improve function, reduce deformity, and correct biomechanical malalignment.

Lower extremity orthoses are prescribed to provide stability and proper alignment or to shift weight bearing off the affected limb. The most common orthoses used for the lower extremity involve the foot and ankle joints. Approximately 80% of patients affected with RA illustrate significant foot involvement. These problems are easily accommodated by providing a deep, wide, soft leather shoe. A metatarsal pad or bar is typically used to remove weight from painful MTP joints, and a rocker-bottom sole can be used to facilitate roll-off. Hindfoot pronation should be addressed with custom inserts. Finally, knee orthoses may be used to control edema, pain, patellar alignment, hyperextension, or collateral or cruciate ligament instability.

Therapeutic exercise

Fatigue and decreased endurance are frequent symptoms in patients with rheumatoid arthritis. When comparing these patients to age-matched subjects without this disease, a reduction in aerobic capacity and muscle strength is noted, due to the disease itself and to the lack of physical activity in these patients. Exercise is an important part of the rehabilitation management of RA.

Aerobic conditioning in affected patients (if tolerated) improves maximum oxygen uptake and decreases perceived exertion at submaximal workloads. At the same time, no adverse effects have been noted in the joints of these patients. In addition, patients undergoing long-term endurance training have been known to feel less isolated, take less sick leave, and develop improved function in activities of daily living. Thirty minutes of daily aerobic exercise, several times each week, should be encouraged in patients with well-controlled rheumatoid RA.

Muscle atrophy often accompanies RA and is exacerbated by inactivity, bed rest, splints, and medications. Isometric exercises restore and maintain strength in affected patients without producing pain. Resistance exercises may be initiated when the isometric program has been well established and when the patient is free of pain.[63] Occupational therapy also can be very useful for patients with RA.[64]

Occupational therapy

Occupational therapy is initiated to help patients use joints and tendons efficiently without stressing these structures; decrease tension on the joints with specially designed splints; and cope with daily life through adaptations to the patients' environment and the use of different aids. An occupational therapist may work in conjunction with the physical therapist to ensure that the patient is able to meet his or her goals.

An occupational therapist may assist in the recommendation and use of splints and orthotics, especially when the upper extremity is affected. Upper extremity orthoses may be classified as either static or dynamic. Static splints are used to support a weak or unstable joint, to rest a joint for pain relief, or to maintain functional alignment. Dynamic splints traditionally have been used to manage the postoperative hand, but they may also be used to increase manual dexterity. The most commonly used splints for the hand are the finger-ring splints and the thumb-post splint. The functional wrist splint and the resting hand splint are commonly used for wrist splinting.

Adaptive equipment

Many assistive devices are available to patients with rheumatoid arthritis and are used to provide maximal function, maintain independence, reduce joint stress, conserve energy, and provide pain relief. Equipment is available to assist patients with transfers, dressing, feeding, toileting, cooking, and ambulation.

Joint protection education

Joint protection education provides the patient with techniques and recommendations for the prevention of joint overuse and the avoidance of biomechanical torques that excessively bend the joint.[60] The use of adaptive equipment is important. Other components of a good joint protection program include maintenance of good posture, avoidance of overuse during inflammation, modification of tasks to decrease joint stress, and use of appropriate splints.

Energy-conservation education

Fatigue is a major component of rheumatoid arthritis and is due to the systemic nature of the disease, as well as to the decreased cardiovascular endurance observed in patients with this inflammatory disorder.

The goal of energy conservation techniques is to save energy while maximizing function. Adaptive equipment is an essential part of this program. Other elements include maintaining joint ROM and strength, improving cardiovascular fitness, and taking short rest periods during the day. Every individual with RA should implement joint protection and energy-conservation programs into their lifestyle.

Williams et al found that in older women with either rheumatoid arthritis or osteoarthritis of the lower limb, an individualized home program of balance-training exercise can improve balance and gait stability.[65] In this study, 39 women (mean age 69.3 y) underwent a 4-month program of balance exercises conducted by a physical therapist. Before exercise training, 64% of patients reported having had fallen during the previous 12 months, and 42% of patients had a moderate fall-risk score. Following the 4-month program, the patients demonstrated improvement on most balance measurements, including their fall-risk score and measurements of activity level, fear of falling, functional reach, and step width.[65] Improvements were also seen in patients' body mass index (BMI) and in their sit-to-stand rising index.

Nonsurgical alternatives

O'Brien wrote an impressive review on the hand function in patients with rheumatoid arthritis (RA).[66] The goal was to identify specific physical therapy regimens that may offer improvement in the function of patients' hands relative to their activities or daily duties. This study suggests that the role of strengthening hand exercises offer significant improvement in the overall function of patients with rheumatoid arthritis. If surgery is not an option, medical management should be pursued in conjunction with a rather thorough physical therapy in order to maintain and preserve function of the hands.

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Surgical Intervention in Rheumatoid Arthritis

Surgical intervention in patients with rheumatoid arthritis can achieve pain relief, deformity correction, and functional improvement.[60] A number of surgical procedures are available to obtain these goals, such as myofascial techniques, excisions, reconstructions, joint fusions, and joint replacements. The timing of surgery is a complex decision; the patient's age, stage of disease, and level of disability, as well as the location of the involved joints, must be considered. Early surgical intervention may be helpful in maintaining a patient's functional level of independence.

Deformities of the hand or wrist lead to loss of the ability to grip, grasp, and pinch, often leaving the patient unable to perform the activities of daily living. The surgical treatments for RA of the hand and wrist include synovectomy, tenosynovectomy, tendon realignment, reconstructive surgery or arthroplasty, and arthrodesis.

Patients with rheumatoid arthritis of the cervical spine who have refractory pain, clearly evident neurologic compromise, or intrinsic spinal cord signal changes on MRI are generally candidates for surgical intervention.

Go to Hand and Wrist Surgery in Rheumatoid Arthritis and Rheumatoid Arthritis of the Cervical Spine for complete information on these topics.

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Complications

Rheumatoid arthritis itself is not fatal, but complications of the disease may shorten survival by years in some individuals. In general, RA is progressive and cannot be cured, but in some patients, the disease gradually becomes less aggressive and symptoms may even improve. However, if bone and ligament destruction and any deformities have occurred, the effects are permanent.

Joint disability and pain with daily life are common. Affected joints can become deformed, and the performance of even ordinary tasks may be very difficult or impossible. According to one survey, 70% of patients with RA believe the disease prevents them from living a fully productive life. In 2000, a study in England found that approximately one third of individuals stop working within 5 years of the onset of disease.

Rheumatoid arthritis is a systemic disease that can affect other parts of the body in addition to joints. These effects include the following:

  • Peripheral neuropathy (affects nerves, most often those in the hands and feet, and can result in tingling, numbness, or burning)
  • Anemia
  • Scleritis (inflammation of the blood vessels in the eye that can result in corneal damage, scleromalacia, and, in severe cases of nodular scleritis, perforation)
  • Infections (patients with RA have a higher risk for infections; immunosuppressive drugs further increase that risk)
  • GI problems (patients with RA may experience stomach and intestinal distress, but lower rates of stomach and colorectal cancers have been reported in RA patients)
  • Osteoporosis (more common than average in postmenopausal women with RA; the hip is particularly affected; risk for osteoporosis appears to be higher than average in men with the disease who are older than 60 y)
  • Lung disease (a small study found a high prevalence of pulmonary inflammation and fibrosis in patients with newly diagnosed RA but may be associated with smoking)
  • Heart disease (RA can affect blood vessels and increase the risk for coronary ischemic heart disease)
  • Sjogren syndrome (keratoconjunctivitis sicca is a common complication of RA; oral sicca and salivary gland enlargement are less common)
  • Felty syndrome (characterized by splenomegaly, leukopenia, and recurrent bacterial infections; may respond to DMARDs)
  • Lymphoma and other cancers (RA-associated immune system alterations may play a role; aggressive treatments for RA may help prevent such cancers)
  • Macrophage activation syndrome (MAS) (life-threatening complication of RA; includes persistent fever, weakness, drowsiness, and lethargy; requires immediate treatment with high-dose steroids and cyclosporin A)

Cardiovascular morbidity and mortality are increased in patients with RA. Nontraditional risk factors appear to play an important role. Myocardial infarction, myocardial dysfunction, and asymptomatic pericardial effusions are common; symptomatic pericarditis and constrictive pericarditis are rare. Myocarditis, coronary vasculitis, valvular disease, and conduction defects are occasionally observed. A large Danish cohort study suggested the presence of an increased risk of atrial fibrillation and stroke in rheumatoid arthritis patients.[67]

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Consultations

In addition to consultation with a rheumatologist, patients may need to be seen by an orthopedist and an infectious disease specialist in the course of their illness. Involvement by cardiology, pulmonology, nephrology, and ophthalmology is often necessitated by secondary organ involvement in those areas.

A major goal is to preserve the patient's sense of worth and independence. However, when fatigue, morning stiffness, or specific joint disease interferes with a patient's capacity to carry out their usual responsibilities at work and at home, counseling will be necessary to recommend modification of work responsibilities and perhaps retraining. Recognition and treatment of concomitant depression is important.

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Long-Term Monitoring

Abandonment is a major fear. Patients are relieved to know that they will be closely observed by the primary physician and healthcare team, working in conjunction with a consulting rheumatologist and physical/occupational therapist, all of whom are committed to maximizing the patient's comfort and independence and to preserving joint function. With the use of occupational therapy, the treatment effort is geared to helping the patient maintain a meaningful work role within the limitations of the illness.

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Contributor Information and Disclosures
Author

Katherine Temprano, MD  Assistant Professor of Internal Medicine, Division of Rheumatology, St Louis University School of Medicine

Katherine Temprano, MD is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine and American College of Rheumatology

Disclosure: Nothing to disclose.

Coauthor(s)

Howard R Smith, MD  Adjunct Professor of Medicine, Case Western Reserve University School of Medicine; Chief of Rheumatology, Director of The Herbert Bell Pain Management Center, Director of Research, Cleveland Clinic, Huron Hospital

Howard R Smith, MD is a member of the following medical societies: American College of Rheumatology and Ohio State Medical Association

Disclosure: Pfizer Honoraria Speaking and teaching; Roche Consulting fee Consulting

Chief Editor

Herbert S Diamond, MD  Adjunct Professor of Medicine, Division of Rheumatology, University of Pittsburgh School of Medicine; Chairman Emeritus, Department of Internal Medicine, Western Pennsylvania Hospital

Herbert S Diamond, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American College of Rheumatology, American Medical Association, and Phi Beta Kappa

Disclosure: Merck Ownership interest Other; Smith Kline Ownership interest Other; Zimmer Ownership interest Other

Additional Contributors

Edward Bessman, MD Chairman, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University School of Medicine

Edward Bessman, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Sarjoo M Bhagia, MD Consulting Staff, OrthoCarolina; Voluntary Teaching Faculty, Carolinas Rehabilitation

Sarjoo M Bhagia, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, North American Spine Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation

Disclosure: Nothing to disclose.

Heather Lyn Carone, MD Attending Physician, Department of Emergency Medicine, St Vincent Mercy Medical Center

Heather Lyn Carone, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Gino A Farina, MD, FACEP, FAAEM Associate Professor of Clinical Emergency Medicine, Albert Einstein College of Medicine; Program Director, Department of Emergency Medicine, Long Island Jewish Medical Center

Gino A Farina, MD, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Patrick M Foye, MD Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain Service (Tailbone Pain Service: www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School

Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, and International Spine Intervention Society

Disclosure: Nothing to disclose.

Harris Gellman, MD Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M Miller School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society

Disclosure: Nothing to disclose.

Elliot Goldberg, MD Dean of the Western Pennsylvania Clinical Campus, Professor, Department of Medicine, Temple University School of Medicine

Elliot Goldberg, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, and American College of Rheumatology

Disclosure: Nothing to disclose.

Kavita Gupta, DO, MEng Department of Orthopedics, Center of Physical Medicine and Rehabilitation, University of Dentistry and Medicine of New Jersey

Kavita Gupta, DO, MEng is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Osteopathic Association, Association of Academic Physiatrists, and Pennsylvania Medical Society

Disclosure: Nothing to disclose.

John A Kare, MD Assistant Professor of Emergency Medicine, Charles R Drew University of Medicine and Science/UCLA, Director of Research, Department of Emergency Medicine, Martin Luther King Jr/Charles R Drew Medical Center

John A Kare, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Student Association/Foundation, and Emergency Medicine Residents Association

Disclosure: Nothing to disclose.

Randall W King, MD, FACEP Assistant Clinical Professor of Emergency Medicine, The University of Toledo College of Medicine; Director, Emergency Medicine Residency Program, Associate Chair, Department of Emergency Medicine, St Vincent Mercy Medical Center

Randall W King, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, Ohio State Medical Association, and Society for Academic Emergency Medicine

Disclosure: Challenger corporation None Physician Advisory Board; Ohio ACEP Consulting fee Editor Rivers review text Emergency Medicine

Milton J Klein, DO, MBA Consulting Physiatrist, Heritage Valley Health System-Sewickley Hospital and Ohio Valley General Hospital

Milton J Klein, DO, MBA is a member of the following medical societies: American Academy of Disability Evaluating Physicians, American Academy of Medical Acupuncture, American Academy of Osteopathy, American Academy of Physical Medicine and Rehabilitation, American Medical Association, American Osteopathic Association, American Osteopathic College of Physical Medicine and Rehabilitation, American Pain Society, and Pennsylvania Medical Society

Disclosure: Nothing to disclose.

Kristine M Lohr, MD, MS Professor, Department of Internal Medicine, Center for the Advancement of Women's Health and Division of Rheumatology, Director, Rheumatology Training Program, University of Kentucky College of Medicine

Kristine M Lohr, MD, MS is a member of the following medical societies: American College of Physicians and American College of Rheumatology

Disclosure: Nothing to disclose.

Robert J Nowinski, DO Clinical Assistant Professor of Orthopaedic Surgery, Ohio State University College of Medicine and Public Health, Ohio University College of Osteopathic Medicine; Private Practice, Orthopedic and Neurological Consultants, Inc, Columbus, Ohio

Robert J Nowinski, DO is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Osteopathic Surgeons, American Medical Association, American Osteopathic Association, Ohio Osteopathic Association, and Ohio State Medical Association

Disclosure: Tornier Grant/research funds Other; Tornier Honoraria Speaking and teaching

Robert E O'Connor, MD, MPH Professor and Chair, Department of Emergency Medicine, University of Virginia Health System

Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Elizabeth Salt, ARPN, PhD Assistant Professor, Division of Rheumatology, University of Kentucky College of Nursing; Rheumatology Nurse Practitioner, University of Kentucky Chandler Medical Center

Elizabeth Scarbrough, MSN is a member of the following medical societies: American College of Rheumatology, Council for the Advancement of Nursing Science, and Sigma Theta Tau International

Disclosure: Nothing to disclose.

Roberto Sandoval, MD Consulting Staff, Department of Emergency Medicine, Anaheim Memorial Medical Center, La Palma Intercommunity Hospital

Roberto Sandoval, MD is a member of the following medical societies: American College of Emergency Physicians and American Medical Association

Disclosure: Nothing to disclose.

Joseph E Sheppard, MD Professor of Clinical Orthopedic Surgery, Chief of Hand and Upper Extremity Service, Department of Orthopedic Surgery, University of Arizona Health Sciences Center, University Physicians Healthcare

Joseph E Sheppard, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Society for Surgery of the Hand, and Orthopaedics Overseas

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Roman V Voytsekhovskiy, MD Fellow in Hand Surgery, Department of Orthopedic Surgery, Rush University Medical Center

Disclosure: Nothing to disclose.

Eleby R Washington III, MD, FACS Associate Professor, Department of Surgery, Division of Orthopedics, Charles R Drew University of Medicine and Science

Eleby R Washington III, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Medical Association, International College of Surgeons, and National Medical Association

Disclosure: Nothing to disclose.

Richard Worthington MD, Department of Emergency Medicine, Wood County Hospital

Richard Worthington is a member of the following medical societies: American College of Emergency Physicians, Ohio State Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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Ankylosis in the cervical spine at several levels due to long-standing juvenile rheumatoid arthritis (also known as juvenile idiopathic arthritis).
Widespread osteopenia, carpal crowding (due to cartilage loss), and several erosions affecting the carpal bones and metacarpal heads in particular in a child with advanced juvenile rheumatoid arthritis (also known as juvenile idiopathic arthritis).
Rheumatoid changes in the hand. Photograph by David Effron MD, FACEP.
Rheumatoid nodules at the elbow. Photograph by David Effron MD, FACEP.
Soft-tissue swelling and early erosions in the proximal interphalangeal joints in a patient with rheumatoid arthritis of the hands.
Subluxation in the metacarpophalangeal joints, with ulnar deviation, in a patient with rheumatoid arthritis of the hands.
Coronal, T1-weighted magnetic resonance imaging scan shows characteristic pannus and erosive changes in the wrist in a patient with active rheumatoid arthritis. Courtesy of J. Tehranzadeh, MD, University of California at Irvine.
Lateral view of the cervical spine in a patient with rheumatoid arthritis shows erosion of the odontoid process.
Boutonniere deformity.
Anteroposterior radiograph of the knee shows uniform joint-space loss in the medial and lateral knee compartments without osteophytosis. A Baker cyst is seen medially (arrowhead).
Ultrasonography-guided synovial biopsy of the second metacarpophalangeal joint of the right hand in a patient with rheumatoid arthritis of the hands. The biopsy needle is seen as a straight echogenic line on the left side of the image in an oblique orientation.
Plain lateral radiograph of the normal cervical spine taken in extension shows measurement of anterior atlantodental interval (yellow line) and posterior atlantodental interval (red line).
Lateral flexion view of the cervical spine shows atlantoaxial subluxation.
Lateral view of the cervical spine in a patient with rheumatoid arthritis shows erosion of the odontoid process.
T1-weighted sagittal magnetic resonance image of the cervical spine shows basilar invagination with cranial migration of an eroded odontoid peg. There is minimal pannus. The tip of the peg indents the medulla, and there is narrowing of the foramen magnum due to the presence of the peg. Inflammatory fusion of several cervical vertebral bodies is shown.
Sagittal T2-weighted magnetic resonance image of the cervical spine in the same case as in Image above. The compromised foramen magnum is easily appreciated, and there is increased signal intensity within the upper cord; this is consistent with compressive myelomalacia. Further narrowing of the canal is seen at multiple levels.
Lateral radiograph of the same patient as in Images 4-5. Midcervical vertebral-body fusions are shown. The eroded peg is difficult to visualize, but inferior subluxation of the anterior arch of C1 is shown.
Lateral radiograph of a normal cervical spine shows the McGregor line. The odontoid tip should not protrude more than 4.5 mm above the line, which is drawn from the posterior edge of the hard palate to the most caudal point of the occiput.
Normal lateral magnified radiograph of the cervical spine shows the Ranawat method of detection of cranial settling. This method is used to measure the distance from the center of the pedicles (sclerotic ring) of C2 to a line drawn connecting the midpoints of the anterior and posterior arches of C1. (Normal values are 15 mm or greater for males and 13 mm or greater for females.)
Lateral radiograph of the cervical spine shows how the cervical height index (CHI) is calculated. The distance from the center of the sclerotic ring of C2 to the tip of the spinous process of C2 (dotted line) is measured. This is then divided into the distance from the center of the sclerotic ring of C2 to the midpoint of the inferior border of the body of C7. A CHI of less than 2 mm is a sensitive predictor of neurologic deficit.
total hip replacement, prosthesis, osteoarthritis, X-ray.
Assistive devices
Assistive Devices to Improve Independence
This gross photo shows destruction of the cartilage and erosion of the underlying bone with pannus from a patient with rheumatoid arthritis.
The hallmark of rheumatoid arthritis is a perivascular mononuclear cell infiltrate in the synovium (pictured here). The early stages are noted to have plasma cells as well, and syphilis needs to be part of the differential diagnosis.
The inflammation involved in rheumatoid arthritis can be intense. It is composed of mononuclear cells and can resemble a pseudosarcoma.
 
 
 
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