What is rheumatoid arthritis?
Rheumatoid arthritis is a chronic inflammatory disease of autoimmune origin, characterized by inflammation of small and medium-sized joints. It is a progressive and subtle developmental ailment, which begins with inflammation of the synovial membranes of the affected joints, often on both sides of the body, so it is said to be symmetrical.
This inflammation of the synovial membrane is responsible for the pain, the swelling that is often observed, and the feeling of stiffness that is usually noticed in the mornings. The joints most frequently affected by arthritis include wrists, hands, ankles, and feet.
Inflammation of the synovial membrane over a long period of time results in damage to the bone that protects, and small notches (erosion). It can also make the cartilage that acted as a pad, allowing a soft friction between the bones, slim and even disappear.
Rheumatoid arthritis is a common disease (one in every 100-300 people suffers it), being more common in women in the fifth decade of life. There is also a variant that would affect children, however, it is not necessary to confuse rheumatoid arthritis with rheumatism; First of all it is advisable to clarify that there is no disease or ailment that receives the name of ‘ rheumatism ‘, it is not a specific disease. (1)
There are, however, more than two hundred different diseases of the locomotive system, also called rheumatic diseases, each one with characteristic characteristics. Rheumatoid arthritis is one of many different rheumatic diseases that are and, therefore, advice from other people who claim to have rheumatism may not be indicated for another rheumatic disease, as it may not be the same.
Types of joints and synovial articulation
As it is a disease that affects the joints it is advisable to describe some concepts: a joint is formed in any part of the body where two bones join; It is a specialized structure that provides stability and movement. Some joints allow a free movement, i.e. circular type, angular etcetera, and are called hidartrosis or synovial joints; Other joints, which have little movement, are called anfiartrosis, for example the articulation located between two adjacent vertebrae; And there are also no movements or osteoarthritis, for example those present in the bones of the skull and face, except for the mandible.
The articular surfaces of the bones in the synovial joints are covered by articular cartilage, and are separated by a joint cavity containing synovial fluid. Arthritis typically affects this type of joint.
The synovial joint consists of the following parts:
» Synovial cavity and synovial fluid: The synovial cavity is a small space where the synovial fluid is found, which, when viscous, is ideal for cushioning and reducing the friction between the cartilage of the ends of the bones.(2)
» Articular cartilage: The articular cartilage is a thin layer of tissue that covers the surfaces of the bones that are confronted. It is a spongy cushion, which absorbs the compression of the joint and helps to reduce the friction between the ends of the bones.
» Articular capsule: The articular capsule encompasses the entire synovial joint; It is composed of two layers, a fibrous and resistant external, that prevents the separation of the bones, and another internal, or synovial membrane, which covers the internal surfaces of the joint. This synovial membrane is responsible for secreting synovial fluid, which provides lubrication and absorbs the blows that are projected to the inside of the joint.
Several aspects of the immune response are involved in the development of rheumatoid arthritis:
- Abnormal recognition of antigens themselves as foreign antigens.
- Improper response to the activation of the immune system.
All this leads to the perpetuation of the inflammatory response, with the ensuing joint damage. For this reason, rheumatoid arthritis is classified as an autoimmune disease.
Causes of rheumatoid arthritis
The causes of rheumatoid arthritis are unknown; It occurs more frequently in people with a genetic predisposition, however, it is not hereditary. Infectious agents (bacteria, viruses …) have been studied and although suggestive data have been found in some cases, there is no evidence involving any particular.
This disease is considered to be the result of the action of an antigen or foreign agent, from the outside of the organism, or from an internal agent, ie an autoantigen, which favors the formation of an antibody and, therefore, of immunocomplexs, translating the whole process into an inflammation of the joints. This exaggerated inflammatory response gives rise to joint erosion and destruction.
What people suffer from reumatoride arthritis?
Rheumatoid arthritis affects 1% of the population approximately. The age of presentation can be anyone, although it is more frequently from 40 to 60 years.
It is a disease that predominates in women, with a proportion of 3:1 with respect to the male, although it can also appear in these and in the children. As for the breed, it has no preference for any in which rheumatoid arthritis is more common.
Symptoms of rheumatoid arthritis
The first symptom of rheumatoid arthritis, which most often refers to patients, is pain in small and large joints. The onset is gradual or insidious, with progression of symptoms and addition of new joints; The course is chronic. Pain is a consequence of inflammation of the joints, which is often seen at first sight in people suffering from rheumatoid arthritis.
The most commonly damaged joints are the wrists, the knuckles, the joints of the fingers, where it is noteworthy that it does not usually affect distal joints joints (articulation closer to the end of the fingers), shoulders, elbows, hips, knees, ankles and toes, followed by hip and temporomandibular joints. Neck pain may also be caused by rheumatoid arthritis and should therefore be valued by the doctor.(3)
In addition to pain and inflammation, morning articular stiffness occurs, that is, there is difficulty in starting movements for more than 45 minutes. Permanent and untreated inflammation may end up damaging the bones, as well as the ligaments and tendons around them. The consequence will be the deformity of the joints progressively, losing the patient the ability to perform normal activities of daily life.
The deformity of the fingers often referred to as “swan Neck” and “Buttonhole” is presented late in the course of rheumatoid arthritis, and is characteristic of chronic disease; It is not normally seen in the initial presentation, where signs of synovitis and joint damage are subtle.
Other associated extra-articular symptoms, which are disease alterations to other levels, are also produced:
- Asthenia or fatigue.
- Inexplicable fever.
- Xerostomia, ie dry mouth.
- Xerophthalmia or dryness in the eyes, feeling of grit and red eyes.
- Lumps in the skin called subcutaneous nodules, which are characteristic of rheumatoid arthritis, although they are not exclusive to it, because sometimes they appear in other diseases.
- Muscle weakness.
- Severe, persistent neck pain.
- tingling in the hands or feet.
- Hoarseness kept without noticing a cold.
In addition to affecting the joints, rheumatoid arthritis also affects other organs, these are:
which are often enlarged, though seldom palpable.
Pleuritis or inflammation of the layer (Pleura) that covers the lung is common, but is usually mild, as are other pulmonary and cardiac manifestations. Pleural effusions may also occur.
Pulmonary rheumatoid nodules are an asymptomatic finding in rheumatoid arthritis. Radiologically They are coin-shaped lesions that can be difficult to differentiate from a neoplasm.
There is more and more evidence that patients with rheumatoid arthritis have a higher incidence of cardiovascular disease, regardless of the traditional risk factors. It seems that the inflammation that occurs in rheumatoid arthritis plays an important role in the development of atherosclerosis.
Palmar erythema, which is a reddening of the palms of the hands, is common. Raynaud’s phenomenon (changes in skin coloring), with Association of Infarcts, cutaneous ulcers and overinfections, may also be present.
In approximately 30% of patients are present the rheumatoid nodules, which are found mainly in the extending surface of the forearm and in areas of pressure of the skin. The nodules have varying sizes and distinct consistency, and are usually asymptomatic, although they may rupture due to trauma and infection. The nodules are not specific to rheumatoid arthritis, but they are useful for diagnosis and prognosis, since they correlate with the activity of the disease and its progression.
In less than 1% of patients the eye is affected. Rheumatoid vasculitis (affectation of Small eye vessels) may result in a severe form of painful scleritis where the deep layers of the eye are affected, and episcleritis, which is benign and disappears.
Rheumatoid arthritis usually respects the central nervous system directly, although vasculitis (involvement of small vessels) can cause peripheral neuropathy.
The subluxation of the joint between the first and second cervical vertebrae, also called Atloaxoidea articulation, is present in one-third of patients with rheumatoid arthritis, but it is usually asymptomatic.
Cervical myelopathy (Spinal cord involvement), due to cervical instability, may be lethal. Symptoms include paresthesias or tingling, weakness, paralysis, sensory loss, urinary incontinence, and syncope.
Renal involvement is the most frequent type of organic failure in rheumatoid arthritis, although skin, liver, and gastrointestinal tract are often also affected.
It consists of the association of Rheumatoid arthritis, splenomegaly (increased spleen size) and neutropenia (decreased neutrophils). They are also frequent hepatomegaly (increased liver size) and lymphadenopathy, and family presentation is more frequent than expected.
Treatment of rheumatoid arthritis
A multidisciplinary approach is required for the treatment of rheumatoid arthritis; It is necessary to have a constant relationship between physiotherapists, occupational therapists, podiatrists, social services and surgeons to keep up with the progress of the patient and the new therapeutic developments.
Medications used for rheumatoid arthritis have side effects, so any treatment to be applied implies the need to consider that the benefit is greater than the risk. In addition, the variable character of the disease forces to readjust the treatment in the same patient. In the end the patient will decide whether to take the treatment after having all the information possible.
Treatment of rheumatoid arthritis can be classified into several groups:
» One group encompasses drugs that are responsible for relieving pain and inflammation in the short term; These are useful to reduce inflammation and cope with the pain of “day to day”, but do not intervene in the evolution of the disease in the long term. This group includes anti-inflammatory drugs and corticosteroids.
Nonsteroidal anti-inflammatory drugs, or NSAIDs, are medications whose response varies in each person, and their choice is based on the characteristics of the patient (age, previous individual response, renal failure, chronic liver disease, ulcerative illness …). Sometimes it is necessary to try several NSAIDs until the desired effects are obtained (allowing them to act at least two weeks at full doses).
Administration of glucocorticoids by mouth and at low doses is used when NSAIDs do not adequately control pain and functional impotence, or are contraindicated; They are used following the particular indications that the rheumatologist knows, and allow in many cases the improvement of the quality of life in the long term.
» Another large group includes drugs that do not serve pain at any given time; Otherwise they act by making the disease’s activity less long-term, that is, delaying the progression of the disease. They are the so-called disease-modifying drugs (fame); These drugs may not be effective in 100% of the patients, and this makes the doctor have to prescribe several sequentially until you find the one that is more effective and better tolerated.
It should be taken into account that they are slow-acting drugs and take weeks and even months to take effect. The most representative of this group are methotrexate and leflunomide, being very effective and fast in their performance. Others such as gold salts, chloroquine, sulfasalazine, cyclosporine a … are usually used when the first ones are not tolerated or have not been effective. In general, they require a control by the rheumatologist and a close collaboration of the patient.
» Biological drugs: When objectives are not achieve with previous drugs it is advisable to start a treatment with anti-TNF (infliximab, etanercept, adalimumab) or tocilizumab. Other drugs are under development to be added to this spectrum of therapeutic tools in the near future.
» Other procedures: infiltration of the joints with corticoids, corrective surgeries of some deformities, splints or other orthopedic devices, etc.
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