How does rheumatoid arthritis progress and how is it treated?

What are the first symptoms of rheumatoid arthritis?

Rheumatoid arthritis often begins with stiffness in the joints (wrists, hands, fingers). Patients may wake up in the middle of the night with joint pain and feel numbness and stiffness in these joints for several minutes upon awakening. This is known as "morning stiffness".

For a person to be diagnosed with rheumatoid arthritis, the following conditions must be met:

• Experience of the symptoms described above for at least 6 weeks,
• At least 3 painful joints in the wrists, hands and fingers,
• Painful joints are symmetrical, i.e. the pain is felt in the same joint on both the left and right sides of the body,
• Pressure put on the feet, especially the metatarsal joints, is painful.

If all of these conditions are present, rheumatoid arthritis may be diagnosed. The patient should then consult his or her doctor as soon as possible so that the diagnosis can be made.

How does rheumatoid arthritis progress?

Rheumatoid arthritis develops in the form of flare-ups alternating with periods of remission. Each flare-up is accompanied by severe fatigue. During the periods of remission, the pain subsides and may even disappear.

If left untreated, rheumatoid arthritis progressively spreads to other joints: shoulders, knees, hips, elbows, cervical spine, etc.

As time goes on, deformities develop in the joints:

• Fingers tend to deviate to the side and bend in on themselves.
• In the majority of cases (90%), the feet are affected and walking is impaired
• Elbows may remain locked in a bent position

After several years, the progression of untreated rheumatoid arthritis can also lead to tendon destruction. Orthopaedic surgery becomes necessary to repair and often replace a joint with a prosthesis.

How is rheumatoid arthritis diagnosed?

Early diagnosis of rheumatoid arthritis allows treatments to be more effective. Therefore, as soon as joint pain or swelling appears, it is essential to consult a doctor quickly. The doctor will look for other joint problems, spinal problems, skin conditions (such as psoriasis), or damage to mucous membranes or internal organs such as the digestive tract.

Diagnosis involves:

• An interview with the patient and a clinical examination.
• Medical imaging such as X-rays of the hand and feet, of the affected joints or of the spine. An MRI or ultrasound may also be performed.
• Blood tests: Measurement of inflammatory markers (ESR and CRP) - and testing for the presence of anti-cyclic citrullinated peptide (anti-CCP) antibodies and another autoimmune marker called rheumatoid factor.

How is rheumatoid arthritis treated?

There are three main focuses in the treatment of rheumatoid arthritis:

• Treatment of pain,
• Treatment of inflammation,
• Treatment of the immune disorder.

Treatment of pain (treating flare-ups)

Treating pain is essential as it is one of the main symptoms of rheumatoid arthritis. The most commonly prescribed painkiller is paracetamol. NSAIDs (non-steroidal anti-inflammatory drugs) such as ketoprofen, ibuprofen or diclofenac can also be used.

Some stronger painkillers can be prescribed but, as these have certain side effects, it is important to assess the disadvantages before prescribing them.

It is important to maintain good patient-doctor communication in order to identify the acceptable residual pain threshold.

Treatment of inflammation (treating flare-ups)

Corticosteroids (from the cortisone family) are often prescribed to reduce inflammation. In low doses, they are prescribed in the early months of the disease to relieve symptoms quickly and effectively (more effectively than with NSAIDs). They may also slow the progression of the condition.

With steroid therapy for longer than three months, there is a higher risk of developing osteoporosis. Bone density is monitored and specific treatment with bisphosphonate, calcium and vitamin D is prescribed if necessary.

Treatment of immune disorder (background treatment)

To slow the progression of rheumatoid arthritis, an immunosuppressant is required as a first-line treatment. This is methotrexate, taken weekly unless the patient has any contraindications, such as pregnancy. A full response is usually achieved within the first six months, with improvement in symptoms, joint mobility and quality of life.

Once treatment has been initiated, the patient is monitored to ensure that the various treatments are well tolerated and effective.

To assess the effectiveness of the treatments, a numerical criterion is used: the DAS-28 score.

>> To calculate your DAS-28, click here <<

The DAS-28 score (DAS for "disease activity score" and 28 for the 28 joints assessed) is a composite index of rheumatoid arthritis activity combining multiple parameters (number of painful joints, number of swollen joints, numerical assessment of pain...) into a single measure with standardised interpretation.

Targeted therapies

When rheumatoid arthritis is active and joint destruction is progressing, and if the desired effects are not achieved with methotrexate, targeted therapies are needed. These treatments each target a specific player in the inflammatory process. They are used in addition to methotrexate.

In 75% of cases, they result in a successful response and prolonged remission in 25% of cases.

Where is rheumatoid arthritis research now?

Research in RA is very active with many promising new areas identified, notably in facilitating diagnosis, improving care and developing new treatments. 

Here is a brief video from the University of Birmingham describing ongoing research in the UK:

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