Hormones 

Various environmental factors have been identified as potential risk factors for RA development including the gut microbiota, vitamin D deficiency, silica dust exposure and mineral oils.

Early diagnosis and intervention are critical to improving the outcome of RA. Studies show that people who receive early treatment for RA feel better sooner and more often, and are more likely to lead an active life. They also are less likely to have the type of joint damage that leads to joint replacement.

Diagnosis of RA depends on the symptoms and results of a physical exam – including warmth, swelling and pain in the joints.

Some blood tests also can help confirm RA.

Telltale pathology  includes:

• Anaemia (a low red blood cell count)
• Rheumatoid Factor (RF). This is an antibody (blood protein) found in about 80% of patients with RA over time, but in as few as 30% at the onset of the disease. Somewhat confusingly about 5% of people without the disease test positive.
• Antibodies to cyclic citrullinated peptides (pieces of proteins), or anti-CCP for short (found in 60–70% of patients with RA)
• Elevated erythrocyte sedimentation rate  (ESR). This is a blood test that, in most patients with RA, confirms the amount of inflammation in the joints)

X-rays can help in detecting RA, but may not show anything abnormal in the initial stages of the disease. However these first X-rays may be useful later to show if the disease is progressing. Often, MRI and ultrasound scanning are done to help judge the severity of RA.

Orthodox Medications Commonly Prescribed 

A number of orthodox medications are commonly prescribed (usually in combination) to people with RA.

These include:

• Disease modifying anti rheumatic drugs (DMARDs)
• Non-steroidal anti-inflammatory drugs (NSAIDs)
• Corticosteroids
• Biologic Agents.

All have considerable side effects.

Disease modifying anti rheumatic drugs (DMARDs)

• Methotrexate (e.g. Methoblastin) is the most commonly used DMARD. It can be administered either orally or intramuscularly. Supplements of folic acid are required to help minimise side effects such as nausea and mouth ulcers. Methotrexate is potentially toxic to the liver and alcohol consumption should be avoided if taking it.
• Sulfasalazine (Pyralin EN and Salazopyrin) is used to treat mild RA. It is less potent than some other DMARDs. It can cause nausea, dyspepsia, diarrhoea, rash and headaches. More seriously, it can cause severe anaemia.
• Leflunomide (Arabloc and Arava) is used to treat severe active RA that does not respond to classical DMARDs such as methotrexate.
• Intramuscular gold injections of sodium aurothiomalate (Myocrisin) is  rarely used. Side effects of gold injections include mouth ulcers, rash, thrombocytopenia (a deficiency of platelets — cells that are involved in blood clotting) and proteinuria (protein in the urine).
• Oral gold such as auranofin (Ridaura) is also rarely used, largely because of poor efficacy. Diarrhoea is a common side effect.
• Antimalarials such as hydroxychloroquine sulfate (Plaquenil) are used in the treatment of mild RA.  Hydroxychloroquine is often used in combination with other DMARDs. Adverse effects include retinal toxicity. A person is required to see an eye specialist periodically if taking this medicine.
• Cyclosporin (Cicloral, Neoral and Sandimmun), originally developed to prevent organ rejection in transplant patients, is used either on its own or in combination with other anti-arthritic drugs. It produces many adverse effects, including hypertension (high blood pressure) and impaired renal (kidney) function.
• Azathioprine (e.g. Imuran) is limited to the treatment of severe active RA that is unresponsive to other DMARDs and to treat people with rheumatoid vasculitis (a serious complication of severe RA in which blood vessels are inflammed). Because of high toxicity it is now seldom used.

Often, doctors prescribe DMARDs along with NSAIDs and/or low-dose corticosteroids in an attempt to lower swelling, pain and fever.

Non-steroidal anti-inflammatory drugs (NSAIDs)

NSAIDs are commonly prescribed to reduce pain and inflammation. They do not stop the disease from progressing.

Ibuprofen (e.g. Nurofen) and naproxen sodium (e.g. Naprogesic), are available over the counter,

Diclofenac (e.g. Voltaren), piroxicam (e.g. Feldene), sulindac (Aclin) and indomethacin (e.g. Indocid), are available as prescription medicines only.

The use of NSAIDs is often limited because they increase the risk of upper gastrointestinal problems, such as gastric ulcer. They are not suitable for use by people who have had a peptic ulcer or gastrointestinal bleeding.

• COX-2 specific inhibitors

The coxibs (e.g. celecoxib — brand name Celebrex) are non-steroidal anti-inflammatory agents. Studies have shown that the coxibs have lower rates of gastric ulcer associated with them than the conventional, older NSAIDs.

However Coxibs are associated with an increased risk of cardiovascular events, such as heart attack and stroke, when taken in high doses. People who have an increased risk of heart attack or stroke should not take these medicines.

Corticosteroids

Corticosteroids, sometimes known as glucocorticoids, such as prednisone (e.g. Panafcort) and prednisolone (e.g. Panafcortelone), work by reducing inflammation and suppressing the immune system. They are used in the treatment of RA, both as tablets and as injections into the joint.

Prednisolone is sometimes prescribed by GP’s for moderate to severe RA when NSAIDs and DMARDs have not had the desired outcome. Oral corticosteroids are usually used at the lowest effective dose but still have adverse effects such as weight gain, hypertension and osteoporosis.

Corticosteroids may be injected into the joints if the arthritis is not being controlled by oral therapy, but this should be limited to 3 to 4 injections a year. Joints commonly injected are fingers, toes, knees and shoulders. Corticosteroids are also sometimes injected into the muscles or given via an intravenous infusion.

Biologic agents

TNF inhibitors

A category of arthritis treatments called biologics has been recently developed. The most notable is the tumour necrosis factor (TNF) inhibitors. TNF occurs naturally in the body and is a key player in the inflammatory process in RA. It is found in high concentrations in the joint fluid of people with RA. By attaching to the TNF molecule or its receptors on cells, these new agents can block its effect.

• Infliximab (Remicade) slows the progression of RA and reduces joint damage. It is given by infusion via a drip into a vein. Each treatment takes approximately 2 hours. Infliximab is given in combination with methotrexate. In Australia there are very tight Government restrictions on which patients with RA can be treated with infliximab.
• Etanercept (Enbrel) is used for the treatment of active RA in adults who have had an inadequate response to several DMARDs, including methotrexate. It is given by injection under the skin once or twice weekly.
• Adalimumab (Humira) is the third TNF inhibitor that has been added to the list of approved agents for RA. It is administered by injection under the skin, once a fortnight.

They can only be prescribed by certain medical specialists (rheumatologists and clinical immunologists).

Studies to evaluate the long-term safety of these powerful and expensive agents, have found in addition to some other side effects, an increased susceptibility to infection in people taking these medicines.

Newer biologic agents

Over the past few years several new biologic agents have been developed which target substances in the body other than TNF.

• Rituximab (Mabthera) is a monoclonal antibody targeted against certain white blood cells called B lymphocytes. (Monoclonal antibodies are proteins that are produced in the laboratory to recognise and bind to proteins found in the body.) It is given as 2 intravenous infusions 2 weeks apart.
• Abatacept (Orencia) is another monoclonal antibody targeted at specific molecules found on cells called T lymphocytes. It is given as a monthly intravenous infusion.
• Anakinra (Kineret) is called an interleukin-1 antagonist. It blocks the action of interleukin-1, a protein present in the body that is produced in high concentrations in people with RA. Anakinra is given by injection under the skin.

RA’s Impact

RA  can have a dramatic impact on both metal health and daily living for individuals.