Rheumatoid Arthritis (RA)

Symptoms

The symptoms of RA can vary from person to person but generally include:

• Joint Pain and Swelling: Pain, swelling, and stiffness are the most common symptoms, particularly in the hands, wrists, and feet. Joint stiffness is often worse in the morning and can last for more than 30 minutes.
• Morning Stiffness: One of the key features of RA is prolonged morning stiffness that lasts for more than 30 minutes. This stiffness usually improves with movement or light exercise.
• Symmetrical Joint Involvement: RA affects joints on both sides of the body equally. For example, if your right wrist is swollen, your left wrist will likely be affected as well.
• Fatigue: Chronic tiredness and low energy are common in RA due to the body's systemic inflammation. Fatigue may also be a result of sleep disturbances due to pain.
• Rheumatoid Nodules: These are hard, painless lumps that can form under the skin, usually around the elbows, hands, or feet. These nodules are an indication of chronic inflammation.
• Deformities: Over time, untreated RA can cause irreversible joint deformities, particularly in the hands and feet, which can limit your ability to perform daily activities.
• Reduced Range of Motion: As the disease progresses, joint stiffness and damage may reduce your ability to move affected joints. This can make it difficult to perform tasks like typing or walking.

Diagnosis

• Joint Pain and Swelling: The hallmark symptoms of RA are pain, swelling, and stiffness in the affected joints, particularly in the hands, wrists, and feet.
• Morning Stiffness: Patients often experience prolonged morning stiffness, lasting for more than 30 minutes, which can improve with movement.
• Symmetrical Joint Involvement: RA typically affects joints on both sides of the body equally (e.g., both wrists, knees, etc.).
• Fatigue: Chronic fatigue is common due to systemic inflammation.
• Rheumatoid Nodules: Hard, painless lumps may form under the skin, usually near the elbows, hands, or feet.
• Systemic Symptoms: Fever, weight loss, and malaise can occur due to inflammation in other organs.
• Deformities: Over time, untreated RA can cause joint deformities and loss of function, particularly in the hands and feet.
• Reduced Range of Motion: As the disease progresses, joints may lose mobility, leading to difficulty performing daily tasks.

 How is the Diagnosis Done?

• Medical History and Physical Examination: The doctor will assess symptoms such as joint pain, swelling, and morning stiffness, as well as check for joint tenderness and deformities.
• Blood Tests:
  • Rheumatoid Factor (RF): An antibody often present in the blood of people with RA, though it is not specific to the disease.
  • Anti-Citrullinated Protein Antibody (ACPA): Highly specific for RA and is often used in the diagnosis, especially in patients who are RF-negative.
  • Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP): Elevated inflammatory markers that indicate the presence of inflammation in the body.
  • Complete Blood Count (CBC): May show anemia (low red blood cell count), which is common in RA.
• Imaging:
  • X-rays: Used to assess joint damage and progression of disease, showing signs of joint erosion, narrowing of joint spaces, and bone damage.
  • Ultrasound: Can detect synovitis (inflammation of the joint lining) and erosions early, even before they appear on X-rays.
  • MRI: Provides detailed images of soft tissues, including cartilage and ligaments, and can detect early signs of inflammation and joint damage.
• Joint Fluid Analysis: In some cases, a sample of synovial fluid may be taken from an inflamed joint to rule out other conditions, such as infection or gout.

Why is Early Diagnosis Important?

• Preventing Joint Damage: Early diagnosis and treatment can help prevent or reduce permanent joint damage, deformities, and loss of function.
• Better Treatment Outcomes: Starting treatment early can lead to more effective disease control, reducing the frequency of flare-ups and improving long-term outcomes.
• Slowing Disease Progression: Early intervention with disease-modifying antirheumatic drugs (DMARDs), including biologics, can significantly slow disease progression and prevent complications such as osteoporosis or cardiovascular issues.
• Improved Quality of Life: Early management helps reduce pain, fatigue, and disability, allowing patients to maintain a higher level of physical function and quality of life.
• Preventing Systemic Complications: RA is a systemic disease that can affect organs like the heart, lungs, and eyes. Early treatment can reduce the risk of these complications.

Prognosis

• Variable Course: The progression of RA varies from person to person. Some may experience mild symptoms with periods of remission, while others may have more severe, persistent symptoms that cause significant disability.
• Joint Damage: Without effective treatment, RA can lead to permanent joint damage, deformities, and functional impairment, particularly in the hands, feet, and knees.
• Systemic Involvement: RA can increase the risk of cardiovascular disease, osteoporosis, and lung disease, which can impact overall health and life expectancy.
• Remission vs. Flare-ups: Many patients can achieve remission or low disease activity with early and aggressive treatment, leading to a better long-term outlook. However, flare-ups are common, especially if treatment is not adequately adjusted.
• Life Expectancy: Although RA can reduce life expectancy due to complications like cardiovascular disease, the prognosis has improved significantly with modern treatments, including biologics and DMARDs.
• Comorbidity Management: With better disease control, patients with RA can live longer, healthier lives, but ongoing management of comorbid conditions is essential.

Scoring

Several scoring systems are used to assess disease activity, monitor progression, and evaluate treatment efficacy:

• The Disease Activity Score 28 (DAS28): A widely used measure that includes the number of swollen and tender joints (28 joints), patient-reported global health, and acute-phase reactants (CRP or ESR). DAS28 helps determine the level of disease activity. Remission: DAS28 < 2.6, Low disease activity: 2.6 ≤ DAS28 ≤ 3.2, Moderate disease activity: 3.2 < DAS28 ≤ 5.1, High disease activity: DAS28 > 5.1
• American College of Rheumatology (ACR) 20/50/70: These scores assess the percentage improvement in RA symptoms and function. ACR20 represents at least 20% improvement in symptoms, ACR50 for 50%, and ACR70 for 70%.
• Simplified Disease Activity Index (SDAI): Another measure of disease activity based on the number of swollen and tender joints, CRP levels, and physician and patient global assessments.
• Clinical Disease Activity Index (CDAI): Similar to the SDAI, but without the use of CRP. It is used to assess disease severity and treatment response.
• Health Assessment Questionnaire (HAQ): A tool to assess physical function and the impact of RA on daily living activities. It helps gauge the patient's ability to perform everyday tasks. 0 to 1: Mild to moderate difficulty, 1 to 2: Moderate to severe difficulty, 2 to 3: Severe to very severe difficulty

These scoring systems help clinicians track disease progression, adjust treatment plans, and assess the impact of RA on the patient's quality of life.