Rheumatoid arthritis

This page is written by registered pharmacists. We hope that the public could acquire professional and trustworthy health information from these pages. Ultimately, it would facilitate everyone to gain understanding on the therapies that they might need. The first theme page would focus on rheumatic diseases. The page will introduce some basic knowledge of the diseases and their pharmacotherapies.

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What is Rheumatoid arthritis(RA)?

Rheumatoid arthritis (RA) is a chronic and progressive inflammatory autoimmune disease that primarily affects the joints. RA usually affects women more than men, and onset tends to be around middle age (40s to 60s). The causes of RA are still unknown, but smoking can be a major risk factor. Family history of RA, certain environmental exposures such as asbestos or silica, and obesity are also known risk factors.


What are the symptoms of RA?

Patients with RA have symptoms including fatigue, morning stiffness, joint swelling, and pain. As the disease progresses, symptoms can spread to other joints, and may result in cartilage damage, bone erosion and deformities, and physical disabilities.


The pathology of RA

Symptoms occur when the immune system mistakenly attacks its own body’s tissues, usually the lining of joints called synovium, leading to painful swelling and inflammation. Normal people have healthy and smooth synovia that produce a fluid called synovial fluid to lubricate and nourish the joints. In RA patients, white blood cells release cytokines that increase blood flow to the affected joints, causing growth and thickening of the synovium. As the synovium starts to thicken, it starts to invade the space in between the joint’s bones, creating an abnormal layer of tissue called pannus, directly causing joint damage and associated symptoms.


How to distinguish RA and osteoarthritis?

Detecting RA can be difficult as symptoms are not specific initially. Many also confuse RA with osteoarthritis, which isn’t an autoimmune disease, but a chronic wear and tear degenerative joint disease. There are some major differences that differentiate the two diseases. Osteoarthritis is more localized, whereas RA is often systemic. RA involves more swelling and inflammation as well as stiffness that can last all day, but osteoarthritis usually has limited inflammation with morning stiffness that lasts only 20 to 30 minutes. It is important to not confuse osteoarthritis with RA, as their treatments are very different.


Diagnosis of RA

Abnormal physical exams and laboratory findings can help guide physicians in diagnosing RA. Inflammation markers and certain antibodies should be tested to confirm if a patient has RA.


Non-pharmacological treatment

Non-pharmacological measures for RA include: education and counseling, rest, physical therapy, occupational therapy, weight and diet control, and smoking cessation.


Pharmacological treatment

Common pharmacotherapy for RA includes:

  1. Disease-modifying anti-rheumatic drugs (DMARDs)
  2. Non-steroidal anti-inflammatory drugs (NSAIDs)
  3. Local or systemic steroids, and
  4. Biologic DMARDs


Ultimately, the primary target is clinical remission. Early and aggressive pharmacotherapy has shown to improve prognosis. The treatment of rheumatoid arthritis divided into treatment for acute flare up and long term control of inflammation. For acute symptoms control, short course of corticosteroid may be used to reduce inflammation. Non-steroidal anti-inflammation drugs are often used to reduce pain and inflammation. Disease-modifying drugs (DMARDs) act on the immune system to slow the progression of rheumatoid arthritis. Patients who progressed may use biological agents to reduce inflammation of the joints and damage to joint structures. These agents target molecules on cells of the immune system that lead to inflammation and joint destruction.

Reference: Singh, J., Saag, K., Bridges, S., et al. (2015). 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis & Rheumatology68(1), 1-26. doi: 10.1002/art.39480