Rheumatoid arthritis is a chronic systemic inflammatory disease affecting multiple joints in the body, usually bilaterally. Patients have complaints such as weakness, fatigue and morning stiffness accompanying joint pain.
Organs such as skin, heart, lung and eye can be involved. In rheumatoid arthritis, joint destruction occurs and if the disease is not treated early, it causes permanent damage.
Why Does Rheumatoid Arthritis Occur?
Rheumatoid Arthritis is an autoimmune disease, meaning that the body’s immune system mistakenly attacks its own healthy tissues. It is very different from osteoarthritis.
In rheumatoid arthritis, the joints become painful and swollen, and eventually the joint is destroyed and deformed. The inflammation in this disease can also damage other parts of the body.
Today, new drugs are very effective in the treatment of the disease. However, severe disease can still cause serious damage and disability.
The prevalence of rheumatoid arthritis in the community is between 0.5-1%, and it is seen 2-3 times more frequently in women. Although it can be seen at any age, it is most common between the ages of 30-50.
It has been reported that the prevalence of rheumatoid arthritis is higher in the relatives of rheumatoid arthritis patients.
The cause of rheumatoid arthritis is not fully understood. In the light of our current knowledge, rheumatoid arthritis starts with the intervention of a triggering factor in people with genetic predisposition.
Genetic factors, infections, immune system disorders, and environmental factors are responsible for the onset, progression, and course of the disease. Some infectious agents have been suspected, but it has not been proven that a specific organism is the cause.
It is associated with many autoimmune responses. Genetic factors also contribute to pathogenesis. In pathogenesis, cellular and humoral mechanisms play a key role.
In rheumatoid arthritis, smoking is a factor in both the development and poor course of the disease.
It has been reported that smoking increases the risk of disease development by 25 times, and that this risk does not return to normal even 20 years after smoking cessation.
What Are The Symptoms Of Rheumatoid Arthritis?
In the vast majority of rheumatoid arthritis patients, the disease has a insidious onset. In the beginning, fatigue, weakness, weight loss, and pain in a few joints are observed, accompanied by a slight fever. In addition to joint pain, an important complaint is the formation of stiffness in the joints, which is defined as stiffness after rest. Morning stiffness that occurs after the first wake-up in the morning or after rest during the day is usually longer than half an hour.
However, shorter stiffness is also reported in the early stages of the disease. Inability to step on the feet in the morning, and the decrease in foot pain with walking may be the first sign of the disease.
In rheumatoid arthritis, serious disease in the early stages may be accompanied by swelling in the tendons (tenosynovitis), pain and swelling in the small joints of the hands and feet, and swelling in the wrist.
Nerve compression symptoms (burning, tingling in the fingers) due to swelling in the wrist may be seen. Carpal tunnel syndrome may be the first symptoms of onset.
The most common affected joints are the hands, wrists, feet, elbows, and knees. In this disease, the spine is not affected much, except for the distal joints of the hand, sacroiliac joints, and upper cervical vertebrae.
Due to involvement of the C1-C2 vertebrae in the neck, pain in the lower part of the head, neck pain, numbness in the arms and legs, and neurological loss may be seen. This is a condition that requires emergency intervention.
In patients, apart from joints, nodules under the skin and internal organ involvements can be seen. Heart involvement is most commonly seen as pericarditis and usually does not cause symptoms.
It does not show a relationship with the duration of the disease and can sometimes be the first symptom of the disease. The most common finding in the lungs is the accumulation of fluid in the lung membrane, which is called pleural effusion. Keratoconjunctivitis sicca, which is seen with the symptom of decreased tear production in the eye, is the most common eye finding.
Neck involvement in rheumatoid arthritis, entrapment neuropathies, peripheral neuropathy, and mononeuritis secondary to vasculitis are reported neurological involvements.
How Is Rheumatoid Arthritis Diagnosed?
Rheumatoid arthritis is diagnosed based on clinical signs and symptoms.
Laboratory findings are used to support the diagnosis or to assess the course of the disease. Rheumatoid factor positivity is detected in most patients. However, rheumatoid factor is not specific to the disease and can be detected in other diseases as well.
It should be kept in mind that the positivity is more likely to be detected after recent infections and with increasing age. Today, anti-CCP antibodies, known as anti-CCP, are more specific to the disease in the early diagnosis of the disease, and anti-CCP positivity indicates a more severe and destructive disease.
In the initial examination of patients with rheumatic diseases, we usually request complete blood count, liver function tests, urea, creatinine, complete urine analysis, and vitamin values. Additional tests such as thyroid function tests, jaundice tests, and tests for infection examination are also requested according to the clinical findings of the patient.
The patient’s painful joints are evaluated by taking direct radiographs and chest X-rays. Soft tissue swelling, osteopenia around the joint, and small nodules (erosions) at the corners of the joint are seen in direct radiographs.
The diagnosis of the disease is made by clinical and laboratory evaluation. It is important to rule out other diseases in the diagnosis of this disease. Other rheumatic diseases, viral infections, and widespread osteoarthritis can be confused with this disease.
Care must be taken when diagnosing the disease in new onset complaints. What I mean by new onset is the presence of pain and joint swelling symptoms for less than six to eight weeks.
Detailed research may be required to diagnose inflammatory rheumatic diseases, and this can lead to a delay in the diagnosis.
Many of our patients stop going to the doctor during this period due to the prolongation of the process and remain untreated. Unfortunately, the diagnosis takes longer when we do not encounter a very fast-moving picture.
This sometimes indicates that the disease is less likely to cause permanent damage. Patients with severe symptoms that we can diagnose are usually patients that we fear the disease is progressing rapidly and will have a severe course.
In patients who have not been diagnosed, the fact that the cause of the pain is not clear and the thought that there is another underlying disease and that it cannot be detected can be disturbing.
What Is Done In The Treatment Of Rheumatoid Arthritis?
The treatment includes drug therapy, exercise, and physical therapy. Interest in complementary medicine methods (ozone, cupping, acupuncture, etc.) and nutrition has been increasing in recent years, and research in these areas is ongoing.
The drugs used in the treatment of rheumatoid arthritis are drugs that suppress the body’s immune system. Corticosteroids, disease-modifying agents (such as methotrexate, sulfasalazine, and leflunomide), and biological agents are among the drugs used in the treatment.
The decision to select a drug in treatment is made by evaluating the clinical and laboratory findings of the disease.
One of the questions our patients ask in inflammatory rheumatic diseases is “Will these drugs harm me?” Every drug can have side effects. The side effects are already written in the prospectuses of the drugs after they are prescribed.
Your doctor is planning your treatment by taking into account the benefit/harm ratio. There is no drug without side effects, even molecules used as placebos can cause complaints such as nausea and stomach ache in the person.
Many patients express that they do not want to use drugs because of the side effects that may occur when we prescribe corticosteroids. In fact, I always think “I wish I didn’t have to prescribe corticosteroids.” I wish we didn’t have to prescribe any medication at all!
However, corticosteroids are still a powerful weapon in our hands, especially in autoimmune diseases. Corticosteroids are the most effective drugs in providing rapid efficacy in the early stages of the disease. By controlling the disease in a short time, we can prevent permanent joint damage.
At that time, corticosteroids are part of the treatment plan for patients who are thought to have a poor course at the beginning of treatment. The treatment usually starts with high-dose corticosteroids and the dose is reduced in the course of treatment. In long-term treatment, low-dose corticosteroids can be used in the continuation of treatment, which has been reported in studies to be effective in controlling the disease, especially in the first year.
In some patients, only corticosteroid use may be possible due to the intolerance of other drugs, concomitant other organ diseases such as liver and kidney. It should be kept in mind that serious side effects can occur with long-term high-dose corticosteroid use and precautions should be taken accordingly.
The most common fear of patients in the use of corticosteroids is usually the fear of gaining excessive weight. Corticosteroids, which can increase appetite in short-term use, cause fat accumulation in certain parts of the body with long-term high-dose use.
In some patients, conditions such as diabetes, hypertension, heart problems, and osteoporosis can also occur.
I should point out that I have had patients who have not gained weight, even lost weight, despite the increase in appetite by paying attention to their diet.
In fact, it is part of the treatment to pay attention to not gaining weight or experiencing hypertension in patients who start these drugs.
After the initial treatment of the disease is started, clinical follow-up is performed in the follow-up. Body functions are monitored with blood tests as drugs may have side effects.
It may take an average of three months to evaluate the effectiveness of a drug. In a disease that cannot be controlled with one drug, multiple drug therapy or transition to another group of drugs can be made.
At each drug transition, the patient is reassessed and both clinical and laboratory monitoring is taken.
Are Rheumatoid Arthritis Medications Lifelong Medications?
Rheumatoid arthritis is a chronic disease that requires long-term treatment and regular follow-up. However, after a period of treatment, if the disease is thought to have entered a silent period called remission, the medications can be gradually reduced or even discontinued. However, the patient should still be monitored and should see their doctor as soon as possible if their symptoms flare up again.
What Would You Like To Say About Rheumatoid Arthritis?
Patients who come to us with complaints of joint pain, swelling, and stiffness have difficulty doing their daily activities. In patients with joint pain and swelling for a long time, inflammatory rheumatic diseases should be investigated.
Joint pain can be caused by many factors. However, joint swelling, which is swelling in the joint itself and the surrounding soft tissues, is an important symptom of inflammatory rheumatism. Our patients understand the swelling when we say swelling, that is, the widespread swelling that occurs throughout the body.
In the very early stages of rheumatic diseases, there can be widespread swelling, but this is a finding that can occur for many reasons and it is important to make a differential diagnosis. Arthrits, which is the condition in which there are symptoms of pain, swelling, limited mobility, heat and color change, redness in the joint, is a problem that requires further investigation.
If we have detected arthritis, both the history and physical examination of the patient will be detailed and the necessary tests will be requested to plan the treatment. In some cases, it can take a long time to make a diagnosis.
Since close follow-up of the patient is important for diagnosis in rheumatic diseases, it is recommended that the patient remain under the follow-up of a doctor and share his complaints with him. When different findings emerge in the course of the disease, it is important to inform the doctor of these findings, which will be a guide to diagnosis, in order to reach a conclusion.
Patients who change doctors because they cannot reach a clear diagnosis are actually prolonging the diagnosis process because their old complaints are ignored or they report new complaints in the new doctor.
Taking a history from the patient, that is, carefully questioning his past and current findings, is an art and can be much more important than physical examination and tests.
Especially in patients with joint swelling, early treatment is important to prevent permanent damage due to the damaging effect of the disease, and treatment can be started with disease-modifying agents and corticosteroids in the period we call “early arthritis” and see as a “window of opportunity”.
As a clinical observation, I want to emphasize the following. Our patients sometimes want the diagnosis to be evaluated by a second eye. This is, of course, a very understandable situation.
However, the following truth that applies to many diseases should not be forgotten: The diagnosis of the disease is made clinically, that is, it is made with the complaints and examination findings of the patient when he comes to the doctor, and the treatment is planned accordingly.
The patient’s clinical condition, especially in rheumatic diseases, can change rapidly. Patients can apply to another doctor with their laboratory findings and imaging results such as X-ray and MRI and ask for information about whether the diagnosis is correct.
As I tell my patients who come to me in this way, “Medicine is an art.”
Every physician practices the art of medicine. Medicine is not an engineering field, two times two does not always equal four. All patients are special and a treatment path is drawn within their own conditions for each patient. A preliminary diagnosis is made with the clinical evaluation made with the existing conditions and treatment is planned. The professional experience of the physician is guiding on the way to diagnosis.
Sometimes the treatments taken in the process can make the symptoms of the disease milder and the patient may think “I didn’t have a disease anyway” when he goes to the next doctor. When the patient’s medication is stopped, the symptoms can flare up again and the treatment can start over.
Sometimes the patient’s initially mild symptoms have become more pronounced, so the thought of “Look how he diagnosed immediately. How could he not diagnose me?” can be formed.
Being aware of these situations and providing information is the right approach for both the patient and the physician.
