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Rheumatoid Arthritis

What is Rheumatoid Arthritis?

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Rheumatoid Arthritis is what we call an inflammatory arthritis. That is an arthritis where the body's own immune systems attacks the lining of the joint. This results in swelling and the accumulation of fluid in joints which are affected.

 

In time, if untreated, the inflammation can result in damage to the bones and the joints. This can cause deformities of the joints, pain and a loss of effective function of the joints.

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What causes Rheumatoid Arthritis?

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We don't really understand what causes Rheumatoid Arthritis. It is thought to be a condition where the body's own immune system instead of protecting the body against foreign invaders, such as bacteria, is instead incited to attack the lining of the joints, and in some cases tendons.

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What are the symptoms of Rheumatoid Arthritis?

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The symptoms of Rheumatoid Arthritis are different for different people. No two people have the same arthritis!

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A common way for Rheumatoid to affect the body is to cause symmetrical involvement of both small and large joints, such as the hands and the knees. People with rheumatoid typically have pain and stiffness in the affected joints worse on waking in the morning, getting better with activity, and then getting worse at the end of the day again. They often have a lot of swelling in the joints, but sometimes the swelling can be quite subtle and it can be difficult to diagnose. They may often have generalised pain and stiffness, feel tired and generally unwell. Some people can have fevers in the initial stage of Rheumatoid Arthritis.

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Typically when there are flares of Rheumatoid or when the disease is active, joints are swollen and people are stiff and sore. However, some people can have swelling in their joints without any pain or stiffness, and other people have very little swelling with a lot of pain. It is very different for each person.

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If Rheumatoid Arthritis is present for a long time, and in particular if the disease has not been well controlled, people can develop problems with other parts of the body.

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Notably: there is a higher risk of cardiovascular disease

People can develop some problems with the eyes such as scleritis. With chronic disease some people may develop leg ulcers, and sometimes the lungs can be involved as well.

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Usually it is a disease confined to joints, it is usually when the disease is poorly controlled for long periods of times  that other complications can arise.

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If the disease is poorly controlled people can develop destruction of the joints, with deformities, increaisng pain and immobility.

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Who gets Rheumatoid Arthritis?

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Rheumatoid Arthritis can affect people of any age, even children.

It is typically diagnosed between the ages of 50-75.

Women are affected 2-3 times more commonly than men.

It affects about 1% of the caucasian population.

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How is Rheumatoid Arthritis diagnosed?

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There are many different types of arthritis, and in the early stages of disease, they can look quite similar. It takes a person skilled in managing arthritis to make a correct diagnosis.

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Typical symptoms such as the symmetrical involvement of many joints and morning stiffness are a key indicator that a person could have Rheumatoid Arthritis.

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Blood tests and x-rays are done to confirm the diagnosis.

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Your doctor will do testings for antibodies called RF and anti CCP antibodies. If they are positive it is a good confirmation of Rheumatoid Arthritis if other joint symptoms are typical. However, if they are negative it doesn't necessarily mean that the arthritis is not rheumatoid, as there can be what we call 'seronegative' Rheumatoid Arthritis. This just means that the antibodies for Rheumatoid Arthritis are not positive in the serum, which is the blood testings.

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Your doctors will order x-rays of hands and feet and sometimes other joints. These are done looking for the presence of 'erosions' in the joints, which are typical of Rheumatoid Arthritis. These are not usually present in the earlier stages of disease, but can occur with longstanding disease.

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How do we treat Rheumatoid Arthritis?

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The treatment of Rheumatoid Arthritis is always tailored for each person. There is no one treatment regime that suits or works for all people. The key is that when the diagnosis is made to start treatment as soon as possible as this improves outcomes in the long term.

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The drugs that we use to treat Rheumatoid Arthritis are called DMARDs. For more information on DMARDs click here.

 

DMARDs are drugs that target particular chemicals in the immune system and suppress the inflammation process that is attacking the joints. They are not a cure, but if a person responds they can keep the disease in 'remission' while the medications are being taken. Unfortunately, not everyone responds to these medications.

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Common ones that we use for Rheumatoid Arthritis are:

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  • Methotrexate

  • Leflunomide

  • Sulfasalazine

  • Hydroxychloroquine

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Your doctor will explain more about these medications in person and there are excellent information leaflets explaining more about them.

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These drugs are the long term drugs.

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Short term, NSAIDs (anti inflammatories) or prednisolone can be used to reduce the swelling and inflammation, to cause less pain and improve function in the short term. Long term, these medications have many side effects which is why the DMARDs are used. The DMARDS can take time to build up in the system so there will often be an overlap period where NSAIDs or prednisolone are used to support a person to minimise their pain until the DMARDs take effect. 

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Sometimes pain killers are needed if people are very affected by pain.

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If people do not respond to the DMARDs, then the next step to consider are what are known as Biologicals drugs. These are drugs specifically designed to target very specific chemicals in the immune process. They are very expensive, so only people with severe disease not responding to DMARDs are eligible to have these drugs funded by the PBS. Speak to your Rheumatologist in more detail about these medications.

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What is the long term outcome with Rheumatoid Arthritis?

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Many years ago, when a diagnosis of Rheumatoid Arthritis was made it was a devastating diagnosis because it usually meant certain lifelong pain, immobility and deformities and horrible complications.

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In this modern day and age we have many medications that most people respond to. Most people respond well to DMARD therapy and it is a minority who do not who then need to consider Biological therapy. And then there are a minority who do not respond to biologicals.

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In my practice, I see people do well if they respond to treatment, and people can lead normal lives with their symptoms under control.

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Because of the great response of most people to treatment we don't see the same complications as we used to 20 years ago, when many people were frequently admitted to hospital because of their disease. Thank goodness for the advances of modern medicine!

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What can I expect once I've been diagnosed with Rheumatoid Arthritis?

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They key thing here is to have no specific expectations, as hard as that may be!!

 

Everyone's disease is different and everyone responds differently to medications.

 

Its important to find a Rheumatologist who you have a good relationship with as the one consistent thing will be a life long relationship with a Rheumatologist!

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When you are first diagnosed, your Rheumatologist will with your permission and after consulting with you start you on DMARD therapy. If you consent to that, your dose of the DMARD will be adjusted until your symptoms are controlled. If you don't respond to one DMARD or, experience side effects, your doctor will recommend another DMARD. 

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It takes time for the DMARDs to work, so patience is important in the initial stages. It can sometimes take many months to find the right dose and/or the medication that is right for you. There is currently no way of predicting which person will respond to which medication. Methotrexate is the medication that many of us prefer to use first as it is very effective, cheap and despite the fact it sounds scary when you read about it, most people do not have a lot of side effects on it!

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Your Rheumatoid may go through ebbs and flows in your life. Sometimes it may be well controlled and at other times you may have flares. Just because you have a flare does not mean that your drug is not working. Sometimes the disease flares and needs support for a short period of time.

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The important thing is to work in partnership with your Rheumatologist with this so that your treatment can be adjusted if your disease and your life changes.

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