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RHEUMATOID ARTHRITIS OVERVIEW — Rheumatoid arthritis (RA) is a chronic inflammatory condition. It primarily affects the joints, but it can affect many different parts of the body. The cause of RA is unknown but likely stems from both genetic and environmental factors. It is different from osteoarthritis (OA), which is the most common form of arthritis; OA occurs when the cartilage protecting the joints wears down over time. However, it is possible for a person to have both types of arthritis.
In people with RA, joint symptoms typically develop gradually. Many people have symptoms that are present continuously, some have symptoms that completely resolve, and others have alternating periods of bothersome symptoms and complete resolution. The onset, severity, symptoms, and complications of this condition can vary greatly from person to person.
This topic discusses the risk factors, symptoms, and diagnosis of rheumatoid arthritis. More information about RA is available separately. (See "Patient education: Rheumatoid arthritis treatment (Beyond the Basics)" and "Patient education: Disease-modifying antirheumatic drugs (DMARDs) in rheumatoid arthritis (Beyond the Basics)" and "Patient education: Rheumatoid arthritis and pregnancy (Beyond the Basics)".)
RHEUMATOID ARTHRITIS RISK FACTORS — Rheumatoid arthritis (RA) affects about 1 percent of people in the United States and northern Europe. The specific cause of RA is not known. Researchers suspect that two types of factors affect a person's risk: susceptibility factors and initiating factors.
Susceptibility factors — RA most likely occurs when a susceptible person is exposed to factors that start the inflammatory process.
Factors that increase a person's susceptibility include:
●Age – RA can occur at any age, but the risk gradually increases with age, leveling off around the age of 50.
●Female sex – Women are about three times as likely as men to develop RA.
●Genetics – People who have a relative with RA have a somewhat increased risk of getting it themselves. This is because certain genes affect the likelihood of developing the disease.
Initiating factors — Many people with the above susceptibility factors never develop RA. Several things appear to increase the chances that a susceptible person will eventually get the disease. While several things have been identified as initiating factors, there may be others that are not known.
Factors that have been proposed to serve as initiating factors include:
●Infection – Researchers suspect that alterations of bacteria in the gut or mouth may be among the factors that initiate RA. There is accumulating evidence that periodontitis (infection of the gums) is a risk factor.
●Cigarette smoking – Smoking is a well-recognized factor that increases the risk of developing RA.
●Stress – People often report episodes of emotional stress or trauma (such as divorce, accidents, or grief) during the months preceding the onset of their RA.
RHEUMATOID ARTHRITIS SYMPTOMS — In most cases, symptoms come on gradually, and weeks or months may pass before becoming bothersome enough to cause a person to seek medical care. Early symptoms may include fatigue, muscle pain, a low-grade fever, weight loss, and numbness and tingling in the hands. In some cases, these symptoms occur before joint pain or stiffness is noticeable.
Pattern of joints affected — Rheumatoid arthritis (RA) usually affects the same joints on both sides of the body; this is often described as "symmetrical arthritis." However, one side may be worse than the other.
In the early stages, small joints are typically affected, especially the joints at the base of the fingers, the middle of the fingers, and the base of the toes. Less often, it may begin in a single, large joint, such as the knee or shoulder, or it may move from one joint to another.
As the condition progresses, most people eventually have inflammation of the joints in the arms or legs. Less commonly, some people have inflammation of the hips and in the upper part of the spine.
Joint symptoms — Joint-related symptoms typically include stiffness, pain, redness, warmth to the touch, and swelling. Joint stiffness is most bothersome in the morning and after being still for a period of time. While other types of arthritis may cause stiffness, the stiffness seen in RA often persists for more than one hour.
Joints that may be affected include:
●Hands – The joints of the hands are often the very first joints affected by RA. These joints are tender when squeezed, and the hand's grip strength is often reduced. Occasionally, visible redness and swelling can affect the entire hand.
In 1 to 5 percent of people with RA, swelling compresses a nerve that runs through the wrist, leading to a condition called carpal tunnel syndrome. This causes weakness, tingling, and numbness in the hand and fingers.
Characteristic hand deformities can occur over time in people with RA if the inflammation in the joints persists. The fingers may appear bent, called "boutonniere" or "swan neck" deformities (picture 1), or point toward the direction of the little finger. The tendons on the back of the hand may become very prominent and tight; this is called the "bowstring sign."
●Wrist – In the early stages of RA, it may become difficult to bend the wrist backward.
●Elbow – Swelling in elbow may occur and can compress nerves that travel through the arm and cause numbness or tingling in the fingers.
●Shoulder – The shoulder may be inflamed in the later stages of RA, causing pain and limited motion.
●Foot – The joints of the feet are often affected in the early stages of disease, especially the joints at the base of the toes and less commonly the big toe. Tenderness at these joints may cause a person to stand and walk with their weight on the heels, with the toes bent upward. The top of the foot may be swollen and red, and, occasionally, the heel may be painful.
●Ankle – Inflammation of the ankle may cause nerve damage, leading to numbness and tingling in the foot.
●Knee – Swelling of the knee can lead to difficulty bending the knee, loosening of the ligaments that surround and support the knee, and damage to the ends of the bones that meet at the knee. RA may also cause the formation of a "Baker's cyst" (a fluid-filled cyst in the hollow space at the back of the knee).
●Hips – The hips may become inflamed in the later stages of RA. Hip pain can make it difficult to walk.
●Neck – RA may cause inflammation of the neck (cervical spine). Inflammation of the cervical spine can cause a painful and stiff neck, cause headaches, and make it difficult to bend the neck and turn the head. If you need to have surgery for any reason, your provider may get X-rays of your neck in order to decide whether any precautions are needed to protect the area.
●Cricoarytenoid joint – A minority of people with RA have inflammation of a joint near the windpipe called the cricoarytenoid joint. Inflammation of this joint can cause hoarseness and difficulty breathing.
Other symptoms and problems — Although joint problems are the most common symptoms of RA, the condition can also be associated with a variety of other problems. These can be related to inflammation in the body, a side effect of medications used to treat the disease (eg, steroids), or a combination of factors:
●Bone loss – Many people with RA have a decrease in bone density and an increased risk of fractures.
●Muscle weakness – This is also a common symptom. It can affect muscles around the joints (for example, inflammation in the knee can lead to weakness of the thigh muscle, which in turn further stresses the joint) or be more widespread. Muscle loss can make it more difficult to get around and perform daily tasks.
●Skin problems – The most common of these are rheumatoid nodules, which are painless lumps that appear beneath the skin. These nodules may move easily when touched, or they may be fixed to deeper tissues. They most often occur on the underside of the forearm and on the elbow, but they can also occur on other pressure points, including the back of the head, the base of the spine, the Achilles tendon, and the tendons of the hand.
●Eye problems – Eye inflammation can cause redness, pain, and vision problems.
●Lung disease – Inflammation of the lung may cause shortness of breath and a dry cough.
●Pericarditis – This is the term for inflammation of the tissue lining the chest cavity and surrounding the heart; it can cause chest pain and difficulty breathing. (See "Patient education: Pericarditis (Beyond the Basics)".)
●Vasculitis (inflammation of the blood vessels) – This is a very rare but serious complication that can cause a wide variety of symptoms, depending upon where the inflamed blood vessels are located. (See "Patient education: Vasculitis (Beyond the Basics)".)
●Sjögren's disease – This is a condition that causes dry eyes and dry mouth. (See "Patient education: Sjögren's disease (Beyond the Basics)".)
●Fatigue – Prolonged inflammation in the body can lead to fatigue, which may be significant and affect the quality of life. Fatigue also does not always go away with treatment of the arthritis.
●Amplified pain – Poor sleep and chronic pain from arthritis can lead to widespread pain throughout the body. This is characterized by pain in the soft tissues (not just the joints) and often persists even after successful treatment of joint inflammation.
●Heart disease – Inflammation in RA can lead to a higher risk of heart attack and stroke over a patient's lifetime.
●Cancer risk – Certain types of cancers, such as lymphomas, are more likely in patients with RA, particularly if the disease is not well controlled. Treatments for RA may also increase the risk of certain types of cancer, particularly skin cancer.
RHEUMATOID ARTHRITIS DIAGNOSIS — There is no single test used to diagnose rheumatoid arthritis (RA). Instead, the diagnosis is based upon multiple factors including a person's medical history, physical examination, and results of blood and imaging tests. In some cases where the disease is suspected, it may be necessary to monitor a person's condition over time before a diagnosis of RA can be made with certainty.
Typically, RA is diagnosed when a person has the following (and in whom other potential causes have been ruled out):
●Signs of inflammation in three or more joints, lasting for six weeks or longer
●Diagnostic antibody blood tests (rheumatoid factor and/or anti-citrullinated peptide/protein antibody)
●Elevated blood levels of C-reactive protein or the erythrocyte sedimentation rate, markers that reflect the level of inflammation in the body
While X-rays are often done to exclude other conditions, and to monitor disease progression in people with confirmed RA, they are usually not necessary to make the initial diagnosis.
RHEUMATOID ARTHRITIS TREATMENT — The goals of treatment in people with rheumatoid arthritis (RA) are controlling symptoms, minimizing joint damage, and improving quality of life. Treatment is discussed in more detail separately. (See "Patient education: Rheumatoid arthritis treatment (Beyond the Basics)".)
RHEUMATOID ARTHRITIS DISEASE COURSE — The course of rheumatoid arthritis (RA) varies from person to person. While some people have periods of worsening symptoms that alternate with periods of remission, most people experience progressive disease if left untreated (although it may progress either slowly or quickly).
The inflammation of RA can damage the bones, cartilage, and other structures of the joints. The joint damage typically worsens over time and is irreversible; this can have an impact on a person's ability to do their usual activities, and eventually lead to significant disability. Many people with RA also have other health conditions as well; this can affect quality of life as well as life expectancy.
Treatment with medications, especially when initiated early in the course of disease, is effective in reducing symptoms, slowing damage to joints, and preventing complications of the disease; this improves quality of life for most people. Occasionally, disease may remit completely, although remission is rare in established disease without drug treatment, and most people require some amount of lifelong treatment. (See "Patient education: Rheumatoid arthritis treatment (Beyond the Basics)" and "Patient education: Disease-modifying antirheumatic drugs (DMARDs) in rheumatoid arthritis (Beyond the Basics)".)
WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: Rheumatoid arthritis (The Basics)
Patient education: Rheumatoid arthritis and pregnancy (The Basics)
Patient education: Hand pain (The Basics)
Patient education: Ganglion cyst (The Basics)
Patient education: Pyoderma gangrenosum (The Basics)
Patient education: Antinuclear antibodies (The Basics)
Patient education: Interstitial lung disease (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Rheumatoid arthritis treatment (Beyond the Basics)
Patient education: Disease-modifying antirheumatic drugs (DMARDs) in rheumatoid arthritis (Beyond the Basics)
Patient education: Rheumatoid arthritis and pregnancy (Beyond the Basics)
Patient education: Pericarditis (Beyond the Basics)
Patient education: Sjögren's disease (Beyond the Basics)
Patient education: Vasculitis (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Assessment of rheumatoid arthritis disease activity and physical function
Cervical subluxation in rheumatoid arthritis
Clinical manifestations of rheumatoid arthritis
Polyarticular juvenile idiopathic arthritis: Clinical manifestations, diagnosis, and complications
Biologic markers in the assessment of rheumatoid arthritis
Diagnosis and differential diagnosis of rheumatoid arthritis
Disease outcome and functional capacity in rheumatoid arthritis
Epidemiology of, risk factors for, and possible causes of rheumatoid arthritis
Evaluation and medical management of end-stage rheumatoid arthritis
General principles and overview of management of rheumatoid arthritis in adults
Interstitial lung disease in rheumatoid arthritis
Pharmacology, dosing, and adverse effects of leflunomide in the treatment of rheumatoid arthritis
Polyarticular juvenile idiopathic arthritis: Treatment
Ocular manifestations of rheumatoid arthritis
Overview of the systemic and nonarticular manifestations of rheumatoid arthritis
Rheumatoid arthritis and pregnancy
Rituximab: Principles of use and adverse effects in rheumatoid arthritis
Sulfasalazine: Pharmacology, administration, and adverse effects in the treatment of rheumatoid arthritis
Surgical management of end-stage rheumatoid arthritis
Alternatives to methotrexate for the initial treatment of rheumatoid arthritis in adults
Initial treatment of rheumatoid arthritis in adults
Treatment of rheumatoid arthritis in adults resistant to initial conventional synthetic (nonbiologic) DMARD therapy
Use of glucocorticoids in the treatment of rheumatoid arthritis
Use of methotrexate in the treatment of rheumatoid arthritis
The following organizations also provide reliable health information.
●National Library of Medicine
(www.medlineplus.gov/arthritis.html, available in Spanish)
●National Institute of Arthritis and Musculoskeletal and Skin Diseases
●American College of Rheumatology
●The Arthritis Foundation
ACKNOWLEDGMENTS — The UpToDate editorial staff acknowledges Ravinder N Maini, BA, MB BChir, FRCP, FMedSci, FRS and PJW Venables, MA, MB BChir, MD, FRCP, who contributed to earlier versions of this topic review.
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