Decoding RA - Understanding Rheumatoid Arthritis

If you have been suffering from chronic joint pain and/or have recently been diagnosed with Rheumatoid Arthritis (RA), then this blog series will shed some light on the disease and what you can do about it.

What is RA?

RA is an autoimmune disease that primarily affects the synovial joints of your body.  The deterioration of the synovial fluid leads to a painful inflammatory process that, over time, can lead to chronic systemic inflammation. RA is one of over one hundred types of arthritis, with some of the most common types including osteoarthritis, gout, and psoriatic arthritis. All of them have different causations, however the common delineator is joint pain and ultimately destruction of the joint(s). The disease affects between 0.8 to 1 percent of all populations and is considered the second most common rheumatic diagnosis after osteoarthritis. It tends to affect two to three times more women than men.

How does RA present?

Symptoms of RA primarily include pain, stiffness, swelling, and redness around the joints. Patients tend to experience symptoms in their hands, shoulders, elbows, hips, and knees. Typically patients will have exacerbations followed by remissions, with a general trend of progressive joint destruction and systemic inflammation-induced damage. The disease usually begins slowly in two thirds of patients and is often not diagnosed in the early stages. Due to the systemic inflammatory nature of the disease, additional symptoms you may experience include malaise, fatigue, loss of appetite, and general muscle aches. 

RA and your Immune System

To understand RA and what you can do about it, you need to understand the process of autoimmunity as RA is both an inflammatory arthritis and autoimmune disorder. In the earliest stages of the disease, before the onset of joint inflammation, a series of events occurs in which the immune system loses the ability to distinguish between your body’s tissues (self) and foreign tissue (non-self). This leads to your immune system mistakenly attacking your own body, which in the case of RA is your joints, however it can also attack surrounding tissue including muscles, ligaments, tendons, bursa, and even other organs. As the tissues begin to deteriorate due to repeated inflammation and immune activation, the joints can become deformed due to tissue destruction. Joint function may also become inhibited or even halted in the advanced stages of the disease. 

rheumatoid-arthritis-joint-damage

What causes RA?

Traditionally RA is considered a chronic idiopathic inflammatory disorder, meaning the cause is unknown. There is evidence that a majority of patients have a genetic predisposition for the disease. As a functional medicine practitioner I see additional root causes such as environmental toxins, food sensitivities, allergies, stress, trauma, infections, bacterial overgrowth (dysbiosis), leaky gut syndrome, and hormonal imbalances.

How is RA diagnosed?

Your doctor establishes a diagnosis of RA through a process of a physical examination, blood tests, and possibly some imaging studies. 

Physical Examination/Medical History:

  1. Joint pain and morning stiffness (over 30 minutes) with history of previous episodes
  2. Family history of RA
  3. Systemic flu like features and fatigue
  4. Three or more tender and swollen joint areas (simultaneously)
  5. Symmetrical joint involvement in hands and/or feet
  6. Pain when squeezing your hands and feet (MCP or MCT joints) 
  7. Presence of rheumatoid nodules (firm lumps in the skin) which are found in common pressure points in your body, most commonly in the elbows.

Blood Tests: 

  1. Rheumatoid Factor (RhF). 
  2. ESR
  3. CRP
  4. Anti-Cyclic Citrullinated Peptide Antibody (ACPA)
  5. Cyclic Citrullinated Protein Antibody (CCP)

Imaging Studies:

  1. X-Ray will often present with visible in your hands and wrists indicating destruction of the bone, however this is typically seen in the later stages of the disease.

It is important to note that many patients will suffer for multiple years with chronic pain as they may not meet the ‘official’ criteria for an RA diagnosis in the early onset phase of the disease. 

How is RA treated?

Common treatment involves the prescription of NSAID’s, steroids, and even narcotics. Sadly, these treatments only mask the disease and long term use will typically cause unpleasant side effects including fatigue, rashes, intestinal distress and bleeding, and anemia. Furthermore, the treatment efficacy will decrease with time and can even worsen pain in the long run. 

Once you have been diagnosed with RA, drug therapy and working with a rheumatologist is considered the gold standard of care. Your doctor will typically prescribe traditionally used disease-modifying anti-rheumatic drugs (DMARD) such as Methotrexate or Plaquenil which focus on dampening the immune process, leading to decreased inflammation and a slowing of joint destruction. Newer DMARD’s called biologics focus on very specific immune cells that may be involved in the disease process instead of targeting the entire immune complex. Whilst these treatments are effective for many, they are palliative at best and provide no cure to the disease.   

The Functional Medicine Approach to RA

Treating RA effectively can often be accomplished through a combination of traditional and functional medicine treatment and management approaches. While medication is often essential during flare ups or an acute attack, a competent functional medicine practitioner can help you to identify and address the underlying root cause(s) to reduce the disease process itself.  

Successful remission and management of the disease will often take time. However, in my clinical experience, I have seen many patients be able to live a pain free life and even discontinue their medication. Gaining an understanding on what factors are involved in your individual case is the first step to taking control of your health.

To discuss your specific symptoms, treatment approach, or for more information we encourage you to schedule a complimentary consultation with Dr. Auer.


References:

Vasquez A, Integrative Rheumatology. Rheumatoid Arthritis. Concepts, Perspectives, Algorithms, and Protocols. 2nd Edition 2007: 235-236

William C. Shiel Jr., M. (2011, november 20). Retrieved from http://en.wikipedia.org/wiki/Rheumatoid_arthritis

Gibofsky A. Overview of epidemiology, pathophysiology, and diagnosis of rheumatoid arthritis. Am J Manag Care 2012;18:S295-302. 

McInnes IB, Schett G. The pathogenesis of rheumatoid arthritis. N Engl J Med 2011;365:2205-19

Smolen JS, Steiner G. Therapeutic strategies for rheumatoid arthritis. Nat Rev Drug Discov 2003;2:473-88.

Hardin JG, Waterman J, Labson LH. Rheumatic disease: Which diagnostic tests are useful? Patient Care 1999; March 15: 83-102

Siegel LB, Gall EP. Viral infection as a cause of arthritis. Am Fam Physician 1996 Nov 1;54(6):2009-15