Is it a challenge having Rheumatoid Arthritis?

Rheumatoid Arthritis (RA) is an autoimmune, systemic disease. It is characterized by chronic inflammation of synovial membranes in joints. This roughly affects 1% of the world’s population. This causes irreversible tissue and bone damage hence, joints may get red, swollen, warm, and painful. The disease tends to be more common in females than males, but men may have more severe symptoms. This can be developed at any age, but mostly starts at the age 40-60. This causes disability and serious effects on the quality of life in today’s world. So, let’s have a look at what RA is, what are the causes, symptoms, treatments and how can you live a sustainable life with the disease.

What is happening in Rheumatoid Arthritis?

 Although inflammation is a protective mechanism in the body an inappropriately activated human immune system leads to inflammatory diseases. Normally the human immune system can identify the difference between self and non-self cells, in Rheumatoid Arthritis, white blood cells (WBC) identify the synovial cells (which provide nourishment to cartilage and bone in joints) as non-self. Then they initiate an inflammatory response against those synovial cells.

 Due to the activation of monocytes and macrophages, they secrete cytokines including Interleukin-1 (IL-1), interleukin-6 (IL-6), and tumor necrosis factor (TNF) into the synovial cavity. This leads to a process in which ultimately the cartilages of joints become thin and the space between bones becomes narrow. Finally, bones come in contact together and are also displaced. On the other hand, bone degrading cells (osteoclasts) cause a bone breakdown. Progressive tissue injury causes bone damage and ultimately leads to significant pain.

There are four stages of progression.

  • Stage 1 (Early RA) – Inflammation inside the joint (in the synovial membrane) starts but the bones are not damaged yet. The person feels stiffness, pain, and swelling of the joint.
  • Stage 2 (Moderate stage) – Inflammation of the synovium affects the cartilage of the bones and damages it. Cartilage is the protective foam that covers the ends of the bones. This causes reduced ability to move joints and the person usually feels stiffness, pain, and limited mobility.
  • Stage 3 (Severe stage) – At this progressive stage, the damage has extended to the bones of the joint. The cartilages between bones are damaged which leads to bones coming in contact and rub together. Bones have been damaged and deformities may occur. Some people feel muscle weakness and more pain. This causes loss of mobility of the joints and feels more pain and swelling.
  • Stage 4 (End stage) – In this stage, there is no more inflammation of the joints, but the damage continuously progresses. Still, pain, stiffness, swelling, and muscle weakness can be experienced. Mobility of joints becomes very less. 

The disease has a symmetrical inflammation pattern, in other words, it affects the joints of both sides of the body. This symmetry indicates the uniqueness of RA from other types of arthritis. Usually, it affects the small joints in the hands and feet such as the wrist, fingers, and toes. In addition, shoulders and knees are also affected. Subsequently, RA spreads to other organs for example heart, eyes, lungs, blood vessels, and even skin.

What are the types of Rheumatoid Arthritis?

arthritis

There are two main types of Rheumatoid Arthritis, namely seropositive RA and seronegative RA. Other than that there is another type called Juvenile RA (Juvenile Idiopathic Arthritis).

The two main types differ according to the presence or absence of a protein called rheumatoid factor (RF) or the antibody anti-cyclic citrullinated peptide (anti-CCP). Studies have shown that 80% of individuals having RA have positive tests for Rheumatoid Factor hence called RF positive. But of course, having RF doesn’t exactly mean that you have the disease. Some patients even with the disease have repetitively shown that they do not have the rheumatoid factor.

  • Seropositive RA

When an individual has RA and tests positive for the rheumatoid factor, it is called Seropositive RA. In the diagnostic process, if the test is positive with the rheumatoid factor (RF), it means that your body is actively producing an immune reaction against your cells. The presence of the Rheumatoid factor is an early indicator for having Rheumatoid Arthritis, however, it is not always happening. You have four times more possibility to develop RA if your parents or siblings test positive for RF.

  • Seronegative RA

People who test negative for rheumatoid factor (RF) and anti-CCP in their blood, but still having the disease are classified as Seronegative RA. Essentially, this test isn’t enough to diagnose the disease. Therefore other laboratory tests and diagnostic tests were performed to confirm the exact disease condition. It is said that people who have negative tests tend to have a mild form of RA than those who test positive.

  • Juvenile Idiopathic Arthritis

This type of RA first appears in teenagers below 16 years old. It has not only the same symptoms of RA, but also it affects other body parts too. For instance, eyes, bones, mouth/jaw, ankles and feet, skin, digestive system, lungs, and heart. “Idiopathic,” says that the actual cause of the disease has not been revealed yet.

Next, let’s have a look at the causes of Rheumatoid Arthritis.

The actual cause of RA, still not explained well. Most of the time, it is said that external triggers, for example, exposure to noxious agents such as cigarette smoke, silica dust, infection, or trauma, can lead to the production of autoantibodies. Then those antibodies initiate an immune reaction. Ultimately, it causes the inflammation of the synovial membrane of the joints as discussed above. The early stage of developing RA is the pre-RA stage.

 This period can be classified into five phases.

1st phase             .  external triggers combine with the genetic factors responsible for RA and interaction between them happens
2nd phaseProduction of autoantibodies including Rheumatoid Factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) starts
3rd phaseInitiation of joint stiffness, but still doesn’t show any clinical manifestations.
4th phaseDevelopment of RA in one or two joints
5th phaseEstablishment of stable Rheumatoid Arthritis

Although the actual cause is unknown, many reasons are involved in pathogenesis. Including genetic factors, environmental, hormonal, socioeconomic, psychological, and lifestyle.

  • Genetic factors – As previously said, RA is an autoimmune disease, there is a clear causal relationship with genetics. The most significant genetic factor responsible for rheumatoid arthritis is the variations in the Human Leukocyte Antigen (HLA) genes, specially HLA-DRB1. According to the GWAS (Genome-Wide Association Studies), over 100 loci (specific locations of the gene on the chromosome) have been identified with the association of RA.

Moreover, there is a 50%-60% influence of heredity on the development of the disease. Also, HLA is involved in 10%-40% inheritability.

Even though you may have those genes by inheritance, it is not essentially said that you may develop the disease. Because several non-genetic factors affect the development. However, if you have a close relative with rheumatoid arthritis, you may have an increased possibility of developing the disease.

  • Environmental Effects – Regardless, the exact cause for RA remains unknown, genetics and various environmental factors play a major role as causes.

For example, smoking, alcohol intake, diet.

In addition, birth weight, region of birth, socioeconomic and also breastfeeding.

It is known that increased prolactin levels in the blood(Hyperprolactinemia) in women increase the risk of RA.

           Furthermore, certain behaviours in diet also have a significant influence.

  1. Vitamin D deficiency
  2. High salt intake
  3. Red meat consumption
  4. Excessive coffee consumption may increase the risk

These risk factors could modulate the variations of genes responsible for the disease. In other words, the intervention of the above factors in DNA methylation, histone protein modifications, and gene expressions have been identified.

According to the research published in 2018, it is identified that the diet with protein arginine, ultimately can induce RA. To put it another way, if your oral cavity is colonized by the bacteria Porphyromonas gingivalis, then if you take foods containing proteins with the amino acid Arginine, above mentioned bacteria produce an enzyme. This enzyme converts the amino acid arginine into citrulline, which is known as Citrullination. Next, those Citrullinated proteins trigger the production of Anti-Citrullinated Protein Antibody (ACPA). Finally, ACPA cross-reacts with tissue antigens and induces rheumatoid arthritis.

What can be the symptoms of rheumatoid arthritis?

The basic symptoms of rheumatoid arthritis are as follows;

  • Pain and stiffness of joints in hands, feet, wrists, elbows, shoulders, jaw, ankles, and also neck.
  • Swelling of those joints.
  • Continuous symmetric inflammation of synovial membranes of joints. It means if the joints of your right side are inflamed, probably the joints of the left side follow the same. As a result, you’ll notice the pain, swelling and the stiffness, and warmth when touching those joints.
  • Morning stiffness can last for hours.

Other than the normal symptoms, some individuals may be experiencing some early signs. Some might think those symptoms cannot be RA. Those early symptoms may be,

  1. Fatigue
  2. Slight fever
  3. Stiffness
  4. Joint tenderness
  5. Joint pain

How does the disease affect your life?

As you already know, the disease affects the whole body systems’ function. Therefore, you can feel additional symptoms like,

  •  general tiredness
  • sleep disturbances
  •  exhaustion, etc.

 It is important to know how these block your everyday life. So you can identify and prevent them. Pain and stiffness around joints block daily work. This includes cooking, washing, gardening work, driving, office work, and relationships, and sexual life. But, most people still want to manage their pain somehow. They change their minds and carry their daily stuff and help their family members. Some people say that when they focus on other work instead of pain, it is much easier to convert lives for the better.

How can it be treated to RA?: Rheumatoid Arthritis Treatment        

 Under rheumatoid arthritis treatment, you’ll get to know the current treatment procedure, alternative therapies, and the new interventions which might help to treat the disease.  

The current treatment procedure

Similarly, as the cause of the RA is unknown, the current recognition is there’s no exact treatment for rheumatoid arthritis. But of course, the medication process aims to reduce inflammation and pain. The RA management therapy has the goal to halt or slow the disease progression. This includes

  • Non-Biologics: disease-modifying antirheumatic drugs (DMARDs). These are usually taken orally as a pill. For example,
  • Hydroxychloroquine
  • Methotrexate
  • Sulphasalazine
  • Azathioprine
  • Leflunomide
  • Gold salts
  •   Biologics: this is a special type of DMARDs. They are genetically engineered proteins. Usually, physicians prescribe these drugs when conventional DMARD therapy is not working. At present, biologics are used alone or as combination therapy with other nonbiologic DMARDs, usually methotrexate. Biologics are administered as intravenous infusion or injection.

When we focus on the categories of biologics, they are,

  1. Tumor necrosis factor (TNF) inhibitors
  2. Interleukin inhibitors
  3. B-cell inhibitors
  4. Selective Co-stimulation modulators

Among them, TNF inhibitors are mostly used.

                For example, TNF inhibitors

  • Etanercept
  • Infliximab
  • Adalimumab
  • Certolizumab
  • Golimumab

Non-TNF inhibitors

  • Tocilizumab
  • Rituximab
  • Anakinra
  • Sarilumab
  • Abatacept
  • Other drugs: anti-inflammatory and /or immunosuppressive agents
  • Non Steroidal Anti Inflammatory Drugs (NSAIDs)
  • Aspirin
  • Celecoxib
  • Diclofenac
  • Etodolac
  • Fenoprofen
  • Ibuprofen
  • Immunosuppressive (corticosteroids)
  • Prednisone
  • Hydrocortisone
  • Prednisolone
  • Dexamethasone
  • Methylprednisolone
  • Analgesics: Acetaminophen
  • Surgical treatments

                  Once the conventional DMARDs and biologics are not going to work, but if you already have joint damage, there is another option. It is surgery. If this is successful, you’ll be able to make movements much better. The best surgical treatments for rheumatoid arthritis are as follows.

  • Knee replacement
  • Total joint replacement
  • Hip replacement
  • Synovectomy
  • Arthroscopy
  • Bone or joint fusion surgery
  • Tendon realignment

Alternative treatments of Rheumatoid Arthritis

Other than the medications, certain alternative treatments can be a great support. This is achieved with the aim of pain management and improving your life. This includes Cognitive behavioral therapy (CBT), physiotherapy, taking care of your diet, and various herbal and ayurvedic methods. So, let’s dive into what those things are?

  • Cognitive therapy

Cognitive Behavioural Therapy (CBT) is psychological therapy. It is used to convert negative thought patterns into positive ones to improve mental health. We can use this method as a help to overcome severe pain. By using this, you can make your mind accept your present condition, adapt to it, and finally, it’ll provide better management of RA.

Cognitive-behavioral therapy is efficacious if it starts early in the course of the disease. However, people have different needs for this therapy and some of the patients have very little stress level on the disease. So, those patients can maintain their minds to manage the disease better despite the pain. Even today, access to cognitive support is still reduced. The usage of this approach tends to be very effective in terms of pain management, disability, and mood. It means after you are diagnosed with rheumatoid arthritis, if you change your mind to live with this, you’ll improve your life for the better. Also, it increases the effectiveness of the medications as well. Likewise, Mindfulness-Based Cognitive Therapy(MBCT) helps to reduce stress, anxiety, and depression in patients with chronic RA.

Although cognitive therapy is important in pain management in chronic disease, there is very little evidence to confirm the success of this method in patients with comorbid psychological disorders. In conclusion, based on the research published, CBT is one of the best treatments for long-term pain management.

  • Physiotherapy

 Have you ever thought, other than the medications, physiotherapy can be a great help for your life support if you have rheumatoid arthritis? This is evidence, that physiotherapy and rehabilitation therapy has a significant impact on improving medications.

  • Physiotherapy – Heat/cold applications, electrical stimulation, and hydrotherapy, etc.
  • Rehabilitation programs – joint protection strategies, massage, exercise, and even patient education.
  • Diet

Do you think your diet has a significant impact on the development and management of your condition? Well, it is. It has been proven that your regular diet can help to combat the disease.

Small changes have a big impact, to clarify if you make small changes in your regular food habits, you can increase the effectiveness of your medicines also. According to scientific research, maintaining a healthy weight is vital. Dietary intake of Vitamin D and omega-3 fatty acids with the DMARD treatment may produce better results in patients with early RA. This is research-based and also it says folate acid intake may not significantly affect to make results worsen or better with medications, especially with methotrexate (MTX).

Instead of taking the usual menu, you can have some small changes in your regular meal. Make it more delicious not only to eat but also to increase the effect of medicine as well.

  1. Eat more oily fish
  2. Take iron-rich foods
  3. Supplements, especially vitamin D
  4. Avoid foods that you tolerate
  5. Eat calcium-rich foods

Most importantly, you have to discuss those changes in your diet with your healthcare provider, since all should match along with your medication.

  • Herbal and ayurvedic methods

Various alternative remedies can be used for the management of RA symptoms.

These are essential oils, meditation, aromatherapy, exercise, deep breath practice, massage, and biofeedback.

Also in Chinese medicine, acupuncture is used to relieve pain.

Are there any new treatments for rheumatoid arthritis?

 Janus Kinase (JAK) Inhibitors are one of the novel treatments for RA. These can be taken orally and widely available. These are small molecule drugs that are used to relieve pain. There are three market available products, all FDA (Food and Drug Administration) approved.

  1. Tofacitinib
  2. Baricitinib
  3. Upadacitinib

 There are four members of the JAK family, all are tyrosine receptor kinases, in general enzymes. JAK enzymes work on cytokine receptors and start an immune response. Inhibiting those enzymes ultimately leads to the inhibition of unwanted immune responses.

Bruton’s tyrosine kinase (BTK) inhibitors are another new oral medication still under clinical trials. BTK is a tyrosine kinase enzyme. It is an important modulator in myeloid cell activity and B cell proliferation. In the early stages, these were considered effective medications for RA. However, by now this is still under clinical trials for evaluating safety and efficacy. ex: Fenebrutinib

Stem cell therapy is another novel treatment to reduce inflammation in the synovium and increase healthy cells. This is still not standard practice because of identified side effects. Stem cells are cells that can convert into different cell types. Mesenchymal stem cells (MSCs) can develop themselves into cartilage and bone cells. Using MSCs in synovial membranes helps to reduce inflammation. However, the FDA still does not approve this therapy due to its inconsistent results.

Precision medicine(PM) means a highly individualized tailored medication plan used for patient management. PM increases its involvement in the treatment since it can provide better management by using unique molecular characteristics. This will be another technology that comes into success shortly.

What are the best foods to improve your condition?

As you know, food cannot cure the disease, but it has some impact on reducing inflammation of the synovium. So, following healthy food habits will help you to improve your life even with RA. For this reason,

  • Fatty fish Salmon, Tuna, herrings, and other cold-water fish contain omega-3 fatty acids(FA). You need to take more omega- 3 FA, but less omega-6 FA. Because researchers have found that omega-6 can induce inflammation. So, be aware of your meal.
  • Vegetables and fruits – these contain antioxidants that help to prevent the formation of free radicals. In addition, they are rich in several vitamins and minerals. These nutrients are essential to keep you healthy. So, taking multicolored veggies and fruits will nourish your body and reduce inflammation.
  • Peas and beans – Rich sources of protein, which is extremely essential for muscle repair.
  • Nuts – Nuts such as almonds, hazelnuts, Walnuts, Pistachio are rich in healthy monounsaturated fatty acids, especially omega-3.
  • Whole grains – Oats, whole wheat, brown rice can reduce the risk of heart disease which occurs in arthritis patients. Whole grains contain much higher amounts of fiber and nutrients than refined grains.
  • Broccoli – Full of vitamin A, C, K and rich in calcium which is essential for bone health.
  • Green tea – contains polyphenols, which are antioxidants. These may reduce inflammation and slow cartilage destruction.
  • Cherries – contains antioxidants to reduce inflammation.
  • Citrus fruits etc.

What foods should you avoid?

Some foods can induce inflammation and eventually worsen the condition. Therefore, you should avoid those pro-inflammatory foods.

  • Sugar – Sugar metabolization produces cytokines that induce inflammatory conditions. Soda, canned juices, beverages with high sugar content, pastries, etc should be taken occasionally. Otherwise, it will be a danger to your health.
  • Alcohol – excessive usage of alcohol causes liver dysfunction. This leads to poor interaction between other organs and finally causes inflamed tissues. The best action is to stop taking alcohol or moderate consumption.
  • Fried, grilled, or broiled meat – meat cooked to high temperature, produces high contents of advanced glycation end products (AGEP), which generates inflammation and tissue damage.
  • Fatty foods with high omega-6 FA content – Margarine, vegetable oils are foods rich with trans fatty acids, cause obesity and ultimately be a risk factor for rheumatoid arthritis. Likewise, they also increase bad cholesterol in the blood and reduce the good cholesterol. Omega- 6 fatty acids can increase the production of pro-inflammatory chemicals.
  • Gluten – If you are allergic to gluten, it is better to avoid foods with gluten. They are found in wheat, barley, and rye, etc. Gluten is likely to start an autoimmune reaction and sometimes produce joint pain, so if you stop taking those foods, you’ll feel much better.
  • Monosodium glutamate – This chemical can induce important pathways that lead to inflammation. MSG is mostly used in Asian foods, prepared soup and soup mixes, soy sauce, and many fast foods used as a flavor enhancer.

How to prevent Arthritis?

 Despite this being a non-curable disease, a lot of studies are going on to find a prevention method. In asymptomatic risk individuals, several prevention methods have been tested, because they have some time to identify the development of the disease. In addition, if you can prevent exposure to triggering factors, that is also effective. If you smoke, quit smoking, reduce alcohol and have a healthy meal and weight are some of them. Keep your gums healthy – New studies indicate the importance of oral health in prevention. That is because there is a connection between periodontal(gum) disease.

How to live a sustainable life with rheumatoid arthritis?

       In summary, the most important question is how can you make your life better, even with this chronic disease. Well, many people have proved, if you set your mindset to accept this and adapt to smaller but effective changes, you can achieve it.

These are some of the steps you can easily follow up.

  1. Take your medication correctly
  2. Adapt to a better pain management routine
  3. Connect with your healthcare provider and get knowledge about the disease
  4. Having a healthy meal
  5. Avoid smoking and alcohol
  6. Focus on what you can enjoy
  7. Talk to a support group with the same experience – this will increase your confidence and boost your energy to fight the disease. Because it increases your mental health.
  8. Exercise – this can be problematic when you are in serious pain, but still, you can follow some exercises. Discuss with experts, they will help you to choose the best plan for you.

Everything considered, Rheumatoid Arthritis is an incurable chronic disease at this moment. It is a challenge, but, as discussed before, you can still make your life happier if you follow up with better management of the disease.

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