Rheumatoid Arthritis and Lupus

Approximately 1.3 million individuals in the US, and 23 million worldwide have rheumatoid arthritis. Keep reading to learn more about the symptoms, diagnosis and treatment of this autoimmune disease that overlaps with lupus.

Introduction

Rheumatoid arthritis (RA) is a chronic inflammatory condition and autoimmune disorder that generally affects the lining of the joints of the hands and feet. RA causes painful swelling that can eventually lead to deformity and erosion of joints and bones. It is often confused with osteoarthritis, which is damage that occurs when the protective cartilage in the joint wears down over time. Like many other autoimmune disorders, such as lupus, RA occurs when the immune system attacks healthy cells and tissues. This abnormal immune response can lead to damage of other organs and systems of the body including skin, eyes, lungs and in the circulatory system.

RA typically moves from smaller, minor joints to larger, major joints. Early signs of RA can be found within the hands and feet, but eventually RA can move into ankles, elbows, knees, hips and shoulders. Like other chronic autoimmune conditions, symptoms may flare and then fade away or disappear altogether. The severity of RA fluctuates widely from person to person, and the inconsistency of symptoms may delay a proper diagnosis.

Symptoms of Rheumatoid Arthritis

Here are the main symptoms of RA:

  • rheumatoid nodules (hard bumps of tissue under the skin along the arms);
  • joint inflammation, including pain, swelling, redness, warmth and tenderness;
  • joint stiffness and bone fatigue;
  • overall fatigue, fever and weight loss; and
  • tendon, muscle, ligament stiffness and pain.

Other, perhaps less common, symptoms that might seem unrelated to RA, but may pose a serious threat include:

  • shortness of breath;
  • numbness or tingling in the hands or feet;
  • inability to move hands or feet;
  • spots on or around the fingertips;
  • high fever or other signs of infections;
  • redness or irritation of the eyes;
  • suddenly bruising easily; and
  • digestion issues or upset stomach.

If anyone is experiencing any of the above symptoms or anything else out of the norm, please consult a healthcare practitioner immediately.

Causes of Rheumatoid Arthritis

The causes of RA is currently unknown, however, there is a very active and on-going research to determine a root cause.

As part of the National Institute of Arthritis and Musculoskeletal and Skin Diseases, the Accelerating Medicine Partnership (AMP) has been assembled to address the needs and challenges for clinicians and researchers of both RA and lupus through its AMP RA/SLE Program. According to their webpage, the AMP program “fosters an enhanced systems-level understanding of gene expression and signaling in target tissues from affected end organs…and blood cells.” The research conducted through this program will hopefully lead to the discovery of the causes of RA and lupus as well as lead to a better overall understanding of both diseases.

Currently, researchers suspect that the following may put certain individuals at risk for developing RA:

  • Environmental factors: Scientists have reported that there is an increase in the risk of developing RA from:
    • smoking tobacco;
    • exposure to the mineral silica that floats in the air as dust when certain building materials are cut or ground (asphalt, brick, cement, concrete, drywall, grout, mortar, stone, sand, and tile); and
    • chronic periodontal disease – inflammation affecting the bone and tissues of the teeth).
  • Heredity: It is believed that the tendency to develop RA may be inherited genetically. Certain genes have been identified that increase the risk for rheumatoid arthritis including 101 novel RA risk loci – fixed positions where specific markers are located on chromosomes. Discoveries like these may lead to the development of more targeted treatments.
  • Other autoimmune diseases: Individuals who have a pre-existing autoimmune disease may be susceptible to developing more. Lupus, for example, shares similar genetic loci to RA, as researchers of a 2011 study found. These loci include the markers BLK and UBE2L3 and may explain the common overlap between the two diseases.

Although infectious agents such as bacteria, viruses, and fungi have long been suspected, none has been proven as a cause of RA.

Diagnosing Rheumatoid Arthritis

RA can be difficult to diagnose in its early stages as it can mimic many other conditions. As with lupus, there is no single test that can determine a diagnosis of RA. A healthcare practitioner will typically use several tests and criteria below to diagnose RA:

  • Physical Exam: A healthcare practitioner will check reflexes, muscle strength and examine joints for swelling, redness and warmth – localized inflammation.
  • Blood tests: Tests may be ordered to check for overall inflammatory activity in the body. Individuals with RA tend to have an elevated erythrocyte sedimentation rate (ESR, or “sed rate”), which can be seen in a blood test. Other common blood tests look for a rheumatoid factor and anti-cyclic citrullinated peptide (anti-CCP) antibodies.
  • X-rays: X-rays may be taken to help track the progression of RA in joints over time.

Diagnostic Criteria

In 2010, the American College of Rheumatology in partnership with the European League Against Rheumatism (EULAR) defined the following criteria for the diagnosis of RA:

 

SymptomScore
Target population (Who should be tested?): Patients who:

 

1)    Have at least 1 joint with definite synovitis (swelling)

2)    With the synovitis not better explained by another disease

 

Classification criteria for RA (score-based algorithm: add score of categories A-D; a score of ≥6/10 is needed for classification of a patient as having definite RA)

A.    Joint involvement
1 large joint0
2-10 large joints1
1-3 small joints (with or without involvement of large joints)2
4-10 small joints (with or without involvement of large joints)3
≥10 joints (at least 1 small joint)5
B.    Serology (at least 1 test result is needed for classification)
Negative RF and negative ACPA0
Low-positive RF or low-positive ACPA2
High-positive RF or high-positive ACPA3
C.     Acute-phase reactants (at least 1 test result is needed for classification)
Normal CRP and normal ESR0
Abnormal CRP or abnormal ESR1
D.    Duration symptoms
<6 weeks0
≥6 weeks1

 

If an individual’s score is lower than 6, they will be closely monitored and retested as needed. There could potentially be worse outcomes, however, if a healthcare practitioner waits until all of the these criteria are met making it imperative to visit a practitioner regularly if there are medical concerns or symptoms that are out of the ordinary. It is important to report ALL symptoms to a practitioner, not just RA symptoms. Keeping a journal may help to track all the symptoms experienced and what may have triggered them.

Treating Rheumatoid Arthritis

As with lupus, a rheumatologist treats RA.

Since, for now, there is no cure, the main goal of treatment for RA is to maximize joint function, reduce inflammation and pain in the joints, and prevent further damage and deformity in the joints. Receiving early medical intervention is key to improving outcomes and the quality of life for individuals with RA, and the patient should be monitored on a regular basis through physical exams and blood tests. Treatment plans may be changed, medication dosages may be adjusted, or new medications might be added, based on the findings of these tests. There are a number of medications available to help ease symptoms, reduce inflammation, and slow the progression of the disease. No single drug works for everyone, but many people find treatments that are very effective.

The ideal treatment for RA will be comprehensive and involve a combination of therapies.

Drug treatment therapy may include:

  • over-the-counter pain treatments, including non-steroidal anti-inflammatory drugs (NSAIDs), ibuprofen (Advil) and/or naproxen (Aleve);
  • COX-2 inhibitors such as celecoxib (Celebrex);
  • disease-modifying antirheumatic drugs (DMARDs) including methotrexate, sulfasalazine and leflunomide;
  • anti-malarials such as hydroxychloroquine (Plaquenil);
  • corticosteroids such as prednisone which are often prescribed in combination with methotrexate; and
  • biologics including adalimumab, rituximab, infliximab, abatacept and tocilizumab.

In 2015, the ACR developed treatment criteria that include the above to assist healthcare practitioners and facilitate discussion and cooperation between practitioners and the individuals they treat. The ACR stresses that they are not “rules” to govern what should be prescribed, but instead, act as a guideline, and they should be based on an individual’s current level of disease activity.

A better understanding of the biological mechanisms that cause RA will help in the development of new drug treatments. Future therapies may specifically target T-cells and B-cells – cells that are responsible for the immune response. These therapies may even be used to prevent the onset of RA.

Other treatments or lifestyle changes may include:

  • getting plenty of rest;
  • joint and muscle strengthening exercises and therapy;
  • joint protection;
  • assistive devices (canes, railings, adapters for making utensils easier to hold, etc.) to assist with limited mobility and pain; and
  • educating individuals with RA and their support system about the disease.

Surgical repair may be considered if medications and other treatments fail to prevent or slow damage to the joints. This option can reduce pain, correct deformities and help restore the ability to move the affected joint(s). However, surgery carries inherent risks, and smaller joints can be very difficult to repair.  So, it is important to discuss the benefits and risks with your healthcare practitioner.

Alternative or complementary treatments can also help relieve the pain and discomfort from RA and other autoimmune diseases. These include:

  • acupuncture;
  • Tai Chi, yoga, and water aerobics;
  • physical and occupational therapy;
  • supplements including: flaxseed, fish oil, boswellia extract and turmeric;
  • an anti-inflammatory diet or paleo diet; and
  • essential oils and even CBD

No matter what treatment plan is prescribed, it is very important to have clear and open communication and cooperation with healthcare practitioners in order to receive the best possible outcome. It is always imperative, therefore, to discuss all alternative or complementary treatments with a healthcare practitioner so they can evaluate an individual’s current health status and to make sure there are no contraindications with a currently prescribed treatment plan.

Rheumatoid Arthritis as an Overlap Disease of Lupus

RA is a very common overlap disease of lupus. Some of the symptoms of RA are actually the same as lupus such as stiffness and joint pain.

  1. Shah, Chengappa K.G. and Vir Singh Negi found that approximately 90% of individuals with lupus have symptoms of arthritis on disease onset and that 34% actually develop arthritis. When an individual has RA and lupus, the overlap condition is sometimes referred to as “rhupus.” These researchers also found that when an individual has both diseases, lupus disease activity is often lower and that these individuals also report having fewer occurrences of “malar rash, autoimmune hemolytic anemia, neuropsychiatric lupus, and lupus nephritis” as well as less of a risk of incurring organ damage. It was also noted that individuals with both RA and lupus have more anticyclic citrullinated peptide antibodies (ACPA) which may lead to the development of more “erosive-deforming” arthritis.

In Conclusion

Rheumatoid arthritis is one of the most common autoimmune diseases and an important overlap disease for those living with lupus to understand.  It can be a debilitating disease, but the pain and disability can be managed with medications, and there is an increasing number of treatments being used with success.  Just remember that, as with most chronic, autoimmune disorders, mental wellbeing and a positive outlook are also critically important. Joining support groups or seeking professional help might make navigating the difficult times easier, and it really can help to know that others are going through similar challenges.

 

References
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Author:  The KFL Team

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