RA is an autoimmune disease of unknown origin that affects 1% to 2% of the population worldwide, with females having a three-to-one incidence to males. It may occur at any age, but the onset commonly occurs between the third and sixth decade of life, increasing after the sixth decade. After the age of 65, it is known as “elderly onset RA”.
- Risk Factors: female gender, older age, family history, environmental influences (diet, geographic location), nulliparity, smoking, and obesity.
Pathophysiology
RA’s mechanism of action is unknown. Evidence points to a genetic predisposition and the development of immunologically mediated joint inflammation. The RA inflammatory process has been implicated in other disease processes e.g. arteriosclerosis, and it is hypothesized that RA process somehow interferes with the production of HDL cholesterol, which is responsible for decreasing cellular lipids, and is therefore antiatherosclerotic. 2. An autoimmune reaction occurs in the synovial tissue. The RA synovium breaks down collagen, causing edema, proliferation of the synovial membrane, and ultimately pannus formation. 3. Pannus destroys cartilage and erodes the bone. The consequence is the loss of articular surfaces and joint motion. 4. Muscle fibers undergo degenerative changes. Tendon and ligament elasticity and contractile power are lost.
Clinical Manifestations
The initial clinical manifestations of RA include symmetric joint pain and morning joint stiffness lasting longer than 1 hour.
- Even early in the course of the disease, functional limitation may be present where joints are actively inflamed. Joints that are hot, swollen, and painful are not easily moved. Immobilization in response to functional limitations may, over time, result in contractures and soft tissue deformity.
- Characteristically, the pattern of joint involvement begins in the small joints of the hands, wrists, and feet, which then progresses to knees, shoulders, hips, elbows, ankles, cervical spine, and temporomandibular joints.
- Over the course of the disease, clinical manifestations begin to vary, but classic symptoms include symmetric or bilateral joint pain, swelling, warmth, erythema, and lack of function.
- Palpation of the joints reveal spongy or boggy tissue. Often, fluid can be aspirated from the inflamed joint.
- Deformities of the hands and feet are common in RA. The deformity may be caused by misalignment resulting from swelling, progressive joint destruction, or the subluxation that occurs when one bone slips over another and eliminates the joint space.
- RA features extra-articular manifestations, most common of which are fever, weight loss, fatigue, anemia, lymph node enlargement, and Raynaud’s phenomenon. Others include arteritis, neuropathy, pericarditis, splenomegaly, and Sjögren’s syndrome (dry eyes and dry mucous membranes).
- Rheumatoid nodules are common in patients with advanced RA, only in those who have the rheumatoid factor. These nodules are usually non-tender and movable in the subcutaneous tissue, usually appearing over bony prominences such as the elbow. They vary in size and can disappear spontaneously, or progress to ulceration.
Diagnostic Examination
Rheumatoid nodules, joint inflammation detected on palpation, and certain laboratory findings are associated with RA. Assessment findings are often documented with a disease activity score, useful in evaluation of the disease, and guiding/monitoring treatment.
- History and physical examination focuses on manifestations such as bilateral and symmetric stiffness, tenderness, swelling, and temperature changes in the joints.
- Extra-articular symptoms are also tested, including weight loss, sensory changes, lymph node enlargement, and fatigue.
- Rheumatoid factor is present in many patients with RA, but its presence alone is not diagnostic of RA, nor does its absence rule out RA.
- Cyclic Citrullinated Peptide Antibodies (Anti-CCP) have a 95% sensitivity in detecting RA.
- In acute phases of RA, ESR and CRP tend to be significantly elevated, making them useful in monitoring active disease and its progression. A CBC during initiation of treatment is used as baseline data. Anemia and elevated platelet counts may be noted.
- Rule out TB (tuberculin skin test), Hep. B, and Hep. C which all may impact treatment if present.
- Liver and Kidney function is evaluated for DMARD therapy, as it may increase liver enzymes and affect kidney function.
Medical Management
In all phases of RA, the main goal is to decrease joint pain and swelling, achieve clinical remission, decrease the likelihood of joint deformity, and minimize disability. Aggressive and early treatment regimens are warranted. The use of a targeted pharmacologic treatment strategy is recommended.
- Early Rheumatoid Arthritis: treatment with a nonbiologic or biologic disease-modifiyng antirheumatic drugs (DMARDs), with the goal of preventing inflammation and joint damage. It is recommended to start with nonbiologic DMARDs. Methotrexate is preferred, but leflunomide, sulfasalazine, or hydroxychloroquine are also used. Tofacitinibic within 3 months of disease onset may also be used.
- Biologic DMARDs are specifically engineered to target the most proinflammatory mediators in RA: TNF-alpha, B cells, T cells, IL-1, and IL-6. These work better, but are more expensive. They are reserved for patients with persistent moderate to severe RA who have not responded to synthetic DMARDs.
- Routine liver and kidney function tests are performed, along with CBCs for anemia. Dosage may need to be modified if renal impairment occurs.
- DMARD treatment often produces relief within 6 weeks, but may take longer. Corticosteroids can act as a temporary “bridge” in treatment.
- Janus Kinase (JAK) Inhibitors, which suppress cytokine production (therefore the immune response), is a new type of drug used in conjunction with synthetic DMARDs, but may be used as monotherapy.
- Analgesia and anti-inflammatory agents are used for pain and inflammation relief. The patient should know that these drugs are only symptomatic and do not modify the disease process.
- NSAIDs such as ibuprofen and naproxen are cheap and commonly prescribed, but are used with caution due to the risk of gastric ulcers when used long-term.
- Some types of Cyclo-oxygenase-2 (COX-2) Enzyme Blockers have been approved for RA treatment. They block COX-2 which is involved in inflammation, but preserves COX-1, which protects the stomach lining, decreasing risks for gastric ulcers. However, they are associated with cardiovascular disease and therefore must be used with caution.
- Opioid analgesics may be used for periods of extreme pain. They are avoided because of the continuing need for pain relief.
- Relaxation techniques, Heat and cold applications, and other pain management techniques are taught.
- Established Rheumatoid Arthritis: a formal program of occupational and physical therapy is prescribed, teaching the patient about principles of pacing activities, work simplification, range of motion, and muscle-strengthening exercises. The patient is encouraged to participate actively.
- Medication programs are reevaluated periodically. Additional agents may be added to enhance disease-modifying effects of methotrexate. Combination therapy using one synthetic and one biologic DMARD is common.
- Reconstructive surgery is indicated when pain cannot be relieved by conservative measures. These can involve synovectomy, tenorrhaphy, arthrodesis, surgical repair, and joint replacement.
- Corticosteroids (systemic) are used when inflammation is unremitting and pain, or needs a “bridging” medication while waiting for slower DMARDs to take effect. Low-dose corticosteroid therapy is prescribed for as short as possible to minimize its side effects. Single large joints with severe inflammation that is unresponsive may be treated with a local injection of a corticosteroid.
- Topical analgesic agents (capsaicin, methylsalicylate) are often prescribed. Topical diclofenac sodium gel may help with joint pain in the hands and knees. Educate the patient on the use of topical medications i.e. avoid open areas of skin, eyes, and mucous membranes, and wash hands after application.
- Depressive symptoms and sleep deprivation may occur with RA from its emotional and potential financial burden. Low-dose antidepressant medicines (amitriptyline, paroxetine, sertraline) can be used to reestablish adequate sleep patterns and manage depressive symptoms. Referrals for talk therapy or group support may be useful.
- Obesity is a prevalent issue, worsening disease progression, function, and quality of life. Certain medications (e.g. corticosteroids) increase appetite, and with the decreased activity of RA, lead to weight gain. A dietician can counsel the patient about better food choices.
Nursing Management
Pain, sleep disturbance, fatigue, altered mood, and limited mobility are the most common issues of patients with RA.
- Pain: comfort measures (hear or cold, massage, positioning, rest, bedding, relaxation techniques, diversional activities), pharmacologic management (analgesia, anti-inflammatory, antirheumatics)
- Fatigue: education, development of appropriate activity/rest scheduling, encourage adherence, refer to and encourage a conditioning program, and an adequate nutrition.
- Impaired Mobility: encourage verbalization of limitations; assess the need for occupational or physical therapy. Assist the patient in identifying and modifying environmental barriers, and encourage independent mobility.
- Patients with newly diagnosed RA needs information about the disease to make daily self-management decisions and cope with having a chronic disease.
Many RA patients are old adults or elderly, and many exhibit comorbidities e.g. cardiovascular disease. Monitor for complications related to comorbidities and medications used to treat RA. Educate the patient on the detection of the adverse side effects of their medications. Medications may need to be stopped or lessened. Nurse counseling for symptom management and any new medications may relieve potential anxiety and distress.