From where do our policy-makers get their wacky ideas?
From where do our policymakers get their ideas, inspirations and aspirations and why are they sleeping behind the Wheel?
What and who influences their thinking and creative minds?
Not to be nitpicky, but shouldn’t our policymakers and community leaders be up in arms with Agribusiness companies from China and the western world? They are very busy exporting disease-induced GM food and chemically –saturated foods to Ghanaian consumers so as to increase chronic diseases like obesity, diabetes and cardiovascular ailments. Where is the outcry and who is educating the public against the consumption of unhealthy food from our food chain?
Can our fragile National Health Insurance scheme be able to confront a rising tide of chronic diseases that are linked to unhealthy diet like the food we consume every day in the west? It’s a fact; the chronic diseases we experience in the western world are undoubtedly linked to poor diet that we consume wantonly. Ironically, it’s the same food we are embracing wholeheartedly in Ghana under the watchful eyes of our sleepy policymakers whilst they’re trying to fund a stable and economically viable national health Insurance care for the citizenry.
Where is the national uproar from our policymakers , leaders and parents when two-hundred thousand of our JSS graduates who took the BECE are left to fend for themselves and perhaps are sentenced to a life of mediocrity? Who is going to mine our impending, infant oil industries when our future work force is forced to end its education abruptly?
Few weeks ago, it was in the news that our security agencies were “urged to identify the emerging threats to the nation for the government to deal with expeditiously”. I beg your pardon? What is more threatening to a nation than its two-hundred thousand students---with potential to lift the country up to its glory ----being left on the way side of education and a bright future? What is more threatening to a nation than a country with fertile land embracing GM food, and without the medical strength to withstand its fallout? Hello!
When are our leaders and policymakers going to search for ideas and solutions to develop proper directions to take our nation and society forward?
Jim Rohn, an American renowned motivational speaker once said: “If you can tell me the books you read and how many times you read, friends you hang around with and what they do for a living, how many hours you spend in front of a television and what you watch, I can pretty much tell you how your bank account looks.” He goes on to say he can tell a person’s bank account by the size of one’s personal library and how one manages his time. He added, “People with small bank account tend to have big television sets and spend their time unprofitably”. In our case it will be the ownership of DVDs and the amount of time we spend on the cellphones and at funeral celebrations that are our Achilles heels.
In a layman’s term what he was trying to say is that we end up pretty much where we expect to be—what we think of the most is what we become. Therefore if we continue doing what we have been doing, we will continue to get exactly the same results. To get stimulated and stretched our minds we need to associate with people and things that can help us think of new ideas and new ways of doing things. How we think determines how we act and tackle issues. I wonder what our policymakers are thinking of when it comes to lifting up those in need.
My inquiring mind wants to know.
Question: With no disrespect, what are the titles of the last five books our leaders read this year? What kind of books and how many books do our politicians, policy makers, community leaderships, chiefs, Assembly men and women and head of institutions read? Who wants to take me up on this one? And, if they don’t read where do they get their inspirations and aspirations from? What is the source of their ideas or inspirations, apart what they get from churches and other religious institutions---which always go out of the window? Or do they just go with the flow, so to speak? My inquiring mind wants to know!
Speaking of leaders, what about the role of heads of our traditional kingdoms? Since they still retain some amount of economic and social influence within the country, they need to sharpen their creativity skills to meet our modern day needs.
How often do our policymakers, teachers, community- leaders and politicians try to be in solitude, mentally or physically? Do they go to bed wondering how best to improve the lives of the ordinary folks under their care or in their constituencies or communities? I wonder what kinds of books they read and how often and what influences their thinking. Finding answers to these and other questions will help us to understand why things are what they are in our part of the world. These questions will also help us to lower our expectations, so as not to be disappointed.
This is not to question one’s leadership prowess and policymaking process. Neither am I trying to belittle our leaders’ competency and ability to do their job---yeah, right! I’m trying to put it very diplomatically and delicately. However, the unnatural decision -making process does not meet our expectations and future goals. The inability of some of our leaders in our communities and districts to solve our basic human problems has forced me to question their sources of ideas and inspirations. Their inability to be creative and think- outside- the- box makes me wonder as to what they do with their spare time and if they see the need to hone their “creative skills”.
This has nothing to do with traditional education because traditional academia only value things that can be quantified and measured. How can we quantify or measure one’s ability to understand or encourage others to live up to their expectations or potential? How do we measure one’s courage to tell the voters the truth they don’t want to hear? How do we measure one’s ability to seek out innovative ways to bring new methods to inspire people and see opportunities where others see obstacles?
How could traditional education alone help one to recognize that every change cracks open the door for opportunity? Or accept full responsibility for his results, rather than expect to be compensated for time alone? How can we encourage others to see the future with optimism, hope, boldness, enthusiasm, and the confidence that can come only from having faith in what may not yet be reality?
How can we measure one’s ability to go against the conventional wisdom, just by showing an academic degree? The Ghanaian traditional education can not do all that. So we need other sources for ideas and inspiration through mental or physical confinement and training.
Being able to have time to confer with oneself helps one to learn a simple technique for seeing things in new ways and stretching one’s thinking. It helps one to approach the usual in an unusual way, which can ultimately lead to new solutions.
Could it be that our leaders don’t easily come up with earth-shaking ideas because they don’t create the right ecology where ideas can be germinated? Or it could be that they‘re afraid to be “Alone”, figuratively? Many of our leaders and policymakers fail to tap their creative leadership power because they confer with everybody and everything else but themselves. Yes, we all know a few individuals who fit into this mode. You know one, don’t you? He’s the fellow who goes to great lengths not to be alone. He feels a compelling need to talk with others every waking moment. He also has an unusual appetite for a huge diet of small talk and gossip.
But, for us to solve our emerging problems our leaders and policymakers and ordinary folks need to have time out to confer with them in order to come up with uplifting ideas and solutions. It will unleash their creativity because what they would encounter each day they confer with themselves without distractions and interruptions may present opportunities for a solution that would be the seed for an idea.
If water shortage is a problem in our communities what are our solutions? If our children are failing academically, what are our solutions? If our towns lack after-schools programs for our kids what are our solutions?
Being in a managed solitude is a leadership tool that every great leader needs and uses in order to map out his or her vision and implement goals. Check the lives of the world’s great religious, social and political leaders. In the past and present, each one of them spent a great amount of time alone—in a managed solitude; voluntarily or coercively.
In managed mental solitude moments our subconscious minds tap our memory bank, which in turn feeds our conscious minds. Great thinkers use solitude to put the pieces of a problem together, to work out solutions, to plan, and, in the “super-thinking”.
From Moses to Buddha to Martin Luther King Jr to Mahatma Gandhi, from Mohammed to Mandela to Kwame Nkrumah and many others, they spent time in jail or in some form of physical or mental confinement where they ironically planned their future moves without any distraction. Lech Walesa, former President of Poland and Solidarity leader was imprisoned before he became a President.
In fact ordinary writers and artists like the late Fela Kuti and Bob Marley were once in self-induced mental or physical confinement in order to hone their mental skills. As a result, these people developed unique skills from being in “solitude confinement”: They used these skills in every endeavor they embarked on.
The people who change history are not the people who do safe things, take the easy route, follow the status quo, say what everyone else says, or try to make everyone happy. They are also not afraid to be “alone”. Do you remember Gandhi, Mandela, Martin Luther Kings Jr and even Jesus? They were all on the “edge.” They could not have lived in the middle of the storm without developing mental solitude.
When I say a “solitary confinement” I mean being mentally or physically alone—without TV, cellphones, friends and anything that will take away your thinking process. By being solitude means to take a week off and confer with you: E.g. spend an hour in the park, turn off the television, cellphone and computer—carve out time for mental restoration. Does that mean one has to be imprisoned or isolated to have impact on the society and history?
Absolutely not. No one claims that being locked up and tortured is great training for being a great leader, or making one more in tune with the needs of one’s community or constituency. But, it’s believed that being in managed seclusion is highly relevant to building leadership skills and strong mental faculties because it allows one to be creative.
The I-can’t-stand- being -alone syndrome shuns independent thought and clouds visions. Decisions and mental observations made alone in managed solitude have an uncanny way of being right most of the time.
Let’s face it, the main job of a good leader is “thinking” and the best preparation for an effective leader is thinking. That is why there is a need for our leaders to be in a managed solitude. Leaders need “quiet places” to generate creative ideas. The spaces between minutes one spends allow solutions and ideas to incubate and grow. That is why great geniuses sometimes accomplish more when they are alone.
Being in a managed confinement mentally or physically allows people to confer with themselves. It also allows people to read good, creativity generating books or brain- storm and develops a positive insight that will reveal a pathway for fairness, integrity, service and humane principles that give them security to adapt to change and take advantage of the opportunities that changes created.
Being in a solitude helps to purge one’s thoughts of pride and superficiality and to expand one’s horizons. The purpose of being in solitude or managed confinement is to repair all that which is faulty in one’s personality and thoughts. It’s a way of learning a lesson and making one more thoughtful and sensitive to others’ needs.
But, what lesson could compensate a person like Mandela for a life spent behind bars? Well, without a doubt Mandela’s imprisonment deepened and enlarged his soul and thought by teaching him to be more compassionate and less privileged. He came out of prison totally different---a person with a lot of power before he went in. The power of ideas comes through thinking and thinking comes alive and powerful from being in solitude.
How many hours do our leaders, policymakers and community leaderships spend on researching and reading about issues and the jobs they were hired or elected for? How much time do our politicians spend attending the needs of their constituencies?
As a chief of your town how much time do you actually spend on one –on-one with your subjects or the ordinary people in your town? How many DVDs do you have as compared to the number of books? As a District Chief Executive or an MP how often do you change your car when you visit your district? After only seven months in office you probably weigh more than when you were elected. Be honest, don’t cheat on this one. What is your source of ideas, if any?
In a country like ours where one’s family or where one is born dictates one’s life outcome, the government needs to play a meaningful role not only in shaping one’s future but in equalizing the playing field. That is why our policymakers should be very creative and sensitive to the needs of the people.
In a broader sense we need a visionary and inclusive leadership at the helm of our institutions –from chieftaincy to presidency. Our leaders should be alone to challenge the status quo and focus less on what Ghana is and more on how it ought to be. Trust me, a good many things are not as they ought to be in our part of the world. Yes, there is a tendency to become overwhelmed by the challenge of trying to fix things. But, we should focus on the possibilities—the endless possibilities within us.
With that I’m proposing the institutionalization of ”Think Week”: This is a time set aside for our policy makers, especially MPs and District Executives , to spend time alone to do their serious, creative thinking. Why not? Microsoft and other Fortune 500 companies do it, as well as every CEO. Perhaps if our leaders learn how to be in mental confinement and be creative, maybe, one day we can address the huge disparity and egregious inequality that exists between our living standards and the developed world.
By the way, leadership is not just the possession of vision and ability to think. It’s has more to do with putting a “system” in place that works for the benefit of the people it’s intended for. A remarkable leader creates not necessarily an earth-shaking idea, but a system which can out live him.
Take our energy situation. We always have electricity interruption in the dry season, when the rainfall doesn’t empty into the barrels of Akosombo Dam. We have been living with such inconveniences but no comprehensive solution has been given other than building more dams that depend on rainfall---instead of pursuing vigorously other alternative energy like natural gas, wind and solar stations across the land. We can even revitalize the rural Ghana with solar panels .What about harvesting our water resources?
On an individual level, there is enough blame to go around. Ghana didn’t get to this juncture by accident. It’s like all the social and economic problems, along with lack of integrity and laziness just sneaked into the country at night when everyone was asleep. Surprise! We can blame our plights on colonization and other forces all we want until the Kingdom come. But, it should be remembered that our plight is more internal than external. Everything that happens to us is largely of our own making. It’s a choice we make!!
These choices, of course, are not single monumental ones. No nation decides, for example, to become poor so that it could go panhandle for money around the globe, or sleep in darkness or scramble for water in the dry season.
Do we try something new, or stick to the tried –and-true? Do we take risk as a nation? Do we indulge our hearts or cater to our fears? Do we do what‘s comfortable? For the most part, we often tend to choose comfortable and familiar, the well-worn but well-known.
Yes, there are some conditions we have no control of like climate. However, whining about uncontrollable conditions won’t get us any where. Is our creativity just to design a way to cheat the system, government or our fellowmen or women all that we can do?
This reminds me of a story about a New Year’s Eve village party. You may have heard it. It’s about a village that was planning a grand New Year’s Eve celebration. Every member of the village was required to bring a bottle of wine and pour it into a huge plastic container, in the middle of the village.
At New Year’s Eve, everyone would share a drink from the container—to celebrate the New Year. To make a long story short, a lot of people came from afar and near to empty their personal bottles into the container and were instructed to wait for mid- night to drink. As their culture dictates, the chief opened the valves and invited the people to join him for celebration. Whoops. Not too fast!
Something unusual happened. Every glass they raised contained water instead of wine. Another Whoop! One thing was obvious .Apparently, everyone in the village had the same wacky idea: “If all my neighbors bring great wine, no one will notice if I just slip in a bottle of water.” “Oh, heck my little bit of deception won’t be too bad to spoil the New Year’s fun” .So they thought. Does that ring a bell?
Unfortunately that behavior plays out in our work situation and everyday life in Ghana. We believe “cheating” the system a little won’t make a big difference. It has a dignified name.
The good old Stealing or duping which is euphemistically called “connection” is practiced with impunity by almost every Ghanaian. But, what if as a mechanic your slacking off to fix the government buses’ brakes resulted in an accident, which unfortunately and coincidentally cost the lives of a lot of people? What if, your own daughter who happened to take the bus free that fateful day among the dead?
What about the road contractor who thought a little cheat is not going to do any harm? He used one hundred bags of cement, instead of the official requirement of three hundred bags? Because of his lousy workmanship and work ethics the bridge he built didn’t last more than a year. It collapsed and claimed the lives of his two colleagues and their loved ones when they were attending a wedding.
As a teacher the student you failed to teach five years ago is the same person who just robbed the bank and killed two innocent customers. He has no education and no marketable skills, so he turned into robbery for his survival.
What about the police officer who refused to arrest the driver who drives around with a faulty brake ? The driver got into an accident and killed fifteen people after giving you GH5.00 bribe (all in coins).
As a chief and a community leader of your town you’re also jointly responsible for the poor academic performance of the students (the main “assets” of the town) because you failed to support them with much needed resources.
You can’t do much because you’re spending the resources on unnecessary litigation instead of funding after-school tutoring programs to help the students on their school assignments. All it takes is to hire a teacher to help the kids to study after school, instead of them congregating at Video centers; to watch video shows and” Agya Koo”.
You’re a District Executive Officer and have engulfed yourself in party business so that the welfare of the people in your locality is secondary to your agenda. You think no one will notice the damage your poor stewardship is causing the district. How do you feel when you go to bed at night? What is the most significant action you took during your tenure? Did the ordinary folks benefit from your stewardship? It’s you and your conscience!!
Speaking of conscience, do we have any? I was in Ghana six months ago, and I inquired about the closure of a citrus -juice factory at Asamankese in the eastern region. I was told that some few greedy citrus farmers decided to invent their own “connection” by beating the system and increasing their fortune by harvesting and supplying immature oranges that subsequently made the company incur a huge financial loss.
As an obvious result, the factory closed its doors, and the credible farmers had no reliable market for their produce. The orange season will soon come and the poor, greedy farmers don’t bother to harvest the oranges any more. The oranges have become waste .A classic example of a “little cheating” and “connection” at work. Look! Who are the losers?
I believe each one of us is equipped with unique skills to accomplish our goals with creativity .So all we need is the right inspiration from books--- by authors like Zig Ziegler, Napoleon Hill, Dale Carnegie and Covey R. Stephen, just to name a few --- and environment to unleash creativity to flourish.
Once we do that, we can engage in work that is an authentic fit and improve our lives and subsequently, this will improve our communities, and ultimately the entire nation. So don’t be afraid to spend some quiet time with yourself to incubate ideas and find solutions to our emerging problems.
It always takes an unexpected, unusual force or event to redirect our thoughts, courage, goals and ideas. So change, even if unwelcome, forces us to reevaluate what our best options are. Those times of mental transitions (“confinements”) are great opportunities to look for ways to build on the good and ignore the bad. “A mind that feeds only on itself soon is undernourished, becoming weak and incapable of creative progressive thought.”
Credit: Kwaku Adu-Gyamfi
NJ, USA
[The author is a social commentator and a founder of Adu-Gyamfi Youth Empowerment Foundation for the youths of Asuom.]
Wednesday, September 16, 2009
Tuesday, September 8, 2009
What is rheumatoid arthritis?
Rheumatoid arthritis (RA) is an autoimmune disease that causes chronic inflammation of the joints. Rheumatoid arthritis can also cause inflammation of the tissue around the joints, as well as in other organs in the body. Autoimmune diseases are illnesses that occur when the body's tissues are mistakenly attacked by their own immune system. The immune system is a complex organization of cells and antibodies designed normally to "seek and destroy" invaders of the body, particularly infections. Patients with autoimmune diseases have antibodies in their blood that target their own body tissues, where they can be associated with inflammation. Because it can affect multiple other organs of the body, rheumatoid arthritis is referred to as a systemic illness and is sometimes called rheumatoid disease.
While rheumatoid arthritis is a chronic illness, meaning it can last for years, patients may experience long periods without symptoms. However, rheumatoid arthritis is typically a progressive illness that has the potential to cause joint destruction and functional disability.
Pictures of Normal and Arthritic Joints - Rheumatoid Arthritis
A joint is where two bones meet to allow movement of body parts. Arthritis means joint inflammation. The joint inflammation of rheumatoid arthritis causes swelling, pain, stiffness, and redness in the joints. The inflammation of rheumatoid disease can also occur in tissues around the joints, such as the tendons, ligaments, and muscles.
In some patients with rheumatoid arthritis, chronic inflammation leads to the destruction of the cartilage, bone, and ligaments, causing deformity of the joints. Damage to the joints can occur early in the disease and be progressive. Moreover, studies have shown that the progressive damage to the joints does not necessarily correlate with the degree of pain, stiffness, or swelling present in the joints.
Rheumatoid arthritis is a common rheumatic disease, affecting approximately 1.3 million people in the United States, according to current census data. The disease is three times more common in women as in men. It afflicts people of all races equally. The disease can begin at any age, but it most often starts after age 40 and before 60. In some families, multiple members can be affected, suggesting a genetic basis for the disorder.
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Rheumatoid arthritis (RA) is an autoimmune disease that causes chronic inflammation of the joints. Rheumatoid arthritis can also cause inflammation of the tissue around the joints, as well as in other organs in the body. Autoimmune diseases are illnesses that occur when the body's tissues are mistakenly attacked by their own immune system. The immune system is a complex organization of cells and antibodies designed normally to "seek and destroy" invaders of the body, particularly infections. Patients with autoimmune diseases have antibodies in their blood that target their own body tissues, where they can be associated with inflammation. Because it can affect multiple other organs of the body, rheumatoid arthritis is referred to as a systemic illness and is sometimes called rheumatoid disease.
While rheumatoid arthritis is a chronic illness, meaning it can last for years, patients may experience long periods without symptoms. However, rheumatoid arthritis is typically a progressive illness that has the potential to cause joint destruction and functional disability.
Pictures of Normal and Arthritic Joints - Rheumatoid Arthritis
A joint is where two bones meet to allow movement of body parts. Arthritis means joint inflammation. The joint inflammation of rheumatoid arthritis causes swelling, pain, stiffness, and redness in the joints. The inflammation of rheumatoid disease can also occur in tissues around the joints, such as the tendons, ligaments, and muscles.
In some patients with rheumatoid arthritis, chronic inflammation leads to the destruction of the cartilage, bone, and ligaments, causing deformity of the joints. Damage to the joints can occur early in the disease and be progressive. Moreover, studies have shown that the progressive damage to the joints does not necessarily correlate with the degree of pain, stiffness, or swelling present in the joints.
Rheumatoid arthritis is a common rheumatic disease, affecting approximately 1.3 million people in the United States, according to current census data. The disease is three times more common in women as in men. It afflicts people of all races equally. The disease can begin at any age, but it most often starts after age 40 and before 60. In some families, multiple members can be affected, suggesting a genetic basis for the disorder.
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What causes rheumatoid arthritis?
The cause of rheumatoid arthritis is unknown. Even though infectious agents such as viruses, bacteria, and fungi have long been suspected, none has been proven as the cause. The cause of rheumatoid arthritis is a very active area of worldwide research. It is believed that the tendency to develop rheumatoid arthritis may be genetically inherited. It is also suspected that certain infections or factors in the environment might trigger the activation of the immune system in susceptible individuals. This misdirected immune system then attacks the body's own tissues. This leads to inflammation in the joints and sometimes in various organs of the body, such as the lungs or eyes.
Regardless of the exact trigger, the result is an immune system that is geared up to promote inflammation in the joints and occasionally other tissues of the body. Immune cells, called lymphocytes, are activated and chemical messengers (cytokines, such as tumor necrosis factor/TNF, interleukin-1/IL-1, and interleukin-6/IL-6) are expressed in the inflamed areas.
Environmental factors also seem to play some role in causing rheumatoid arthritis. For example, scientists have reported that smoking tobacco increases the risk of developing rheumatoid arthritis.
What are the symptoms and signs of rheumatoid arthritis?
The symptoms of rheumatoid arthritis come and go, depending on the degree of tissue inflammation. When body tissues are inflamed, the disease is active. When tissue inflammation subsides, the disease is inactive (in remission). Remissions can occur spontaneously or with treatment and can last weeks, months, or years. During remissions, symptoms of the disease disappear, and patients generally feel well. When the disease becomes active again (relapse), symptoms return. The return of disease activity and symptoms is called a flare. The course of rheumatoid arthritis varies from patient to patient, and periods of flares and remissions are typical.
When the disease is active, symptoms can include fatigue, loss of energy, lack of appetite, low-grade fever, muscle and joint aches, and stiffness. Muscle and joint stiffness are usually most notable in the morning and after periods of inactivity. Arthritis is common during disease flares. Also during flares, joints frequently become red, swollen, painful, and tender. This occurs because the lining tissue of the joint (synovium) becomes inflamed, resulting in the production of excessive joint fluid (synovial fluid). The synovium also thickens with inflammation (synovitis).
In rheumatoid arthritis, multiple joints are usually inflamed in a symmetrical pattern (both sides of the body affected). The small joints of both the hands and wrists are often involved. Simple tasks of daily living, such as turning door knobs and opening jars, can become difficult during flares. The small joints of the feet are also commonly involved. Occasionally, only one joint is inflamed. When only one joint is involved, the arthritis can mimic the joint inflammation caused by other forms of arthritis, such as gout or joint infection. Chronic inflammation can cause damage to body tissues, including cartilage and bone. This leads to a loss of cartilage and erosion and weakness of the bones as well as the muscles, resulting in joint deformity, destruction, and loss of function. Rarely, rheumatoid arthritis can even affect the joint that is responsible for the tightening of our vocal cords to change the tone of our voice, the cricoarytenoid joint. When this joint is inflamed, it can cause hoarseness of the voice.
Since rheumatoid arthritis is a systemic disease, its inflammation can affect organs and areas of the body other than the joints. Inflammation of the glands of the eyes and mouth can cause dryness of these areas and is referred to as Sjogren's syndrome. Rheumatoid inflammation of the lung lining (pleuritis) causes chest pain with deep breathing, shortness of breath, or coughing. The lung tissue itself can also become inflamed, scarred, and sometimes nodules of inflammation (rheumatoid nodules) develop within the lungs. Inflammation of the tissue (pericardium) surrounding the heart, called pericarditis, can cause a chest pain that typically changes in intensity when lying down or leaning forward. The rheumatoid disease can reduce the number of red blood cells (anemia) and white blood cells. Decreased white cells can be associated with an enlarged spleen (referred to as Felty's syndrome) and can increase the risk of infections. Firm lumps under the skin (rheumatoid nodules) can occur around the elbows and fingers where there is frequent pressure. Even though these nodules usually do not cause symptoms, occasionally they can become infected. Nerves can become pinched in the wrists to cause carpal tunnel syndrome. A rare, serious complication, usually with long-standing rheumatoid disease, is blood vessel inflammation (vasculitis). Vasculitis can impair blood supply to tissues and lead to tissue death (necrosis). This is most often initially visible as tiny black areas around the nail beds or as leg ulcers.
The cause of rheumatoid arthritis is unknown. Even though infectious agents such as viruses, bacteria, and fungi have long been suspected, none has been proven as the cause. The cause of rheumatoid arthritis is a very active area of worldwide research. It is believed that the tendency to develop rheumatoid arthritis may be genetically inherited. It is also suspected that certain infections or factors in the environment might trigger the activation of the immune system in susceptible individuals. This misdirected immune system then attacks the body's own tissues. This leads to inflammation in the joints and sometimes in various organs of the body, such as the lungs or eyes.
Regardless of the exact trigger, the result is an immune system that is geared up to promote inflammation in the joints and occasionally other tissues of the body. Immune cells, called lymphocytes, are activated and chemical messengers (cytokines, such as tumor necrosis factor/TNF, interleukin-1/IL-1, and interleukin-6/IL-6) are expressed in the inflamed areas.
Environmental factors also seem to play some role in causing rheumatoid arthritis. For example, scientists have reported that smoking tobacco increases the risk of developing rheumatoid arthritis.
What are the symptoms and signs of rheumatoid arthritis?
The symptoms of rheumatoid arthritis come and go, depending on the degree of tissue inflammation. When body tissues are inflamed, the disease is active. When tissue inflammation subsides, the disease is inactive (in remission). Remissions can occur spontaneously or with treatment and can last weeks, months, or years. During remissions, symptoms of the disease disappear, and patients generally feel well. When the disease becomes active again (relapse), symptoms return. The return of disease activity and symptoms is called a flare. The course of rheumatoid arthritis varies from patient to patient, and periods of flares and remissions are typical.
When the disease is active, symptoms can include fatigue, loss of energy, lack of appetite, low-grade fever, muscle and joint aches, and stiffness. Muscle and joint stiffness are usually most notable in the morning and after periods of inactivity. Arthritis is common during disease flares. Also during flares, joints frequently become red, swollen, painful, and tender. This occurs because the lining tissue of the joint (synovium) becomes inflamed, resulting in the production of excessive joint fluid (synovial fluid). The synovium also thickens with inflammation (synovitis).
In rheumatoid arthritis, multiple joints are usually inflamed in a symmetrical pattern (both sides of the body affected). The small joints of both the hands and wrists are often involved. Simple tasks of daily living, such as turning door knobs and opening jars, can become difficult during flares. The small joints of the feet are also commonly involved. Occasionally, only one joint is inflamed. When only one joint is involved, the arthritis can mimic the joint inflammation caused by other forms of arthritis, such as gout or joint infection. Chronic inflammation can cause damage to body tissues, including cartilage and bone. This leads to a loss of cartilage and erosion and weakness of the bones as well as the muscles, resulting in joint deformity, destruction, and loss of function. Rarely, rheumatoid arthritis can even affect the joint that is responsible for the tightening of our vocal cords to change the tone of our voice, the cricoarytenoid joint. When this joint is inflamed, it can cause hoarseness of the voice.
Since rheumatoid arthritis is a systemic disease, its inflammation can affect organs and areas of the body other than the joints. Inflammation of the glands of the eyes and mouth can cause dryness of these areas and is referred to as Sjogren's syndrome. Rheumatoid inflammation of the lung lining (pleuritis) causes chest pain with deep breathing, shortness of breath, or coughing. The lung tissue itself can also become inflamed, scarred, and sometimes nodules of inflammation (rheumatoid nodules) develop within the lungs. Inflammation of the tissue (pericardium) surrounding the heart, called pericarditis, can cause a chest pain that typically changes in intensity when lying down or leaning forward. The rheumatoid disease can reduce the number of red blood cells (anemia) and white blood cells. Decreased white cells can be associated with an enlarged spleen (referred to as Felty's syndrome) and can increase the risk of infections. Firm lumps under the skin (rheumatoid nodules) can occur around the elbows and fingers where there is frequent pressure. Even though these nodules usually do not cause symptoms, occasionally they can become infected. Nerves can become pinched in the wrists to cause carpal tunnel syndrome. A rare, serious complication, usually with long-standing rheumatoid disease, is blood vessel inflammation (vasculitis). Vasculitis can impair blood supply to tissues and lead to tissue death (necrosis). This is most often initially visible as tiny black areas around the nail beds or as leg ulcers.
How is rheumatoid arthritis diagnosed?
The first step in the diagnosis of rheumatoid arthritis is a meeting between the doctor and the patient. The doctor reviews the history of symptoms, examines the joints for inflammation and deformity, the skin for rheumatoid nodules, and other parts of the body for inflammation. Certain blood and X-ray tests are often obtained. The diagnosis will be based on the pattern of symptoms, the distribution of the inflamed joints, and the blood and X-ray findings. Several visits may be necessary before the doctor can be certain of the diagnosis. A doctor with special training in arthritis and related diseases is called a rheumatologist.
The distribution of joint inflammation is important to the doctor in making a diagnosis. In rheumatoid arthritis, the small joints of the hands, wrists, feet, and knees are typically inflamed in a symmetrical distribution (affecting both sides of the body). When only one or two joints are inflamed, the diagnosis of rheumatoid arthritis becomes more difficult. The doctor may then perform other tests to exclude arthritis due to infection or gout. The detection of rheumatoid nodules (described above), most often around the elbows and fingers, can suggest the diagnosis.
Abnormal antibodies can be found in the blood of patients with rheumatoid arthritis. An antibody called "rheumatoid factor" can be found in 80% of patients. Citrulline antibody (also referred to as anti-citrulline antibody, anti-cyclic citrullinated peptide antibody, and anti-CCP) is present in most patients with rheumatoid arthritis. It is useful in the diagnosis of rheumatoid arthritis when evaluating patients with unexplained joint inflammation. A test for citrulline antibodies is most helpful in looking for the cause of previously undiagnosed inflammatory arthritis when the traditional blood test for rheumatoid arthritis, rheumatoid factor, is not present. Citrulline antibodies have been felt to represent the earlier stages of rheumatoid arthritis in this setting. Another antibody called the "antinuclear antibody" (ANA) is also frequently found in patients with rheumatoid arthritis.
A blood test called the sedimentation rate (sed rate) is a measure of how fast red blood cells fall to the bottom of a test tube. The sed rate is used as a crude measure of the inflammation of the joints. The sed rate is usually faster during disease flares and slower during remissions. Another blood test that is used to measure the degree of inflammation present in the body is the C-reactive protein. Blood testing may also reveal anemia, since anemia is common in rheumatoid arthritis, particularly because of the chronic inflammation.
The rheumatoid factor, ANA, sed rate, and C-reactive protein tests can also be abnormal in other systemic autoimmune and inflammatory conditions. Therefore, abnormalities in these blood tests alone are not sufficient for a firm diagnosis of rheumatoid arthritis.
Joint X-rays may be normal or only show swelling of soft tissues early in the disease. As the disease progresses, X-rays can show bony erosions typical of rheumatoid arthritis in the joints. Joint X-rays can also be helpful in monitoring the progression of disease and joint damage over time. Bone scanning, a radioactive test procedure, can demonstrate the inflamed joints. Bone scanning, a radioactive procedure, can also be used to demonstrate the inflamed joints. MRI scanning can also be used to demonstrate joint damage.
The American College of Rheumatology has developed a system for classifying rheumatoid arthritis that is primarily based upon the X-ray appearance of the joints. This system helps medical professionals classify the severity of your rheumatoid arthritis.
Stage I
* no damage seen on X-rays, although there may be signs of bone thinning
Stage II
*on X-ray,evidence of bone thinning around a joint with or without slight bone damage
* slight cartilage damage possible
* joint mobility may be limited; no joint deformities observed * atrophy of adjacent muscle
* abnormalities of soft tissue around joint possible
Stage III
* on X-ray, evidence of cartilage and bone damage and bone thinning around the joint
* joint deformity without permanent stiffening or fixation of the joint
* extensive muscle atrophy
* abnormalities of soft tissue around joint possible
Stage IV
* on X-ray, evidence of cartilage and bone damage and osteoporosis around joint
* joint deformity with permanent fixation of the joint (referred to as ankylosis)
* extensive muscle atrophy
* abnormalities of soft tissue around joint possible
Rheumatologists also classify the functional status of people with rheumatoid arthritis as follows:
Class I: completely able to perform usual activities of daily living
Class II: able to perform usual self-care and work activities but limited in activities outside of work (such as playing sports, household chores)
Class III: able to perform usual self-care activities but limited in work and other activities
Class IV: limited in ability to perform usual self-care, work, and other activities
The doctor may elect to perform an office procedure called arthrocentesis. In this procedure, a sterile needle and syringe are used to drain joint fluid out of the joint for study in the laboratory. Analysis of the joint fluid in the laboratory can help to exclude other causes of arthritis, such as infection and gout. Arthrocentesis can also be helpful in relieving joint swelling and pain. Occasionally, cortisone medications are injected into the joint during the arthrocentesis in order to rapidly relieve joint inflammation and further reduce symptoms.
The first step in the diagnosis of rheumatoid arthritis is a meeting between the doctor and the patient. The doctor reviews the history of symptoms, examines the joints for inflammation and deformity, the skin for rheumatoid nodules, and other parts of the body for inflammation. Certain blood and X-ray tests are often obtained. The diagnosis will be based on the pattern of symptoms, the distribution of the inflamed joints, and the blood and X-ray findings. Several visits may be necessary before the doctor can be certain of the diagnosis. A doctor with special training in arthritis and related diseases is called a rheumatologist.
The distribution of joint inflammation is important to the doctor in making a diagnosis. In rheumatoid arthritis, the small joints of the hands, wrists, feet, and knees are typically inflamed in a symmetrical distribution (affecting both sides of the body). When only one or two joints are inflamed, the diagnosis of rheumatoid arthritis becomes more difficult. The doctor may then perform other tests to exclude arthritis due to infection or gout. The detection of rheumatoid nodules (described above), most often around the elbows and fingers, can suggest the diagnosis.
Abnormal antibodies can be found in the blood of patients with rheumatoid arthritis. An antibody called "rheumatoid factor" can be found in 80% of patients. Citrulline antibody (also referred to as anti-citrulline antibody, anti-cyclic citrullinated peptide antibody, and anti-CCP) is present in most patients with rheumatoid arthritis. It is useful in the diagnosis of rheumatoid arthritis when evaluating patients with unexplained joint inflammation. A test for citrulline antibodies is most helpful in looking for the cause of previously undiagnosed inflammatory arthritis when the traditional blood test for rheumatoid arthritis, rheumatoid factor, is not present. Citrulline antibodies have been felt to represent the earlier stages of rheumatoid arthritis in this setting. Another antibody called the "antinuclear antibody" (ANA) is also frequently found in patients with rheumatoid arthritis.
A blood test called the sedimentation rate (sed rate) is a measure of how fast red blood cells fall to the bottom of a test tube. The sed rate is used as a crude measure of the inflammation of the joints. The sed rate is usually faster during disease flares and slower during remissions. Another blood test that is used to measure the degree of inflammation present in the body is the C-reactive protein. Blood testing may also reveal anemia, since anemia is common in rheumatoid arthritis, particularly because of the chronic inflammation.
The rheumatoid factor, ANA, sed rate, and C-reactive protein tests can also be abnormal in other systemic autoimmune and inflammatory conditions. Therefore, abnormalities in these blood tests alone are not sufficient for a firm diagnosis of rheumatoid arthritis.
Joint X-rays may be normal or only show swelling of soft tissues early in the disease. As the disease progresses, X-rays can show bony erosions typical of rheumatoid arthritis in the joints. Joint X-rays can also be helpful in monitoring the progression of disease and joint damage over time. Bone scanning, a radioactive test procedure, can demonstrate the inflamed joints. Bone scanning, a radioactive procedure, can also be used to demonstrate the inflamed joints. MRI scanning can also be used to demonstrate joint damage.
The American College of Rheumatology has developed a system for classifying rheumatoid arthritis that is primarily based upon the X-ray appearance of the joints. This system helps medical professionals classify the severity of your rheumatoid arthritis.
Stage I
* no damage seen on X-rays, although there may be signs of bone thinning
Stage II
*on X-ray,evidence of bone thinning around a joint with or without slight bone damage
* slight cartilage damage possible
* joint mobility may be limited; no joint deformities observed * atrophy of adjacent muscle
* abnormalities of soft tissue around joint possible
Stage III
* on X-ray, evidence of cartilage and bone damage and bone thinning around the joint
* joint deformity without permanent stiffening or fixation of the joint
* extensive muscle atrophy
* abnormalities of soft tissue around joint possible
Stage IV
* on X-ray, evidence of cartilage and bone damage and osteoporosis around joint
* joint deformity with permanent fixation of the joint (referred to as ankylosis)
* extensive muscle atrophy
* abnormalities of soft tissue around joint possible
Rheumatologists also classify the functional status of people with rheumatoid arthritis as follows:
Class I: completely able to perform usual activities of daily living
Class II: able to perform usual self-care and work activities but limited in activities outside of work (such as playing sports, household chores)
Class III: able to perform usual self-care activities but limited in work and other activities
Class IV: limited in ability to perform usual self-care, work, and other activities
The doctor may elect to perform an office procedure called arthrocentesis. In this procedure, a sterile needle and syringe are used to drain joint fluid out of the joint for study in the laboratory. Analysis of the joint fluid in the laboratory can help to exclude other causes of arthritis, such as infection and gout. Arthrocentesis can also be helpful in relieving joint swelling and pain. Occasionally, cortisone medications are injected into the joint during the arthrocentesis in order to rapidly relieve joint inflammation and further reduce symptoms.
How is rheumatoid arthritis treated?
There is no known cure for rheumatoid arthritis. To date, the goal of treatment in rheumatoid arthritis is to reduce joint inflammation and pain, maximize joint function, and prevent joint destruction and deformity. Early medical intervention has been shown to be important in improving outcomes. Aggressive management can improve function, stop damage to joints as monitored on X-rays, and prevent work disability. Optimal treatment for the disease involves a combination of medications, rest, joint-strengthening exercises, joint protection, and patient (and family) education. Treatment is customized according to many factors such as disease activity, types of joints involved, general health, age, and patient occupation. Treatment is most successful when there is close cooperation between the doctor, patient, and family members.
Two classes of medications are used in treating rheumatoid arthritis: fast-acting "first-line drugs" and slow-acting "second-line drugs" (also referred to as disease-modifying antirheumatic drugs or DMARDs). The first-line drugs, such as aspirin and cortisone (corticosteroids), are used to reduce pain and inflammation. The slow-acting second-line drugs, such as gold, methotrexate, and hydroxychloroquine (Plaquenil), promote disease remission and prevent progressive joint destruction, but they are not antiinflammatory agents.
The degree of destructiveness of rheumatoid arthritis varies from patient to patient. Patients with uncommon, less destructive forms of the disease or disease that has quieted after years of activity ("burned out" rheumatoid arthritis) can be managed with rest, pain and antiinflammatory medications alone. In general, however, patients improve function and minimize disability and joint destruction when treated earlier with second-line drugs (disease-modifying antirheumatic drugs), even within months of the diagnosis. Most patients require more aggressive second-line drugs, such as methotrexate, in addition to antiinflammatory agents. Sometimes these second-line drugs are used in combination. In some patients with severe joint deformity, surgery may be necessary.
There is no known cure for rheumatoid arthritis. To date, the goal of treatment in rheumatoid arthritis is to reduce joint inflammation and pain, maximize joint function, and prevent joint destruction and deformity. Early medical intervention has been shown to be important in improving outcomes. Aggressive management can improve function, stop damage to joints as monitored on X-rays, and prevent work disability. Optimal treatment for the disease involves a combination of medications, rest, joint-strengthening exercises, joint protection, and patient (and family) education. Treatment is customized according to many factors such as disease activity, types of joints involved, general health, age, and patient occupation. Treatment is most successful when there is close cooperation between the doctor, patient, and family members.
Two classes of medications are used in treating rheumatoid arthritis: fast-acting "first-line drugs" and slow-acting "second-line drugs" (also referred to as disease-modifying antirheumatic drugs or DMARDs). The first-line drugs, such as aspirin and cortisone (corticosteroids), are used to reduce pain and inflammation. The slow-acting second-line drugs, such as gold, methotrexate, and hydroxychloroquine (Plaquenil), promote disease remission and prevent progressive joint destruction, but they are not antiinflammatory agents.
The degree of destructiveness of rheumatoid arthritis varies from patient to patient. Patients with uncommon, less destructive forms of the disease or disease that has quieted after years of activity ("burned out" rheumatoid arthritis) can be managed with rest, pain and antiinflammatory medications alone. In general, however, patients improve function and minimize disability and joint destruction when treated earlier with second-line drugs (disease-modifying antirheumatic drugs), even within months of the diagnosis. Most patients require more aggressive second-line drugs, such as methotrexate, in addition to antiinflammatory agents. Sometimes these second-line drugs are used in combination. In some patients with severe joint deformity, surgery may be necessary.
"First-line" medications
Acetylsalicylate (aspirin), naproxen (Naprosyn), ibuprofen (Advil, Medipren, Motrin), and etodolac (Lodine) are examples of nonsteroidal antiinflammatory drugs (NSAIDs). NSAIDs are medications that can reduce tissue inflammation, pain, and swelling. NSAIDs are not cortisone. Aspirin, in doses higher than that used in treating headaches and fever, is an effective antiinflammatory medication for rheumatoid arthritis. Aspirin has been used for joint problems since the ancient Egyptian era. The newer NSAIDs are just as effective as aspirin in reducing inflammation and pain and require fewer dosages per day. Patients' responses to different NSAID medications vary. Therefore, it is not unusual for a doctor to try several NSAID drugs in order to identify the most effective agent with the fewest side effects. The most common side effects of aspirin and other NSAIDs include stomach upset, abdominal pain, ulcers, and even gastrointestinal bleeding. In order to reduce stomach side effects, NSAIDs are usually taken with food. Additional medications are frequently recommended to protect the stomach from the ulcer effects of NSAIDs. These medications include antacids, sucralfate (Carafate), proton-pump inhibitors (Prevacid and others), and misoprostol (Cytotec). Newer NSAIDs include selective Cox-2 inhibitors, such as celecoxib (Celebrex), which offer antiinflammatory effects with less risk of stomach irritation and bleeding risk.
Corticosteroid medications can be given orally or injected directly into tissues and joints. They are more potent than NSAIDs in reducing inflammation and in restoring joint mobility and function. Corticosteroids are useful for short periods during severe flares of disease activity or when the disease is not responding to NSAIDs. However, corticosteroids can have serious side effects, especially when given in high doses for long periods of time. These side effects include weight gain, facial puffiness, thinning of the skin and bone, easy bruising, cataracts, risk of infection, muscle wasting, and destruction of large joints, such as the hips. Corticosteroids also carry some increased risk of contracting infections. These side effects can be partially avoided by gradually tapering the doses of corticosteroids as the patient achieves improvement of the disease. Abruptly discontinuing corticosteroids can lead to flares of the disease or other symptoms of corticosteroid withdrawal and is discouraged. Thinning of the bones due to osteoporosis may be prevented by calcium and vitamin D supplements. For further information on corticosteroids, please read the article on prednisone.
Acetylsalicylate (aspirin), naproxen (Naprosyn), ibuprofen (Advil, Medipren, Motrin), and etodolac (Lodine) are examples of nonsteroidal antiinflammatory drugs (NSAIDs). NSAIDs are medications that can reduce tissue inflammation, pain, and swelling. NSAIDs are not cortisone. Aspirin, in doses higher than that used in treating headaches and fever, is an effective antiinflammatory medication for rheumatoid arthritis. Aspirin has been used for joint problems since the ancient Egyptian era. The newer NSAIDs are just as effective as aspirin in reducing inflammation and pain and require fewer dosages per day. Patients' responses to different NSAID medications vary. Therefore, it is not unusual for a doctor to try several NSAID drugs in order to identify the most effective agent with the fewest side effects. The most common side effects of aspirin and other NSAIDs include stomach upset, abdominal pain, ulcers, and even gastrointestinal bleeding. In order to reduce stomach side effects, NSAIDs are usually taken with food. Additional medications are frequently recommended to protect the stomach from the ulcer effects of NSAIDs. These medications include antacids, sucralfate (Carafate), proton-pump inhibitors (Prevacid and others), and misoprostol (Cytotec). Newer NSAIDs include selective Cox-2 inhibitors, such as celecoxib (Celebrex), which offer antiinflammatory effects with less risk of stomach irritation and bleeding risk.
Corticosteroid medications can be given orally or injected directly into tissues and joints. They are more potent than NSAIDs in reducing inflammation and in restoring joint mobility and function. Corticosteroids are useful for short periods during severe flares of disease activity or when the disease is not responding to NSAIDs. However, corticosteroids can have serious side effects, especially when given in high doses for long periods of time. These side effects include weight gain, facial puffiness, thinning of the skin and bone, easy bruising, cataracts, risk of infection, muscle wasting, and destruction of large joints, such as the hips. Corticosteroids also carry some increased risk of contracting infections. These side effects can be partially avoided by gradually tapering the doses of corticosteroids as the patient achieves improvement of the disease. Abruptly discontinuing corticosteroids can lead to flares of the disease or other symptoms of corticosteroid withdrawal and is discouraged. Thinning of the bones due to osteoporosis may be prevented by calcium and vitamin D supplements. For further information on corticosteroids, please read the article on prednisone.
Newer treatments
Newer "second-line" drugs for the treatment of rheumatoid arthritis include leflunomide (Arava) and the "biologic" medications etanercept (Enbrel), infliximab (Remicade), anakinra (Kineret), adalimumab (Humira), rituximab (Rituxan), and abatacept (Orencia).
Leflunomide (Arava) is available to relieve the symptoms and halt the progression of the disease. It seems to work by blocking the action of an important enzyme that has a role in immune activation. Arava can cause liver disease, diarrhea, hair loss, and/or rash in some patients. It should not be taken just before or during pregnancy because of possible birth defects and is generally avoided in women who might become pregnant.
Newer medications that represent a novel approach to the treatment of rheumatoid arthritis are products of modern biotechnology. These are referred to as the biologic medications or biological response modifiers. In comparison with traditional DMARDs, the biologic medications have a much more rapid onset of action and can have powerful effects on stopping progressive joint damage. In general, their methods of action are also more directed, defined, and targeted.
Etanercept, infliximab, and adalimumab are biologic medications that intercept a messenger protein in the joints (tumor necrosis factor or TNF) that promotes inflammation of the joints in rheumatoid arthritis. These TNF-blockers intercept TNF before it can act on its natural receptor to "switch on" inflammation. This effectively blocks the TNF inflammation messenger from recruiting the cells of inflammation. Symptoms can be significantly, and often rapidly, improved in patients using these drugs. Etanercept must be injected subcutaneously once or twice a week. Infliximab is given by infusion directly into a vein (intravenously). Adalimumab is injected subcutaneously either every other week or weekly. Each of these medications is being evaluated by doctors in practice to determine what role they may have in treating patients in various stages of rheumatoid arthritis. Research has shown that biological response modifiers also prevent the progressive joint destruction of rheumatoid arthritis. They are currently recommended for use after other second-line medications have not been effective. The biological response modifiers (TNF-inhibitors) are expensive treatments. They are also frequently used in combination with methotrexate and other DMARDs. Furthermore, it should be noted that the TNF-blocking biologics all are more effective when combined with methotrexate.
Anakinra is another biologic treatment that is used to treat moderate to severe rheumatoid arthritis. Anakinra works by binding to a cell messenger protein (IL-1, a proinflammation cytokine). Anakinra is injected under the skin daily. Anakinra can be used alone or with other DMARDs. The response rate of anakinra does not seem to be as high as with other biologic medications.
Rituxan is an antibody that was first used to treat lymphoma, a cancer of the lymph nodes. Rituxan can be effective in treating autoimmune diseases like rheumatoid arthritis because it depletes B-cells, which are important cells of inflammation and in producing abnormal antibodies that are common in these conditions. Rituxan is now available to treat moderate to severely active rheumatoid arthritis in patients who have failed treatment with the TNF-blocking biologics. Preliminary studies have shown that Rituxan was also found to be beneficial in treating severe rheumatoid arthritis complicated by blood vessel inflammation (vasculitis) and cryoglobulinemia.
Orencia is a recently developed biologic medication that blocks T-cell activation. Orencia is now available to treat adult patients who have failed treatment with a traditional DMARD or TNF-blocking biologic medication.
While biologic medications are often combined with traditional DMARDs in the treatment of rheumatoid arthritis, they are generally not used with other biologic medications because of the unacceptable risk for serious infections.
The Prosorba column therapy involves pumping blood drawn from a vein in the arm into an apheresis machine, or cell separator. This machine separates the liquid part of the blood (the plasma) from the blood cells. The Prosorba column is a plastic cylinder about the size of a coffee mug that contains a sand-like substance coated with a special material called Protein A. Protein A is unique in that it binds unwanted antibodies from the blood that promote the arthritis. The Prosorba column works to counter the effect of these harmful antibodies. The Prosorba column is indicated to reduce the signs and symptoms of moderate to severe rheumatoid arthritis in adult patients with long-standing disease who have failed or are intolerant to disease-modifying antirheumatic drugs (DMARDs). The exact role of this treatment is being evaluated by doctors, and it is not commonly used currently.
Newer "second-line" drugs for the treatment of rheumatoid arthritis include leflunomide (Arava) and the "biologic" medications etanercept (Enbrel), infliximab (Remicade), anakinra (Kineret), adalimumab (Humira), rituximab (Rituxan), and abatacept (Orencia).
Leflunomide (Arava) is available to relieve the symptoms and halt the progression of the disease. It seems to work by blocking the action of an important enzyme that has a role in immune activation. Arava can cause liver disease, diarrhea, hair loss, and/or rash in some patients. It should not be taken just before or during pregnancy because of possible birth defects and is generally avoided in women who might become pregnant.
Newer medications that represent a novel approach to the treatment of rheumatoid arthritis are products of modern biotechnology. These are referred to as the biologic medications or biological response modifiers. In comparison with traditional DMARDs, the biologic medications have a much more rapid onset of action and can have powerful effects on stopping progressive joint damage. In general, their methods of action are also more directed, defined, and targeted.
Etanercept, infliximab, and adalimumab are biologic medications that intercept a messenger protein in the joints (tumor necrosis factor or TNF) that promotes inflammation of the joints in rheumatoid arthritis. These TNF-blockers intercept TNF before it can act on its natural receptor to "switch on" inflammation. This effectively blocks the TNF inflammation messenger from recruiting the cells of inflammation. Symptoms can be significantly, and often rapidly, improved in patients using these drugs. Etanercept must be injected subcutaneously once or twice a week. Infliximab is given by infusion directly into a vein (intravenously). Adalimumab is injected subcutaneously either every other week or weekly. Each of these medications is being evaluated by doctors in practice to determine what role they may have in treating patients in various stages of rheumatoid arthritis. Research has shown that biological response modifiers also prevent the progressive joint destruction of rheumatoid arthritis. They are currently recommended for use after other second-line medications have not been effective. The biological response modifiers (TNF-inhibitors) are expensive treatments. They are also frequently used in combination with methotrexate and other DMARDs. Furthermore, it should be noted that the TNF-blocking biologics all are more effective when combined with methotrexate.
Anakinra is another biologic treatment that is used to treat moderate to severe rheumatoid arthritis. Anakinra works by binding to a cell messenger protein (IL-1, a proinflammation cytokine). Anakinra is injected under the skin daily. Anakinra can be used alone or with other DMARDs. The response rate of anakinra does not seem to be as high as with other biologic medications.
Rituxan is an antibody that was first used to treat lymphoma, a cancer of the lymph nodes. Rituxan can be effective in treating autoimmune diseases like rheumatoid arthritis because it depletes B-cells, which are important cells of inflammation and in producing abnormal antibodies that are common in these conditions. Rituxan is now available to treat moderate to severely active rheumatoid arthritis in patients who have failed treatment with the TNF-blocking biologics. Preliminary studies have shown that Rituxan was also found to be beneficial in treating severe rheumatoid arthritis complicated by blood vessel inflammation (vasculitis) and cryoglobulinemia.
Orencia is a recently developed biologic medication that blocks T-cell activation. Orencia is now available to treat adult patients who have failed treatment with a traditional DMARD or TNF-blocking biologic medication.
While biologic medications are often combined with traditional DMARDs in the treatment of rheumatoid arthritis, they are generally not used with other biologic medications because of the unacceptable risk for serious infections.
The Prosorba column therapy involves pumping blood drawn from a vein in the arm into an apheresis machine, or cell separator. This machine separates the liquid part of the blood (the plasma) from the blood cells. The Prosorba column is a plastic cylinder about the size of a coffee mug that contains a sand-like substance coated with a special material called Protein A. Protein A is unique in that it binds unwanted antibodies from the blood that promote the arthritis. The Prosorba column works to counter the effect of these harmful antibodies. The Prosorba column is indicated to reduce the signs and symptoms of moderate to severe rheumatoid arthritis in adult patients with long-standing disease who have failed or are intolerant to disease-modifying antirheumatic drugs (DMARDs). The exact role of this treatment is being evaluated by doctors, and it is not commonly used currently.
Other treatments
There is no special diet for rheumatoid arthritis. One hundred years ago, it was touted that "night-shade" foods, such as tomatoes, would aggravate rheumatoid arthritis. This is no longer accepted as true. Fish oil may have antiinflammatory beneficial effects, but so far this has only been shown in laboratory experiments studying inflammatory cells. Likewise, the benefits of cartilage preparations remain unproven. Symptomatic pain relief can often be achieved with oral acetaminophen (Tylenol) or over-the-counter topical preparations, which are rubbed into the skin. Antibiotics, in particular the tetracycline drug minocycline (Minocin), have been tried for rheumatoid arthritis recently in clinical trials. Early results have demonstrated mild to moderate improvement in the symptoms of arthritis. Minocycline has been shown to impede important mediator enzymes of tissue destruction, called metalloproteinases, in the laboratory as well as in humans.
The areas of the body other than the joints that are affected by rheumatoid inflammation are treated individually. Sjogren's syndrome (described above, see symptoms) can be helped by artificial tears and humidifying rooms of the home or office. Medicated eyedrops, cortisporine ophthalmic drops (Restasis), are also available to help the dry eyes in those affected. Regular eye checkups and early antibiotic treatment for infection of the eyes are important. Inflammation of the tendons (tendinitis), bursae (bursitis), and rheumatoid nodules can be injected with cortisone. Inflammation of the lining of the heart and/or lungs may require high doses of oral cortisone.
Proper, regular exercise is important in maintaining joint mobility and in strengthening the muscles around the joints. Swimming is particularly helpful because it allows exercise with minimal stress on the joints. Physical and occupational therapists are trained to provide specific exercise instructions and can offer splinting supports. For example, wrist and finger splints can be helpful in reducing inflammation and maintaining joint alignment. Devices such as canes, toilet seat raisers, and jar grippers can assist in the activities of daily living. Heat and cold applications are modalities that can ease symptoms before and after exercise.
Surgery may be recommended to restore joint mobility or repair damaged joints. Doctors who specialize in joint surgery are orthopedic surgeons. The types of joint surgery range from arthroscopy to partial and complete replacement of the joint. Arthroscopy is a surgical technique whereby a doctor inserts a tube-like instrument into the joint to see and repair abnormal tissues.
Total joint replacement is a surgical procedure whereby a destroyed joint is replaced with artificial materials. For example, the small joints of the hand can be replaced with plastic material. Large joints, such as the hips or knees, are replaced with metals.
Finally, minimizing emotional stress can help improve the overall health in patients with rheumatoid arthritis. Support and extracurricular groups afford patients time to discuss their problems with others and learn more about their illness.
There is no special diet for rheumatoid arthritis. One hundred years ago, it was touted that "night-shade" foods, such as tomatoes, would aggravate rheumatoid arthritis. This is no longer accepted as true. Fish oil may have antiinflammatory beneficial effects, but so far this has only been shown in laboratory experiments studying inflammatory cells. Likewise, the benefits of cartilage preparations remain unproven. Symptomatic pain relief can often be achieved with oral acetaminophen (Tylenol) or over-the-counter topical preparations, which are rubbed into the skin. Antibiotics, in particular the tetracycline drug minocycline (Minocin), have been tried for rheumatoid arthritis recently in clinical trials. Early results have demonstrated mild to moderate improvement in the symptoms of arthritis. Minocycline has been shown to impede important mediator enzymes of tissue destruction, called metalloproteinases, in the laboratory as well as in humans.
The areas of the body other than the joints that are affected by rheumatoid inflammation are treated individually. Sjogren's syndrome (described above, see symptoms) can be helped by artificial tears and humidifying rooms of the home or office. Medicated eyedrops, cortisporine ophthalmic drops (Restasis), are also available to help the dry eyes in those affected. Regular eye checkups and early antibiotic treatment for infection of the eyes are important. Inflammation of the tendons (tendinitis), bursae (bursitis), and rheumatoid nodules can be injected with cortisone. Inflammation of the lining of the heart and/or lungs may require high doses of oral cortisone.
Proper, regular exercise is important in maintaining joint mobility and in strengthening the muscles around the joints. Swimming is particularly helpful because it allows exercise with minimal stress on the joints. Physical and occupational therapists are trained to provide specific exercise instructions and can offer splinting supports. For example, wrist and finger splints can be helpful in reducing inflammation and maintaining joint alignment. Devices such as canes, toilet seat raisers, and jar grippers can assist in the activities of daily living. Heat and cold applications are modalities that can ease symptoms before and after exercise.
Surgery may be recommended to restore joint mobility or repair damaged joints. Doctors who specialize in joint surgery are orthopedic surgeons. The types of joint surgery range from arthroscopy to partial and complete replacement of the joint. Arthroscopy is a surgical technique whereby a doctor inserts a tube-like instrument into the joint to see and repair abnormal tissues.
Total joint replacement is a surgical procedure whereby a destroyed joint is replaced with artificial materials. For example, the small joints of the hand can be replaced with plastic material. Large joints, such as the hips or knees, are replaced with metals.
Finally, minimizing emotional stress can help improve the overall health in patients with rheumatoid arthritis. Support and extracurricular groups afford patients time to discuss their problems with others and learn more about their illness.
Future treatments
Scientists throughout the world are studying many promising areas of new treatment approaches for rheumatoid arthritis. These areas include treatments that block the action of the special inflammation factors, such as tumor necrosis factor (TNFalpha) and interleukin-1 (IL-1), as described above. Also, biologic medications that block interleukin-6 (IL-6) have been shown by researchers to be of benefit in treating rheumatoid arthritis. Many other drugs are being developed that act against certain critical white blood cells involved in rheumatoid inflammation. Also, new NSAIDs with mechanisms of action that are different from current drugs are on the horizon.
Better methods of more accurately defining which patients are more likely to develop more aggressive disease are becoming available. Recent antibody research has found that the presence of citrulline antibodies in the blood (see above, in diagnosis) has been associated with a greater tendency toward more destructive forms of rheumatoid arthritis.
Studies involving various types of the connective tissue collagen are in progress and show encouraging signs of reducing rheumatoid disease activity. Finally, genetic research and engineering is likely to bring forth many new avenues for earlier diagnosis and accurate treatment in the near future. Gene profiling, also known as gene array analysis, is being identified as a helpful method of defining which people will respond to which medications. Studies are under way that are using gene array analysis to determine which patients will be at more risk for more aggressive disease. This is all occurring because of improvements in technology. We are at the threshold of tremendous improvements in the way rheumatoid arthritis is managed.
Rheumatoid Arthritis At A Glance
* Rheumatoid arthritis is an autoimmune disease that can cause chronic inflammation of the joints and other areas of the body.
* Rheumatoid arthritis can affect people of all ages.
* The cause of rheumatoid arthritis is not known.
* Rheumatoid arthritis is a chronic disease, characterized by periods of disease flares and remissions.
* In rheumatoid arthritis, multiple joints are usually, but not always, affected in a symmetrical pattern.
* Chronic inflammation of rheumatoid arthritis can cause permanent joint destruction and deformity.
* Damage to joints can occur early and does not correlate with the severity of symptoms.
* The "rheumatoid factor" is an antibody that can be found in the blood of 80% of patients with rheumatoid arthritis.
* There is no known cure for rheumatoid arthritis.
* The treatment of rheumatoid arthritis optimally involves a combination of patient education, rest and exercise, joint protection, medications, and occasionally surgery.
* Early treatment of rheumatoid arthritis results in better outcomes.
For further information about rheumatoid arthritis, please visit the following site:
The Arthritis Foundation (http://www.arthritis.org)
P.O. Box 19000
Atlanta, Georgia 30326
(or contact your local chapter)
For additional information, please contact:
National Arthritis and Musculoskeletal and Skin Diseases Clearinghouse
Box AMS
Bethesda, Maryland 20892
301-495-4484
References: Clinical Primer of Rheumatology, Lippincott Williams & Wilkens, edited by William Koopman, et al., 2003.
Kelley's Textbook of Rheumatology, W B Saunders Co, edited by Shaun Ruddy, et al., 2000.
Scientists throughout the world are studying many promising areas of new treatment approaches for rheumatoid arthritis. These areas include treatments that block the action of the special inflammation factors, such as tumor necrosis factor (TNFalpha) and interleukin-1 (IL-1), as described above. Also, biologic medications that block interleukin-6 (IL-6) have been shown by researchers to be of benefit in treating rheumatoid arthritis. Many other drugs are being developed that act against certain critical white blood cells involved in rheumatoid inflammation. Also, new NSAIDs with mechanisms of action that are different from current drugs are on the horizon.
Better methods of more accurately defining which patients are more likely to develop more aggressive disease are becoming available. Recent antibody research has found that the presence of citrulline antibodies in the blood (see above, in diagnosis) has been associated with a greater tendency toward more destructive forms of rheumatoid arthritis.
Studies involving various types of the connective tissue collagen are in progress and show encouraging signs of reducing rheumatoid disease activity. Finally, genetic research and engineering is likely to bring forth many new avenues for earlier diagnosis and accurate treatment in the near future. Gene profiling, also known as gene array analysis, is being identified as a helpful method of defining which people will respond to which medications. Studies are under way that are using gene array analysis to determine which patients will be at more risk for more aggressive disease. This is all occurring because of improvements in technology. We are at the threshold of tremendous improvements in the way rheumatoid arthritis is managed.
Rheumatoid Arthritis At A Glance
* Rheumatoid arthritis is an autoimmune disease that can cause chronic inflammation of the joints and other areas of the body.
* Rheumatoid arthritis can affect people of all ages.
* The cause of rheumatoid arthritis is not known.
* Rheumatoid arthritis is a chronic disease, characterized by periods of disease flares and remissions.
* In rheumatoid arthritis, multiple joints are usually, but not always, affected in a symmetrical pattern.
* Chronic inflammation of rheumatoid arthritis can cause permanent joint destruction and deformity.
* Damage to joints can occur early and does not correlate with the severity of symptoms.
* The "rheumatoid factor" is an antibody that can be found in the blood of 80% of patients with rheumatoid arthritis.
* There is no known cure for rheumatoid arthritis.
* The treatment of rheumatoid arthritis optimally involves a combination of patient education, rest and exercise, joint protection, medications, and occasionally surgery.
* Early treatment of rheumatoid arthritis results in better outcomes.
For further information about rheumatoid arthritis, please visit the following site:
The Arthritis Foundation (http://www.arthritis.org)
P.O. Box 19000
Atlanta, Georgia 30326
(or contact your local chapter)
For additional information, please contact:
National Arthritis and Musculoskeletal and Skin Diseases Clearinghouse
Box AMS
Bethesda, Maryland 20892
301-495-4484
References: Clinical Primer of Rheumatology, Lippincott Williams & Wilkens, edited by William Koopman, et al., 2003.
Kelley's Textbook of Rheumatology, W B Saunders Co, edited by Shaun Ruddy, et al., 2000.
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