Treatment and Controversies:
The medical treatment of rheumatoid arthritis most commonly includes non-steroidal anti-inflammatory (NSAIDS), disease modifying anti-rheumatic drugs (DMARDs), and steroids. NSAIDS (such as ibuprofen and naprosyn) help in the short-term with the relief of pain and swelling, but they do not slow the progression of the disease. In addition, long-term use of NSAIDs is associated with an increased risk of bleeding ulcers, heart attacks, impaired kidney function, and worsening hypertension (high blood pressure).
While NSAIDS are important for symptom control, ultimately the goal of treating R.A. is to decrease the destruction of bone with DMARDs (optimally within 3 months of diagnosis). DMARDs include methotrexate, sulfasalazine, intramuscular gold, penicillamine, minocycline, leflunomide and various biologic agents.
Because it has been extremely well-researched, the DMARD methotrexate remains a common first choice treatment. This medication typically provides a prolonged treatment response. In fact, patients with R.A. who are treated with methotrexate seem to live longer than R.A. patients not treated with methotrexate. While there are risks from taking methotrexate (e.g., damage to the liver or a lowering of the red and white blood cell count), monitoring labs and taking folic acid minimizes these complications. Other possible side effects of methotrexate include anemia (a low number of red blood cells), neutropenia (a low number of white blood cells), an increased risk of bruising, nausea and vomiting, dermatitis (inflammation of the skin) and diarrhea. A small percentage of patients develop hepatitis (liver infection), and there is an increased risk of pulmonary fibrosis (scarring of the lung). Methotrexate should not be taken if a patient is pregnant or has liver or kidney disease. Because of the risk to the liver, patients should not drink alcohol while taking methotrexate. Recent studies suggest that people treated with a combination of a DMARD and methotrexate have a greater decrease in their R.A. symptoms than people on methotrexate alone.
The DMARDs penicillamine and oral gold are not commonly used because of the potential for toxic side effects such as damage to the liver, kidney, lowering of the blood count, and skin reactions. Sulfasalazine, another anti-inflammatory drug, is typically well tolerated and often used in combination with other agents. However, sulfasalazine can cause a person's urine or skin to turn yellowish-orange. In addition this medication can cause diarrhea, headache, loss of appetite, upset stomach, vomiting, and/or stomach pain
Biologics, or biologic response modifiers, are some of the newest medications designed specifically to treat R.A. The medications are genetically-engineered proteins which either inhibit or supplement specific components of the immune system called cytokines, which in turn then suppresses inflammation. These medications are very different from the other RA medications listed above because they impact a specific component of the immune system (rather than the entire immune system). Thus, biologics usually have fewer side effects than DMARDs like methotrexate. Because these medications are newer, there is not much information on their long-term safety. Biologics also have potential side effects such as an increased vulnerability to other infections and diseases, and a tendency to cause other chronic diseases (e.g., tuberculosis) to worsen. Finally, biologics are more expensive than other treatments, and they can only be given by injection or intravenous infusion (i.v.).
Steroids are also used for treating R.A. These medications are strongly anti-inflammatory and can stop the disease from worsening. However, there are numerous potential long-term complications from steroids including osteoporosis, hypertension (high blood pressure), and elevated lipids (fats in the bloodstream). Women who are on long-term steroids should be followed and treated for osteoporosis as well as monitored for cardiac risks. Often, steroids are used as a bridge until a response is seen with DMARDs, or for treating "flares" (temporary periods of increased symptoms).
While the medications for treatment of rheumatoid arthritis have variable side effects and risks, typically the benefits of treatment with the drugs outweighs the risks. Bone erosions and joint deformity are irreversible, and treatment is necessary to minimize these complications of R.A.. Close monitoring of liver function, blood count and kidney function can lessen any medication risks.
Prevention:
While there is no known way to prevent the disease, measures can be taken to prevent complications once R.A. begins. Given that R.A. patients have two times the risk of infection as other patients, they should receive yearly influenza vaccines. In addition, the pneumococcal vaccine (typically recommended once for women older than 65), is recommended for all R.A. patients. It is ideally given when a patient is not on a DMARD to maximize its long-term effectiveness. Because there is double the risk of developing osteoporosis, women with R.A. should also receive bone density screening soon after diagnosis. This baseline screening allows monitoring and treatment of osteoporosis as needed. It is also important to aggressively treat cardiovascular disease and risk factors for heart disease in all R.A. patients.
Prognosis:
At this time, there is no cure for rheumatoid arthritis. Treatment aims at minimizing disability and creating periods of long remission of the disease with minimal symptoms. People with higher lab values (e.g., more rheumatoid factor or ESR) may have more severe disease and more joint damage, and require more aggressive treatments. Overall, the course of the disease remains very hard to predict.
Impact on Mental Health:
Dealing with pain, the unpredictability of flares (times when the disease is worse), physical limitations, and an inability to engage in some previously pleasurable activities (such as running) can cause depression or anxiety in individuals with rheumatoid arthritis. Chronic joint pain and fatigue can make daily tasks (working, raising a family, exercising) challenging, which in turn, can lead to feelings of helplessness, hopelessness, and lowered self-esteem. In turn, both anxiety and depression can affect R.A. For instance, people with rheumatoid arthritis who also are depressed often experience more pain than RA individuals who do not have depression.
Women with rheumatoid arthritis who also experience depression or anxiety should discuss these feelings with their doctors. A referral to a mental health professional may be appropriate and important in helping someone deal successfully with RA. In addition, research shows that patients with RA who maintain strong family and friendship connections have lower levels of anxiety and depression.
