Diagnosis of Rheumatoid Arthritis
Rheumatoid arthritis can be difficult to diagnose in its early stages for several reasons:
- There is no single test for the disease.
- Symptoms differ from person to person and can be more severe in some people than in others.
- Symptoms can be similar to those of other types of arthritis and joint conditions, and it may take some time for other conditions to be ruled out.
- The disease develops over time, and only a few symptoms may be present in the early stages.
As a result, doctors use a variety of the following tools to diagnose the disease and to rule out other conditions.
Medical History
The doctor will begin by asking you to describe your symptoms, when and how they started, and how they have changed over time. The doctor will also ask about any other medical problems you and close family members have and about any medications you’re taking. Answers to these questions can help the doctor make a diagnosis and understand the impact the disease has on your life.
Physical Examination
The doctor will:
- Check your reflexes and general health, including muscle strength.
- Examine bothersome joints and watch how you walk, bend, and carry out activities of daily living.
- Look at your skin for a rash.
- Listen to your chest for signs of inflammation in the lungs.
Laboratory Tests
A number of lab tests may be useful in confirming a diagnosis of rheumatoid arthritis. Some of the common tests include:
- Rheumatoid factor (RF): This blood test checks for RF, an antibody most people with rheumatoid arthritis eventually have in their blood. (An antibody is a special protein made by the immune system that normally helps fight invaders in the body.) Not all people with rheumatoid arthritis test positive for RF, and some people test positive for RF but never develop the disease. RF also can be positive in some other diseases. However, a positive RF in a person who has symptoms consistent with rheumatoid arthritis can be useful in confirming a diagnosis. Also, high levels of RF are associated with more severe rheumatoid arthritis.
- Anti-CCP antibodies: This blood test detects antibodies to cyclic citrullinated peptide (anti-CCP). This test is positive in most people with rheumatoid arthritis and can even be positive years before rheumatoid arthritis symptoms develop. When used with the RF, this test’s results are very useful in confirming a rheumatoid arthritis diagnosis.
- Others: Other common blood tests include:
- White blood cell count.
- Blood test for anemia, which is common in rheumatoid arthritis.
- Erythrocyte sedimentation rate (often called the sed rate), which measures inflammation in the body.
- C-reactive protein, another common test for inflammation that is useful both in making a diagnosis and monitoring disease activity and response to anti-inflammatory therapy.
Imaging Tests
Doctors use x-rays to see the degree of joint damage. They are not useful in the early stages of rheumatoid arthritis before damage is evident. Doctors may use them to rule out other causes of joint pain. X-rays may also be used later to monitor the progression of the disease. Magnetic resonance imaging (MRI) and ultrasound may be useful in identifying the early stages of rheumatoid arthritis and can help determine the severity of the disease.
Treatment of Rheumatoid Arthritis
Doctors use a variety of approaches to treat rheumatoid arthritis. They may be used in combination and at different times during the course of the disease. Your doctor will choose treatments based on your situation.
No matter which treatment is chosen, the goals are the same:
- Relieve pain.
- Reduce inflammation.
- Slow down or stop joint damage.
- Improve well-being and ability to function.
To treat rheumatoid arthritis, doctors may suggest:
- Medications.
- Surgery.
- Routine monitoring and ongoing care.
- Complementary therapies.
Medications
Most people who have rheumatoid arthritis take medications. Studies show that early treatment with powerful drugs and drug combinations instead of one medication alone may be more effective in reducing or preventing joint damage than beginning with aspirin or other pain relievers. If you have persistent rheumatoid arthritis symptoms, see a doctor familiar with the disease and its treatment to reduce the risk of damage.
Many of the drugs used to treat rheumatoid arthritis reduce the inflammation that can cause pain and joint damage. However, inflammation is also one way the body fights infection and disease. But the level of risk is hard to judge because infections and cancer can occur in people with rheumatoid arthritis who are not on treatment. It is important to talk with your doctor about these risks.
Pain Relief and Anti-Inflammatory Drugs
Your doctor may prescribe some medications (analgesics) that only help with pain relief. Others, such as corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs), can reduce inflammation.
Disease-Modifying Anti-Rheumatic Drugs (DMARDS)
DMARDs may to slow the course of the disease. Common DMARDs your doctor may prescribe include:
- Hydroxychloroquine.
- Leflunomide.
- Methotrexate.
- Sulfasalazine.
Other DMARDs, called biologic response modifiers, may be used if your disease is more severe. These are genetically engineered medications that help reduce inflammation and damage to the joints by interrupting the inflammatory process. Currently, several biologic response modifiers are approved for rheumatoid arthritis, including:
- Abatacept.
- Adalimumab.
- Anakinra.
- Certolizumab.
- Etanercept.
- Golimumab.
- Infliximab.
- Rituximab.
- Tocilizumab.
Another DMARD, tofacitinib, is from a new class of drugs called jak kinase (JAK) inhibitors. It fights inflammation from inside the cell.
Surgery
The primary purpose of surgery is to reduce pain, improve the affected joint’s function, and improve your ability to perform daily activities.
Surgery is not for everyone. Talk with your doctor and together decide what is the right choice for you. Discuss:
- Your overall health.
- The condition of the joint or tendon that will be operated on.
- The reason for, and the risks and benefits of the surgery.
Routine Monitoring and Ongoing Care
Regular medical care is important to monitor the course of the disease, determine the effectiveness and any negative effects of medications, and change therapies as needed.
Monitoring typically includes regular visits to the doctor. It also may include blood, urine, and other lab tests and x-rays.
Good communication between you and your doctor is necessary for effective treatment. Talking to the doctor regularly can help ensure that you receive:
- Necessary exercise and pain management programs.
- Necessary and appropriate medications.
- Information about surgical options if necessary.
Another factor to discuss with your doctor is the risk of osteoporosis, which is a condition in which bones become weakened and fragile. Having rheumatoid arthritis increases your risk of developing osteoporosis, particularly if you take corticosteroids. You may want to discuss with your doctor the potential benefits of calcium and vitamin D supplements or other osteoporosis treatments.
Complementary Therapies
Special diets, vitamins, and other complementary therapies are sometimes suggested to treat rheumatoid arthritis.
Research shows that some of these approaches, such as taking fish oil supplements, may help reduce inflammation. However, few, if any controlled scientific studies have been conducted on complementary approaches, and some studies have found no definite benefit to these therapies.
As with any therapy, you should discuss the benefits and risks with your doctor before beginning any complementary or new type of therapy. However, it is important not to neglect regular health care.
Who Treats Rheumatoid Arthritis?
Diagnosing and treating rheumatoid arthritis requires a team effort involving you and several types of health care professionals. These may include:
- Internists, who specialize in the diagnosis and medical treatment of adults.
- Rheumatologists, who specialize in arthritis and other diseases of the bones, joints, and muscles.
- Orthopaedists, who specialize in the treatment of, and surgery for, bone and joint diseases or injuries.
- Physical therapists, who help to improve joint function.
- Occupational therapists, who teach ways to protect joints, minimize pain, perform activities of daily living, and conserve energy.
- Dietitians, who teach ways to eat a good diet to improve health and maintain a healthy weight.
- Nurse educators, who specialize in helping people understand their overall condition and implement their treatment plans.
- Mental health professionals, who help people cope with difficulties in the home and workplace that may result from their medical conditions.
Living With Rheumatoid Arthritis
Health care professionals can prescribe or recommend treatments to help you manage your rheumatoid arthritis However, research shows that people who take part in their own care report less pain and make fewer doctor visits. They also enjoy a better quality of life.
Self-management programs teach about rheumatoid arthritis and its treatments, exercise and relaxation approaches, communication between you and your health care team, and problem solving. Research on these programs has shown that they help people:
- Understand the disease.
- Reduce pain while remaining active.
- Cope physically, emotionally, and mentally.
- Have greater control over the disease and build a sense of confidence in the ability to function and lead full, active, and independent lives.
Lifestyle Changes
Certain activities can help improve your ability to function on your own and maintain a positive outlook.
- Rest and exercise: Balance your rest and exercise, with more rest when the disease is active and more exercise when it is not. Rest helps to reduce active joint inflammation and pain and to fight fatigue. In general, shorter rest breaks every now and then are more helpful than long times spent in bed. Exercise is important for maintaining healthy and strong muscles, preserving joint mobility, and maintaining flexibility. Exercise can also help you sleep well, reduce pain, maintain a positive attitude, and manage weight. An exercise program should take into account your physical abilities, limitations, and changing needs.
- Joint care: Some people find wearing a splint for a short time around a painful joint reduces pain and swelling. People use splints mostly on wrists and hands, but also on ankles and feet. A doctor or a physical or occupational therapist can help you choose a splint and make sure it fits properly. Other ways to reduce stress on joints include:
- Self-help devices (for example, zipper pullers or long-handled shoe horns).
- Devices to help with getting on and off chairs, toilet seats, and beds.
- Changes in the ways you carry out daily activities.
- Stress reduction: The emotions you may feel because of the disease, fear, anger, and frustration, combined with any pain and physical limitations can increase your stress level. Although there is no evidence that stress plays a role in causing rheumatoid arthritis, it can make living with the disease more difficult. Stress also may affect the amount of pain you feel. Ways to cope with stress include:
- Regular rest periods.
- Relaxation, distraction, or visualization exercises.
- Exercise programs.
- Participation in support groups.
- Good communication with your health care team.
- Healthful diet: With the exception of several types of oils, there is no scientific evidence that any specific food or nutrient helps or harms people with rheumatoid arthritis. However, an overall nutritious diet with balanced calories, protein, and calcium is important. You may need to be careful about drinking alcoholic beverages because they may interact with the medications you take for rheumatoid arthritis. If you take methotrexate you may need to avoid alcohol altogether, because one of the most serious possible long-term side effects of methotrexate is liver damage. Alcohol use can make it worse.
- Climate: Some people notice that their rheumatoid arthritis gets worse when there is a sudden change in the weather. However, there is no evidence that a specific climate can prevent or reduce the effects of rheumatoid arthritis. Moving to a new place with a different climate usually does not make a long-term difference in a person’s rheumatoid arthritis.