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RHEUMATOID ARTHRITIS (RA) is a chronic systemic inflammatory autoimmune disease that attacks the synovium, the membrane that surrounds joints and creates a protective sac. Within this sac is synovial fluid that lubricates the joints. In addition to cushioning joints, synovial fluid supplies nutrients and oxygen to cartilage, a slippery tissue coating the ends of bones. Cartilage is composed primarily of collagen, a protein that forms a mesh to provide support and flexibility to joints.
In RA, an abnormal immune response produces destructive molecules that cause continuous inflammation of the synovium (synovitis). Collagen is gradually destroyed, narrowing the joint space and eventually damaging bone. As the disease progresses, destruction to the cartilage accelerates, forming a pannus (a growth of thickened synovial tissue that invades bone and cartilage, leading to damage and joint deformity).
The cause of RA is unknown. Genetic and environmental factors may play important roles in development of the disease. The incidence of the disease in immediate and extended families of patients with RA is high. Most recently, RA is thought to be initiated by T lymphocytes recognizing antigens in the synovial tissue. Activated T cells, macrophages, and fibroblasts produce proinflammatory cytokines that play a key role in synovitis and tissue destruction in RA.
Now that we know what RA is, let's take a look at how to recognize it in your patients.
Signs and symptoms of RA usually begin with the small joints in the hands, wrists, and feet (see Figure 1). As the disease progresses, the knees, shoulders, hips, elbows, ankles, cervical spine, and temporomandibular joints are affected (see Figure 2). The onset of symptoms is usually acute. In addition to joint pain and swelling, another classic sign of RA is joint stiffness, especially after arising from a period of rest or sleep lasting more than 30 minutes.
Deformities of the hands and feet are common in RA. The deformity may be caused by swelling, progressive joint destruction, or the subluxation (partial dislocation) that occurs when a bone slips over another and eliminates the joint space. Weight loss, loss of appetite, fatigue, and fever are other common symptoms. Fatigue usually results from chronic pain and decreased production of red blood cells due to the inflammatory process. Although arthritis represents the major manifestation of RA, the disease may involve other body organs as well (see Extra-articular manifestations of RA).
To be classified as having RA, a patient must meet four or more criteria established by the American College of Rheumatology (ACR). (See ACR criteria for classification of RA.) The criteria for diagnosis must be present for 6 weeks or longer. Evaluating the patient's lab and imaging study results is important to determine a diagnosis of RA and monitor the patient's progress.
X-rays. An X-ray will show bony erosions and narrowed joint spaces as the disease progresses. Keep abreast of any changes in radiographic findings that demonstrate progressive erosion of joint surfaces.
Analysis of synovial fluid. Aspirating fluid from a joint that has significant buildup is often necessary. The synovial fluid typically appears cloudy, milky, or dark yellow. Lab studies on the fluid commonly indicate many inflammatory components such as polymorphonuclear leukocytes and complement. Cultures for microorganisms are usually negative.
Blood work. Serologic testing is a key component of diagnosing and monitoring RA. About three-quarters of patients with RA have a positive rheumatoid factor test. About 30% of patients also have antibodies against antinuclear antigen. The antibody anticyclic citrullinated peptide is highly specific for a diagnosis of RA.
Assessing for anemia is important because chronic inflammation tends to reduce the patient's red blood cell (RBC) count and hemoglobin and hematocrit levels. A decreased RBC count may be connected with the fatigue that sometimes accompanies RA. Increased C-reactive protein, erythrocyte sedimentation rate, white blood cell count, and immunoglobulin levels often indicate an acute or chronic inflammatory response associated with the disease. Liver enzymes such as alkaline phosphatase may be elevated as well. During the early phases of inflammation, you may see an elevated serum complement (C3 and C4), while chronic inflammation often leads to a decrease in these levels.
Urine studies. Systemic inflammation may cause microscopic hematuria (blood in the urine) and proteinuria (excess albumin in the urine) in a 24-hour urine specimen.
Once RA has been diagnosed, you'll play a crucial role in the treatment and management of the disease. Let's review what you can do to help your patient manage and live with RA.
An interdisciplinary team of nurses, a rheumatologist, physical and occupational therapists, social workers, health educators, health psychologists, pain management specialists, and orthopedic physicians may be involved in comprehensive management of a patient's RA. The ultimate goals are to:
* prevent or control joint damage
* prevent loss of function
* decrease pain.
The initial approach to managing RA begins with teaching the patient and her family about the disease and the benefits and adverse effects of the treatments available. It's important to obtain a complete health history while performing a head-to-toe assessment. Also listen to the patient's report of pain and assess her pain with a reliable pain scale.
Common medications used to treat RA include nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, disease-modifying antirheumatic drugs (DMARDs), and biologic response modifiers (BRMs). (See Medications commonly used to treat RA.) The use of NSAIDs helps decrease the inflammatory response and improve the patient's levels of pain and function. Intra-articular injections of corticosteroids are sometimes helpful when a patient has inflammation, swelling, and pain in a joint. Some patients may also require oral or I.V. corticosteroids if the joint inflammation is severe or the disease affects other organs.
To slow the progression of RA, DMARDs may be prescribed. A combination of DMARDs and NSAIDs is used when joint inflammation and swelling are persistent. The newer class of drugs known as BRMs have been used to slow the progression of RA by targeting the immune system response that causes inflammation and joint and tissue damage.
Muscle relaxants, anticonvulsants, antidepressants, and nonopioid analgesics are sometimes used when the patient's pain interferes with activities of daily living. When a patient is experiencing an exacerbation (flare) of the disease, opioids such as morphine and oxycodone (Oxycontin) are sometimes necessary to provide relief.
Opioids should be used only when pain isn't being controlled by other medications and is significantly interfering with the quality of the patient's life. Teach patients the possible adverse effects of these medications and tell them to report any adverse effects to their health care provider. Encourage patients to keep a journal of their pain experience, including pain level. A journal is a good way for the health care team to evaluate the patient's pain experience as well as an effective way for the patient to cope with pain and frustration.
A number of nonpharmacologic approaches are also used to relieve pain and joint stiffness in RA. Many patients get relief from hot packs and warm baths. Ice packs, cold packs, and iced water, particularly for warm swollen joints, can also provide relief. Besides helping to relieve joint pain and stiffness, techniques such as exercise, hydrotherapy, splinting, biofeedback, meditation, acupressure, acupuncture, yoga, hypnosis, and massage may produce a sense of psychological well-being and relaxation.
An occupational therapist can teach the patient ways to help prevent trauma to her joints. Common techniques include:
* avoiding activities that cause pain or discomfort
* avoiding gripping things tightly
* avoiding positions that push the joints toward deformity
* using stronger and more stable joints for any activity.
Regular aerobic exercise programs can help the patient improve joint mobility, muscle strength, aerobic fitness and function, and psychological well-being without increasing fatigue or joint symptoms.
Surgery is considered as a treatment for RA only when the patient's pain is unacceptable, loss of mobility is significant, or functional impairment is severe. Surgical options include synovectomy (removal of inflamed joint tissue), arthroplasty (replacing all or part of a hip or knee joint), and arthroscopy (using a small lighted instrument to remove debris or inflamed tissue from the synovial sac). More patients are electing to have joint replacement when pain and immobility become unbearable.
Physical symptoms aren't the only manifestation of RA-it can have a devastating psychological impact too. Let's look at how RA can affect a patient and her family.
Depression is a primary psychological symptom associated with RA. The causes are related to increased pain, reduced ability to engage in activities of daily living, sleep deprivation, living with a chronic illness, and lack of a supportive social network.
If your patient shows signs of depression, encourage her to seek counseling to help her cope with the stress of the disease. Talking about the frustration of pain, disfigurement, and immobility can help. The ability to share and read about others with RA helps the patient and her family cope with their overwhelming anxiety, frustration, and social isolation. Encourage the patient's family to be a part of the counseling process.
Difficulties in sexual performance are usually related to problems of overall disability and hip involvement, while diminished desire and satisfaction are influenced more by pain, age, and depression. Encourage the patient to get plenty of rest. Tricyclic antidepressants such as amitriptyline are very effective in promoting sleep and addressing depression that's secondary to coping with a chronic illness. Selective serotonin reuptake inhibitors are effective in managing pain, anxiety, and depression.
Rheumatoid arthritis also affects family relationships. The impact of RA can be a financial and social burden on the patient and family. Encourage the patient and family to be involved in self-help groups and be aware of the most recent research and clinical trials in RA (see On the Web).
The journey through RA involves the patient's mind, body, and spirit. Your knowledge of RA, chronic pain management, and the demonstration of caring behaviors can help the patient and family to cope with this chronic illness. LPN
Four or more of these are necessary for a diagnosis of RA:
* Morning stiffness in and around joints lasting at least 1 hour before maximal improvement
* Soft tissue swelling of three or more joint areas joints observed by a health care provider
* Swelling of the proximal interphalangeal, metacarpophalangeal, or wrist joints
* Symmetric arthritis
* Subcutaneous nodules
* Positive test for RF rheumatoid factor
* Radiographic erosions or periarticular osteopenia in hand or wrist joints.
Adapted from Arnett FC, et al. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis and Rheumatism. 31(3):315-324, March 1988.
American Autoimmune-Related Diseases Association: http://www.aarda.org
American College of Rheumatology: http://www.rheumatology.org
Arthritis Foundation: http://www.arthritis.org
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