Rheumatoid arthritis is a common autoimmune disease that causes joint pain, stiffness, swelling and other issues, such as decreased mobility and in some cases disfigurement. This inflammatory type of arthritis affects about 1.5 million Americans,…
Rheumatoid arthritis is a common autoimmune disease that causes joint pain, stiffness, swelling and other issues, such as decreased mobility and in some cases disfigurement. This inflammatory type of arthritis affects about 1.5 million Americans, the Arthritis Foundation reports, and it can lead to debilitating consequences in some cases.
An Autoimmune Disease
Rheumatoid arthritis is an autoimmune disease, meaning that the immune system, which is designed to protect the body from disease agents such as bacteria and viruses, gets confused and begins attacking healthy cells. With RA, the focus of this attack centers on tissue in the joints, but over time, it can also take a toll on other organs. Rheumatoid arthritis is systemic, and as such, impacts the entire body.
The joints are usually the first place where symptoms arise. “Symptomatically, RA is typically associated with swelling,” which your rheumatologist may refer to as “synovitis,” says Dr. Hareth Madhoun, assistant professor of clinical medicine in the department of internal medicine division of rheumatology at The Ohio State University Wexner Medical Center. “Symptoms include morning stiffness that lasts about an hour, but as the day progresses symptoms tend to improve a little.” In many cases, the joints manifest the worst of the noticeable symptoms of the disease.
But RA’s dirty work isn’t confined just to the joints. Especially when it’s not controlled properly, rheumatoid arthritis can result in serious complications that can become life-threatening.
As an inflammatory autoimmune disease, RA causes complications in many organ systems and tissues throughout the body, including the heart, blood vessels, lungs, bones, eyes, skin, kidneys, salivary glands and nerve tissue. According to the Mayo Clinic, approximately 40 percent of people with RA have signs and symptoms that don’t involve the joints.
The wide range of complications that can arise from rheumatoid arthritis include:
— Heart disease. Of all the non-joint-related complications of RA, cardiovascular disease is the most serious. It is the leading cause of death in both men and women in the U.S. The Arthritis Foundation reports that people with RA have twice the risk of most cardiovascular-related problems compared with the general population, including heart attack, strokes and atherosclerosis — hardening of the arteries caused by the buildup of plaque on the inner walls of the blood vessels. The risk of heart failure is also increased. The Arthritis Foundation reports that “more than 50 percent of premature deaths in people with rheumatoid arthritis result from cardiovascular disease.” Therefore, “anything you can do to reduce cardiac risks of heart attack and stroke,” such as quitting smoking and keeping your cholesterol levels normal, exercising and eating right can all reduce the risk of heart disease, Madhoun says. It’s also important to note that the cardiovascular disease that develops in people with RA is different from the disease that occurs in people who do not have RA, probably because it is the result of the systemic inflammation that RA unleashes. It occurs earlier, is more severe and the outlook is worse following an event such as a heart attack or stroke.
— Lung problems. The Mayo Clinic reports that RA causes inflammation in the body that can lead to scarring within the lungs, lung nodules (small lumps in the lung) and pleural disease (inflammation of the tissue surrounding the lungs). Called interstitial lung disease, this complication can lead to breathing problems. RA is also linked with an increased risk of developing chronic obstructive pulmonary disease, also related to scarring in the lung tissue. Using the common autoimmune medication methotrexate may also elevate risk for lung problems.
— Osteoporosis. RA can cause damage to the bones, and the medications commonly used to treat the condition can also have the side effect of osteoporosis — a condition that causes the bones to weaken, become brittle and prone to fracture. The Osteoporosis and Related Bone Diseases National Resource Center of the National Institutes of Health reports that corticosteroid medications often prescribed to treat RA can cause substantial bone loss. Pain and loss of joint function can also lead to inactivity, which increases the risk of osteoporosis even more. RA itself may cause osteoporosis, too, so it’s not just about the medications.
— Blood vessels. In some patients, especially those who’ve had RA for more than 10 years, a condition called rheumatoid vasculitis can develop in which the blood vessels become inflamed. This serious complication of RA can weaken and narrow blood vessels, causing restricted blood flow that can lead to heart attacks or strokes. The Cleveland Clinic reports that only about 5 percent of people with RA will develop rheumatoid vasculitis.
— Eye problems. Rheumatoid arthritis can cause the eyes to become very dry, and dry eyes are more susceptible to infection. The Mayo Clinic reports that “severe dry eyes can cause damage to the cornea, the clear dome-shaped surface of the eye that helps your eye focus. Dry eyes can also be a symptom of Sjögren’s syndrome — an autoimmune disorder that’s often associated with rheumatoid arthritis.” Sjögren’s features dry eyes and decreased saliva production.
— Other autoimmune conditions. Having rheumatoid arthritis, or indeed any autoimmune disease for that matter, increases your risk of developing other types of autoimmune conditions. This means people with RA have a higher risk of developing diseases such as Type 1 diabetes, Hashimoto’s thyroiditis, psoriasis, multiple sclerosis and lupus, among others. All of these conditions are autoimmune in nature, with the focus of the immune system’s attack falling respectively to the pancreas, the thyroid, the skin, the nervous system and many different organs and tissues. Systemic inflammation is the culprit, and it can manifest in many different ways if not controlled adequately.
Rheumatoid arthritis can also lead to myriad additional complications. According to the Mayo Clinic, these include:
— Rheumatoid nodules. These are firm lumps of tissue that can occur throughout the body, including the lungs, although they are most often found around pressure points, such as the elbows.
— Infections. RA medications and RA itself can impair immune system functioning, which can increase the incidence of infection.
— Abnormal body composition. Individuals with RA often have a higher proportion of fat compared to lean mass, even in people who have a normal body mass index.
— Carpal tunnel syndrome. When RA affects the wrist joints, the inflammation can compress the median nerve in the wrist.
— Lymphoma. RA increases the risk of developing lymphoma, a group of blood cancers that arise in the lymph system.
— Sleep difficulties. A handful of studies indicate that people with RA may have an increased risk of obstructive sleep apnea, which is characterized by multiple pauses in breathing during sleep that can last from seconds to more than a minute. The interruptions cause the patient to wake, even momentarily, and thus not get adequate or restful sleep. “There does seem to be a higher prevalence of obstructive sleep apnea in RA patients,” says Dr. Clete Kushida, professor of psychiatry and behavioral sciences at the Stanford University Medical Center. A sleep study is necessary to determine if insomnia is caused by a sleep disorder. “Pain can also disrupt sleep and can lead to daytime sleepiness,” Kushida says.
Diagnosis and Treatment
If you or your doctor suspects that you’re dealing with a case of rheumatoid arthritis, it’s important to make sure you’ve got the right diagnosis so that you can begin appropriate treatment. Being treated early and with the right medications can help slow the progression of this chronic, incurable disease and help you lead a more normal life with fewer symptoms.
“To reduce complications, the main goal is to diagnose RA early, before joint damage can develop, and then control arthritis with the modern medicines that are available,” says Dr. Kevin Deane, a rheumatologist and associate professor of medicine at the University of Colorado in Denver. “Good control of joint disease also seems to help reduce other complications like cardiovascular disease that may be a direct result of inflammation.”
Additional measures may help prevent complications, Deane advises, including getting appropriate vaccines and watching for infections, monitoring and treating bone health, stopping smoking and maintaining optimal body weight because obesity is a risk factor for poor disease control.
Currently there are some good options for treating rheumatoid arthritis, and these medications can help suppress your body’s overactive immune response. Newer medications, called biologics, have changed the way some people with RA experience their disease, says Dr. David Pugliese, a rheumatologist at Geisinger in Danville, Pennsylvania. “Before biologics we had a whole class of medicines called disease-modifying anti-rheumatic drugs. That describes medicines that suppress the immune system so that it stops attacking itself.” One of the most common drugs used to treat rheumatoid conditions was methotrexate, but there are other medications that fall under the header of disease-modifying anti-rheumatic drugs, “and they all have different interactions with the immune system, they require monitoring and they work, but they work probably somewhere around 60 to 70 percent of the time.”
Newer biologic medications typically cause fewer side effects while more effectively controlling symptoms in some people. Pugliese says biologics are “much more elegant drugs that are focused on specific components of the immune system. Drugs like methotrexate were broad strokes that suppressed the immune system overall. But biologic drugs target specific chemicals that attract the immune response to create inflammation.” These drugs “work at the intercellular level to block the communication of one inflammatory cell with another to stop the recruitment process of all this inflammation that the immune system generates on its own.”
Biologics are typically delivered via injection or IV infusion and are “still immune-suppressing” medications that can be expensive and may not be appropriate for all comers. But by and large, they “have transformed how we’re able to get patients into remission and keep them in remission so that they don’t go on to have further damage,” he says.
Dr. Esther Lipstein-Kresch, chief of rheumatology at ProHEALTH Care in New York, agrees. “The outlook should be great for individuals with rheumatoid arthritis. We now have drugs that we didn’t have 25 years ago that can make a tremendous impact on their disease,” and potentially reduce the number and severity of complications that can arise. Therefore, it’s important to make sure that you see your doctor regularly for appropriate care.