Rheumatoid Arthritis

About Rheumatoid Arthritis

For you or a loved one with rheumatoid arthritis, this section goes into the medical treatment methods and alternative therapies available. Perhaps most importantly, though, it emphasizes the importance of a support network and empowers people with practical things they can do to make it easier to live with the condition.

What is rheumatoid arthritis?

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Rheumatoid arthritis (RA) is a long-term disease that causes pain and swelling in the membranes that hold together and protect the bones in your joints. This can lead the membranes to bend and stretch, and eventually harm the bone and cartilage in your joints. RA may also affect other body organs and tissues.

Rheumatoid arthritis is one of the most common types of inflammatory arthritis, and as with many of the other types, RA is “chronic” – meaning once it starts, it likely persists life-long. Symptoms usually come and go in waves, and though we don’t yet know what triggers rheumatoid arthritis or how to cure it, we do know the types of RA symptoms, how to treat symptoms, and how the disease progresses.

What are the effects of rheumatoid arthritis?

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Inflammation is a natural process that your body normally uses to protect itself from harm. Inflammation is behind the pain and swelling you feel from:

  • Bumping your knee
  • An infection in your throat
  • Burning your hand while cooking
  • A sunburn
  • A paper cut
  • Etc. 

Joints affected by rheumatoid arthritis may become red, swollen and painful, and feel hot or warm to the touch: this is called inflammation. The joints also get stiff, especially in the first few hours after waking up.

RA symptoms tend to change over time, and appear differently in each person. People with rheumatoid arthritis will often suffer from a cycle of very painful episodes, called flares, followed by periods when symptoms disappear, called remissions.

Symptoms can vary: pain can be mild or extreme, periods of stiffness can be short or very long, and the time between flares can range from weeks to years.

If RA inflammation is left untreated, it can eventually lead to joint deformities and severe stiffness that make daily activities difficult. Fortunately, there are many ways to treat rheumatoid arthritis and prevent damage before it happens.

Which body parts are affected?

Rheumatoid arthritis tends to affect smaller joints first, like the joints that link your fingers to your hands or your toes to your feet.

It’s common for joints in the hands and feet to be involved, and for joints to feel stiffness in the morning that lasts for several hours.

There is an important telltale sign that the joint inflammation is caused by RA: the joints are affected in a symmetrical way, meaning the same joints on both sides of the body are affected (e.g. both wrists and/or both thumbs).

Joints commonly affected by RA:

  • Knuckles
  • Wrists
  • Elbows
  • Shoulders
  • Ankles
  • Knees
  • Hips

In some cases, RA may also affect the eyes, and linings around the heart and lungs.

Are there other symptoms?

The inflammation from rheumatoid arthritis sometimes also causes tingling in the fingers and flu-like symptoms:

  • Feeling extremely tired
  • Feeling generally ill
  • Having a low fever
  • Losing your appetite
  • Losing weight 

Support means everything

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No man is an island: in other words, it is not helpful to try to live with rheumatoid arthritis by yourself. Your friends and family can help, along with your team of health care professionals.

Living with any chronic disease can make you feel isolated – especially when you have to adapt or change your daily routine, see your health care practitioners, and learn medical terms. But you don’t need to do it alone.

Rheumatoid arthritis is different for every patient, with treatment tailored to each individual case. The key is to communicate regularly with your doctor about your progress and the effects of your treatment, and to follow your treatment instructions every day, as medication can take time to work. If you feel there’s a problem with your regimen, or are experiencing any side effects, talk to your doctor right away about trying alternative methods. Don't hesitate to ask questions and get involved in decision-making regarding your health. And keep in mind there are many options available to you, so if one approach isn’t working, another one just might.

When you have rheumatoid arthritis, it’s invaluable to keep the lines of communication open with your family, friends and coworkers: they can’t understand what it’s like to live with RA if you don’t talk openly about it.

Here are some tips and helpful insights we’ve learned from patients with RA:

  • Ask those closest to you to learn about your condition. This way they’ll understand your symptoms, or even go with you to your appointments. They can read this or other Web sites, or consult reliable sources like libraries, or the Canadian Arthritis Society.
  • Let them know you need their support. This could be just a sympathetic ear when you need to talk. If there are times when you are more limited physically, be sure to tell them that inflammatory diseases always have good and bad days.
  • Always be open and honest about your RA. It’s the only way people can help you. Remember, if you’ve ever told a friend or family member, “You don’t know what it’s like”, that’s because you haven’t told them.

When we stop doing the things we love, our mood drops, pain feels more intense, and it becomes even harder to get motivated. Keeping fun in your life is absolutely essential — make it a top priority. It boosts your mood, your relationships, and your energy level. Find one activity you love — even a small one — that you can add to each week without fail, and one you can add to each day. Once they become routine, you'll start feeling better and will want to add more.

Lifestyle options

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If you have rheumatoid arthritis, there are many things you can do to ease your symptoms. Moderate exercise, healthy eating and relaxation techniques are all important factors in caring for your joints. Ask your health care professional if you’re unsure whether these tips are right for you.

Exercise to ease pain and stiffness

Exercise doesn’t make stiff and painful joints feel worse. In fact, a bit of moderate exercise may be just the trick to relieving joint tension. And physical activity strengthens muscles and tissues, so weakened or damaged joints are better supported.

To keep exercising fun:

  • Know your limits and trust your instincts on the amount of exercise your joints can handle
  • Start slowly if you haven’t been active for a while
  • Don’t overwork your muscles

Try smooth, low-impact activities like stretching, swimming, tai chi or light yoga. Always make sure that you don’t overdo it. For extra motivation, you can ask a professional to design a fitness regimen. Be sure to tell them about your condition, so the routine will be right for you.

Imagine the extra strain it would put on your joints to carry around a heavy backpack and suitcases all day long. Extra body weight can have the same damaging effect on your joints.

If you have rheumatoid arthritis, maintaining a healthy weight is the main reason to watch what you eat. Losing just a few pounds can mean big stress relief on your knees and other joints. And choose nutrient-packed foods for optimal health and energy!

Protect your joints from damage by making a few changes to daily activities:

  • Protect your knuckles — use gadgets to twist open lids, enlarge the grip on tools and kitchen utensils, and push doors open using your body instead of just your fingers
  • Lift big pans and other heavy objects with two hands, and carry them close to your body
  • Use a reacher to pick up items from the ground, or a cane to decrease pressure on a knee or hip
  • Use a computer wisely: make sure your neck, wrists and lower back are in relaxed and neutral positions. Take a break and stand up every half hour or so
  • Balance periods of activity and rest: neither sitting nor standing all day is good for you
  • Pick a raised seat to decrease stress on hip and knee joints 

One of the symptoms of rheumatoid arthritis is extreme tiredness, and dealing with pain can be exhausting. Even so, it’s important to keep up some level of activity and movement. Prevent strain by alternating between demanding activities and easier ones. The key is to rest and take breaks, and listen to what your body is telling you.

Relax to handle stress

Stress can lead to an increase in blood pressure, interrupt sleep, and play a role in the intensity of RA symptoms. The first step is identifying stress triggers — then developing relaxation and coping skills to improve your overall wellbeing and give you a greater sense of control over your rheumatoid arthritis.

Complementary therapy options

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For some people with rheumatoid arthritis, complementary and alternative therapies — treatments that fall outside the scope of traditional western medicine — can sometimes work very well for pain relief. Ask your health care professional about alternative therapies. 

Heat or cold can help reduce rheumatoid arthritis pain. Below is a general guide as to when you should choose one over the other, and when it’s best to avoid heat/cold.

  • Heat: Stiff joints can benefit from a bit of heat, especially first thing in the morning. Take a warm shower or hot bath, or apply warm compresses to help relax the muscles and relieve joint stiffness and pain. However, heat should never be applied directly to already warm or inflamed joints to avoid making symptoms worse.
  • Cold: Applying a cold compress (or a plastic bag of ice cubes wrapped in a towel) to hot and inflamed joints for about 15 minutes can help constrict blood flow, and decrease the pain and swelling. Cold can make a joint feel stiffer, however, so don’t use it on already stiff joints.

Some people add natural relief therapies to their medical treatments for rheumatoid arthritis, such as acupuncture, Swedish or “classic” massage therapy, vitamin or mineral supplementation (e.g. glucosamine), or biofeedback (with or without hypnosis). Always first discuss these treatment options with your physician, and be sure to tell any alternative health specialist about your condition in order to avoid injury.

You and your doctor may consider surgery if medical therapies are not working well enough for you. The decision usually depends on the amount of pain and disability in the affected joint. Surgery can sometimes improve the appearance of deformed joints. Or, doctors may perform surgery to get a closer look at the damaged joint to better understand how to treat it.

Medical treatments

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Medications for rheumatoid arthritis are divided into two general categories: those that relieve symptoms and inflammation, and those that relieve symptoms and modify the progression of the disease. Your doctor can explain the differences, benefits and side effects of each. You will likely try different therapies or combinations before finding the best prolonged pain relief.

Four types of medication are used to treat rheumatoid arthritis.

Non-steroidal anti-inflammatory drugs (NSAIDs) are a class of medications that can be used to treat the pain and inflammation of RA. NSAIDs do not control the disease, they only treat symptoms. Therefore, they are taken on an as-needed basis.

Your doctor may recommend an NSAID to reduce joint swelling and relieve pain, tenderness and stiffness. You may start to experience benefits within a few weeks.

There are many NSAIDs available, including prescription and non-prescription types. All NSAIDs have an anti-inflammatory effect. Each person reacts differently to different drugs, so you may find that one NSAID brings you more relief than another.

The most common side effects associated with NSAID use are indigestion, heartburn, stomach and abdominal pain. They can also alter the protective lining of the stomach and gut, making you susceptible to ulcers and bleeding, so you should avoid taking more than two different kinds of NSAIDs together. COX-2 inhibitors are custom-designed types of NSAIDs that minimize the risk of ulcers and bleeding. People with heart disease, or a history of stroke or chest pain, should not take NSAIDs. Discuss the use of NSAIDs with your doctor if you have kidney, stomach or heart problems.

The body naturally produces cortisone and other steroids to regulate inflammation. Physicians use corticosteroids as fast-working medication for particularly severe and painful symptoms of rheumatoid arthritis. They provide the same type of relief as NSAIDs, but are stronger, and are not meant for chronic or long-term use. Corticosteroids can have severe side effects, so they are usually taken for limited periods of time, or used to provide relief while waiting for slower-acting medications to take effect.

Corticosteroids can be injected directly into a joint or taken orally. Some of the side effects of oral corticosteroids include facial rounding, fluid retention, fatty deposits in arms, legs or back, increased appetite and weight gain, difficulty sleeping, acne, hair growth, blurry vision, increase in blood pressure, increase in blood sugar levels, and mood swings. As the dosage is decreased or stopped, these side effects disappear. 

Disease-modifying anti-rheumatic drugs (DMARDs) are prescription medications that relieve rheumatoid arthritis symptoms and limit joint damage. While they cannot reverse joint damage that has already happened, early treatment with DMARDs can prevent joint damage that may occur with RA over time, and slow or even stop the progression of rheumatoid arthritis. With DMARDs it can take time before there is a noticeable difference in pain and joint swelling. During this time, you might be prescribed an additional medication, like a steroid or NSAID, to help control symptoms.

DMARDs are meant for the long-term management of rheumatoid arthritis and may be taken for months or years in order to keep RA in remission. They are sometimes prescribed with NSAIDs, other DMARDs or biologic medications.

Common side effects of DMARDs include nausea, diarrhea, upset stomach, dizziness, increased risk of infection, and liver problems. Regular blood work is needed to monitor blood cell counts and liver function. 

Biologic response modifiers, or biologics for short, are medications specifically designed to target your body’s immune system. Like DMARDs, biologics are used to slow the progression of rheumatoid arthritis, help prevent damage to the joints, and ease joint swelling, tenderness and pain.

Biologics can take some time to work. Some people notice the effects of the medication quickly (within a week), while it takes others longer to feel the effects. Biologics are often combined with other medications to treat RA, such as DMARDs. They are also prescribed when other RA therapies aren’t effective.

Common side effects with biologics include mild skin reactions at the injection site, nausea, abdominal pain and headaches. Rarely, people who take biologics may develop serious infections, lupus-like reactions, nervous system diseases, and cancer. You should not take a biologic if you are pregnant or nursing, or have a history of multiple sclerosis or cancer. Tell your doctor if you have a history of tuberculosis, hepatitis B, or recurrent infections.

Biologics are administered in two ways: infusion or injection. Your doctor can provide you with information and help make the right choice for you.

Understanding biologic and biosimilar medications

Most people are familiar with conventional medications such as pain relievers. These medications are made from chemicals (chemically synthesized).

Some of you may also have heard about biological or “biologic” medications which are used to treat serious illnesses, such as cancer, inflammatory bowel disease, psoriasis and rheumatoid arthritis. Biologics are special medications created using the biologic processes within living cells.

Conventional medicines and biologic medicines have important differences.

 

Conventional medicines Biologic medicines
Made from chemicals Created in living cells
Generally small molecules Complex large molecules

 

Some history on biologics…

  • In the 1970s and 1980s scientists started inserting selected genes into living cells to make specific proteins, or “biologics” that could be used as treatments for people.
  • The first biologic was human insulin, used to treat diabetes.

It is common knowledge that when the patent expires on a conventional medication, other companies are allowed to make copies called generics. Although the active ingredient in a generic is exactly the same as the active ingredient in the original conventional medication, non-medicinal ingredients, like fillers and colouring, may be different.

When the patent on a biologic medication expires, other companies are allowed to make copies. However, since it is impossible to make exact copies of biologic medications because of the way they are made, the copies are not called generics or even biogenerics. The correct term is biosimilar since it can only be similar and not identical to the original. In Canada, the official term for a biosimilar medication is Subsequent Entry Biologic or SEB.

Is a biosimilar a generic version of the original biologic drug?

No, biosimilars are similar to, but not identical to the original biologic drug. This is because the group of cells used to produce the drugs (the cell line), the actual drug molecule and the manufacturing process are different.

In Canada, manufacturers of biosimilars are required to show Health Canada that their product is similar to the original biologic and that the benefits of their product outweigh the risks. SEBs must have a label that is different from the original biologic medication.

Does the difference between a biosimilar and the original biologic matter to me and my care?

Yes, original biologics and biosimilars may act differently in your body and could have different side effects.

Since original biologics and the biosimilar versions are not identical, it’s important that you review your prescription with your doctor so you know which one is being prescribed.

Health Canada does not support automatic substitution of a biosimilar for an original biologic at the pharmacy.

For more information about biosimilar medicines, visit:

Health Canada
www.hc-sc.gc.ca/dhp-mps/brgtherap/applic-demande/guides/seb-pbu/01-2010-seb-pbu-qa-qr-eng.php

Alliance for Safe Biologic Medicines (USA)
www.safebiologics.org

Disclaimer 

Please note that the information on this Web site should not be used as a substitute for seeking medical advice or treatment from a physician. You should not use this information to diagnose or treat a medical condition or health problem. Speak to your health care provider if you have any questions about your medical condition, symptoms or treatment options. The information found on this section can be referenced at: www.arthritis.ca.